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BACKGROUND A small percentage of patients will have positive histological margins after primary wide local excision (WLE) of cutaneous melanoma (CM). Risk factors that predict marginal involvement at WLE remain unclear. OBJECTIVE To identify risk factors associated with positive margins after WLE of CM. MATERIALS AND METHODS A retrospective review of patients treated at a single institution for CM with sentinel lymph node biopsy from 1997 to 2011 was conducted. RESULTS Positive margins occurred in 6% of patients. Patients with positive margins were older (72.4 vs 60.7, p < .001), had thicker tumors (3.6 vs 1.9 mm, p < .001), and often involved the head and neck region (p < .001). Patients with positive margins at WLE had positive margins on initial biopsy (p = .012) and a higher rate of a melanoma in situ component on initial biopsy (24% vs 11%, p = .02). The 5-year local recurrence rate was significantly different between those with positive and negative margins at WLE (16.0% vs 6.9%; p = .047). CONCLUSION Positive margins after WLE are uncommon. When a patient has multiple risk factors for positive margins at WLE, histologically clear margins should be obtained through mapped serial excision or Mohs micrographic surgery.

Background and objectives: Approximately two-thirds of kidney transplant recipients with no previous history of diabetes experience inpatient hyperglycemia immediately after kidney transplant surgery; whether inpatient hyperglycemia predicts future new onset diabetes after transplant (NODAT) is not established. Design, setting, participants, & measurements: A retrospective study was conducted to determine the risk conferred by inpatient hyperglycemia on development of NODAT within 1 year posttransplant. All adult nondiabetic kidney transplant recipients between June 1999 and January 2008 were included. Posttransplant inpatient hyperglycemia was defined as any bedside capillary blood glucose ≥ 200 mg/dl or insulin therapy during hospitalization. NODAT was defined as HbA1C ≥ 6.5%, fasting venous serum glucose ≥ 126 mg/dl, or prescribed diet or medical therapy for diabetes mellitus. Results: The study cohort included 377 patients. NODAT developed in 1 (4%) of the 28 patients without inpatient hyperglycemia, 4 (18%) of the 22 patients with inpatient hyperglycemia but not treated with insulin, and in 98 (30%) of the 327 of the patients who were diagnosed with inpatient hyperglycemia and were treated with insulin. In adjusted analyses, requirement of insulin therapy during hospitalization posttransplant was associated with a 4-fold increase in NODAT (relative risk 4.01; confidence interval, 1.49 to 10.7; P = 0.006). Conclusion: Development of inpatient hyperglycemia after kidney transplantation in nondiabetic patients significantly increased the risk of NODAT. Additionally, we observed a significantly increased risk of cardiovascular events in patients who developed NODAT.

Although its mechanism of action is still debated, the effect of APOE genotype on risk and age at onset of Alzheimer disease (AD)1 has been replicated many times. Because APOE e4 increases AD risk, e4 carriers have provided an unparalleled opportunity to study the metabolic, structural, pathologic, and cognitive changes that precede the symptomatic expression of mild cognitive impairment (MCI) and dementia and have led to the identification and characterization of presymptomatic stage AD.2 By contrast, APOE e2 confers a reduced risk of AD, but is the least prevalent of the 3 common APOE alleles. Although e2's protective effect has been considered for therapeutic purposes of primary prevention, surprisingly few studies have examined the e2 effect on brain and cognitive aging. In this issue of Neurology ®, Chiang and colleagues3 report findings from the Alzheimer's Disease Neuroimaging Initiative, showing that e2 carriers have a lower rate of annual hippocampal atrophy than individuals with the e3/3 genotype. The e2 carriers also had a higher CSF β-amyloid and lower phosphotau (p-tau), a CSF biomarker profile that suggests less AD pathology. The authors conclude that, consistent with its previously demonstrated protective effect, the e2 allele confers less AD-related brain pathology over time compared to the …