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Summary: Mohs micrographic surgery (MMS) is considered the gold‐standard treatment for basal cell carcinoma (BCC) particularly for sites with a high‐risk of incomplete excision such as the central face, for tumours with an aggressive growth pattern and consequent unpredictable subclinical extension and for recurrent tumours. However, the process is more time‐consuming than for standard excision (SE), and the magnitude of benefit is uncertain. This article aims to provide a more complete picture of current evidence, including a review of cosmetic outcomes, tissue‐sparing ability and cost‐effectiveness of MMS. Although robust evidence is lacking, there is a large volume of observational data supporting a low recurrence rate after MMS. The risk of incomplete excision and higher recurrence rate of standard excision favours the use of MMS at high‐risk sites. There is some low‐certainty evidence that MMS results in a smaller defect size compared with SE, and that incomplete excision with SE results in larger defects. Larger defects may affect cosmetic outcome but there is no direct evidence that MMS improves cosmetic outcome compared with SE. There is conflicting evidence regarding the cost of MMS compared with SE, as some studies consider MMS less expensive than SE and others consider it more expensive, which may reflect the healthcare setting. A multicentre 10‐year randomized controlled trial comparing MMS and SE in the treatment of high‐risk BCC would be desirable, but is unlikely to be feasible or ethical. Collection of robust registry data capturing both MMS and SE outcomes would provide additional long‐term outcomes. Click here for the corresponding questions to this CME article. [ABSTRACT FROM AUTHOR]

Image plane beam combination in optical interferometers multiplexes the interference fringes from multiple baselines on to a single detector. The beams of starlight are arranged in a non-redundant pattern at the entrance of the combiner so that the signal from each baseline can be separated from one another in the frequency domain. If the signals from different baselines overlap in the frequency domain, this can give rise to a systematic error in the fringe measurements known as baseline crosstalk. In this paper, we quantify crosstalk arising from the combination of atmospheric seeing and beam propagation over distances of the order of hundreds of metres. We find that in idealized conditions atmospheric wavefront errors and beam propagation do not contribute to crosstalk. However, when aperture stops are included in the optical beam train we observe that wavefront errors can result in squared visibility errors arising from crosstalk as high as Δ V 2 = 6.6 × 10−3 under realistic observing conditions. [ABSTRACT FROM AUTHOR]

Summary: Background: Pemphigus foliaceus (PF) has both genetic and environmental susceptibility factors. Current data on human leucocyte antigen (HLA) in patients with sporadic PF are limited. Aim: To better define the distribution of HLA alleles in patients with PF in the UK. Methods: We recruited 36 patients [26 of white British (WB) descent, 10 of Indo‐Asian (IA) descent] with PF who were living in the UK and 159 ethnically matched normal controls, and analysed their class II HLA DRB1 and DQB1 allele distribution. Results: There was an increased frequency of DRB1*1404 in association with DQB1*0503 in IA patients with PF. The DRB1*04 allele group as a whole had an increased frequency (P < 0.001) in the WB patient group compared with controls. The alleles contributing to this significance were DRB1*0401 (P = 0.03) and DRB1*0404 (P < 0.01). Conclusion: This is the largest HLA association study in sporadic PF from the UK to date. There appears to be a difference in PF susceptibility alleles between WB and IA patients, highlighting the importance of racial variation in genetic susceptibility to disease development. [ABSTRACT FROM AUTHOR]

Objective To determine if a web-based personally controlled health management system (PCHMS) could increase the uptake of sexually transmitted infections (STI) screening among a young university population. Methods A non-blinded parallel-group randomized controlled trial was conducted. Participants aged 18-29 years were recruited from a university environment between April and August 2013, and randomized 1:1 to either the intervention group (immediate online PCHMS access) or control group (no PCHMS access). The study outcome was self-reported STI testing, measured by an online follow-up survey in October 2013. Results Of the 369 participants allocated to the PCHMS, 150 completed the follow-up survey, and of the 378 in the control group, 225 completed the follow-up survey. The proportion of the PCHMS group who underwent an STI test during the study period was 15.3% (23/150) compared with 7.6% (17/225) in the control group (P=.017). The difference in STI testing rates within the sub-group of sexually active participants (20.4% (23/113) of the PCHMS group compared with 9.6% (15/157) of the control group) was significantly higher (P=.027) than among non-sexually active participants. Discussion Access to the PCHMS was associated with a significant increase in participants undergoing STI testing. This is also the first study to demonstrate efficacy of a PCHMS targeting a health concern where susceptibility is generally perceived as low and the majority of infections are asymptomatic. Conclusion PCHMS interventions may provide an effective means of increasing the demand for STI testing which, combined with increased opportunistic testing by clinicians, could reduce the high and sustained rates of STIs in young people. [ABSTRACT FROM AUTHOR]

The Equal Access to Justice Act (EAJA) provides for attorneys fees and court costs to be awarded to parties prevailing in litigation against US federal agencies. We examined EAJA awards paid by the US Forest Service from 1999 to 2005, finding more than $6 million awarded to various plaintiffs. Awards were most commonly paid to environmental litigants, although all categories of litigant stakeholders made use of the law. Although it remains uncertain whether EAJA provides an incentive to sue the US Forest Service in any specific instance, because litigation against the US Forest Service generally has a low probability of success, EAJA one-way fee shifting does alter litigation risks among potential plaintiffs. Frequent EAJA claimants often possess considerable financial resources calling into question how the purposes of the law have evolved in the last 20 years. [ABSTRACT FROM AUTHOR]

Interdisciplinary (ID) teams were created by the US Forest Service in response to environmental legislation. In 2008, we surveyed ID team leaders for National Environmental Policy Act (NEPA) analysis of 106 recreation-related projects conducted between 2005 and 2008. Results were compared with current workforce data and previous studies of ID team leadership and composition for NEPA assessments. ID teams were large in size and diverse in composition, with representatives of a broad range of disciplines and functional areas. The composition of ID teams may be changing from traditional natural resource management to more discipline-specific expertise. The role of social scientists and other human dimension specialists remains modest, despite the importance of social science questions inherent in recreation projects. Results reflect changes in agency hiring practices in the last 20 years and raise questions about the interdisciplinary nature of US Forest Service ID teams. [ABSTRACT FROM AUTHOR]

The National Environmental Policy Act (NEPA) and its accompanying regulations provide a spectrum of alternative analytical pathways for federal agencies proposing major actions that might significantly impact the human environment. Although guidance from the President's Council on Environmental Quality suggests the decision to develop an environmental impact statement (EIS), which requires the most rigorous level of analysis, should be based on the likelihood of significant environmental impacts, findings from an Internet survey with US Forest Service project leaders suggest that the decision may more commonly be based on process-related risks, including the threat of litigation, perceived defensibility in court, and the level of public and political interest in the agency's proposed action. An analysis of judicial decisions in NEPA-related litigation reveals that EISs do not appear to be more defensible than environmental assessments in the courts, suggesting that current decisionmaking about NEPA documentation may be misguided, leading to unnecessary project expenditures and delays. [ABSTRACT FROM AUTHOR]

Eleven executives of the US Forest Service were interviewed to explore the current status and meaning of ecosystem management (EM). The main method of inquiry was open-ended questions, but these questions were complemented by a questionnaire, designed to elicit further conversation about ideas often associated with EM. Participants indicated that EM is still practiced by managers but is seldom used in the agency's environmental speech. The idea that EM is of declining importance to the agency's discourse was also supported by the lack of agreement in participant definitions of EM, where the importance of "scale" and "systems thinking" were the only commonly included ideas in participant definitions of EM. Participants commonly noted the ambiguity and controversy surrounding objectives-oriented components of EM, while process-oriented components were widely accepted by our participants. Our analysis suggests that despite the reduced importance of the term ecosystem management, many of EM's component ideas, particularly those addressing management processes, continue to compete in the agency's broader environmental discourse. [ABSTRACT FROM AUTHOR]

Background Pemphigus vulgaris (PV, OMIM 169610) is a severe blistering disorder of the skin and mucous membranes, caused by the production of autoantibodies directed against the epithelial adhesive protein desmoglein 3. Although an association between PV and HLA class II alleles has been established, the genetic factors predisposing to the disease remain poorly understood, the rarity of PV hampering the recruitment of substantial patient cohorts. Objectives To investigate DSG3 as a candidate PV susceptibility gene. Methods We examined five DSG3 single nucleotide polymorphisms (rs8085532, rs3911655, rs3848485, rs3794925 and rs1466379) in two case–control datasets respectively originating from the U.K. (62 PV patients, 154 controls) and northern India (28 patients, 98 controls). Results In the U.K. sample, we observed a significant association between PV and the DSG3*TCCTC haplotype (Fisher's exact test P = 0·002). A related haplotype (DSG3*TCCCC) was associated with PV in the Indian dataset ( P = 0·002). We also found that all British and Indian patients bearing DSG3 risk haplotypes carried at least one copy of a PV-associated HLA allele. Conclusions These results suggest that genetic variation of DSG3 may be an additive risk factor predisposing to PV and warrant further investigations of this gene. [ABSTRACT FROM AUTHOR]

Toxic epidermal necrolysis (TEN) is a rare disorder characterized by extensive epidermal death. Almost all cases appear to be caused by an idiosyncratic drug reaction. Proposed pathogenic mechanisms are conflicting, and the evidence for the benefits of individual treatments is inadequate, and in some cases contradictory. The mortality rate remains high. We review the literature pertaining to the pathogenesis of TEN and drug reactions in general. The rationale for therapeutic interventions, together with reported evidence of efficacy, are considered. We present a composite model of TEN, based on previous work and suggested pathogeneses of TEN, mechanisms of drug reactions and reported cytotoxic lymphocyte (CTL) cytolytic pathways. In this system, TEN, like some other cutaneous drug eruptions, is an HLA class I-restricted, specific drug sensitivity, resulting in clonal expansion of CD8+ CTLs. Cytotoxicity is mediated by CTL granzyme and possibly death receptor (DR) ligand (DR-L), probably Fas ligand (FasL). Particular to TEN, there is then an amplification sequence involving further DR-L expression. FasL is likely to be particularly important but tumour necrosis factor (TNF) may well contribute, via the TNF receptor 1 (TNF-R1) death pathway. Alternatively, we suggest the possibility of upregulation of an antiapoptotic TNF-R1–nuclear factor κB pathway, which would proscribe treatments which downregulate this pathway. None of the published data on individual treatment efficacies is sufficiently strong to suggest a definitive single treatment. Currently a multifaceted regimen appears indicated, targeting various likely intermediary mechanisms, including elimination of residual drug, immunosuppression, inhibition of DR pathways, general antiapoptotic strategies, and aggressive supportive care. Particular attention has been directed at avoiding potential conflicts between different treatments and avoiding agents that theoretically might have a net proapoptotic rather than antiapoptotic effect. Nursing on a specialized unit is of paramount importance. [ABSTRACT FROM AUTHOR]

Uses a policy analysis framework to determine the effect of the U.S. Department of Agriculture Forest Service's administrative appeals process in agency decision-making and management. Role of stakeholder's interest in maintaining the appeals process in preventing the reformation of this appeals process; Issue of the public involvement in Forest Service decision-making and how such involvement can be best achieved for the benefit of everyone.

Views on the legal and ethical components of forester licensing in the U.S. Protection of the public from unqualified practitioners through licensure; Enhancement of the professional status of foresters; Link of licensure to an enforceable code of ethics.

Large surgical defects of the scalp provide a challenge for the reconstructive surgeon due to the relative inelasticity of scalp skin and the lack of an adjacent tissue reservoir. Often they necessitate a repair utilizing a full- or partial-thickness skin graft. Not uncommonly, however, Mohs extirpation of more extensive or aggressive tumours may necessitate removal of periosteum resulting in exposure of bare bone, which is an avascular bed and may not support a skin graft placed directly upon it. The role of cortical bone fenestration in facilitating granulation of such defects to heal by secondary intention has recently been elegantly described by Barry et al. We discuss our techniques of utilizing galeal/periosteal flaps (GPFs) to resurface exposed bone, providing a vascular bed for a skin graft and allowing immediate reconstruction of large scalp defects. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "A successful therapeutic trial of rituximab in the treatment of a patient with recalcitrant, high-titre epidermolysis bullosa acquisita."

The article presents information on pseudolymphomatous reactions, which is triggered owing to tattooing. Reactions to tattoo dyes are uncommon although the exact incidence is unknown. Red pigments are the usual culprits, although there are rare reports in the literature of reactions to purple, light blue, green, black and yellow pigments. Histologically lichenoid changes are most often seen. No consistently effective treatment for tattoo reactions has been reported and in most cases where treatment with corticosteroids was attempted. More recently the Q-switched Nd : YAG laser has been advocated for the treatment of red tattoo reactions.

A letter to the editor is presented which discusses marginal eyelid suture's utilization in Mohs surgery for eyelid-related tumours.

In this article the author describes how and why forest carbon policies should be transparent in their goals and why policymakers must face the growth of inconsistencies with environmental programs in the U.S. They describe the terms that permeate the discussions on how forest play a role in carbon markets which include baseline, additionality, leakage and permanence. Also investigated is the adoption of policies to subsidize the production of environmentally beneficial practices on lands.

A letter to the editor is presented in response to the article on facilitating closure of surgical defects below the knee through bending the knee in the 2009 issue.

A letter to the editor is presented which focuses on application of crossover tip-stitch during O-T flap repair.

The article presents a study on the proficient method during the classic elliptical excisions performance as a fundamental skill needed in the field of dermatology. Study shows that such practice differs from a similar described method taking place prior to commencing surgery. Such technique is hence, expected to prevent the tendency to excise a lesion narrowly.

A letter to the editor is presented about the use of dietary manipulation in patients referred to a contact dermatitis clinic.

A letter to the editor is presented that discusses the case of 63-year-old woman diagnosed with staphylococcal scalded skin syndrome caused by septic arthritis complication.

Acute generalized exanthematous pustulosis (AGEP) is identified by several characteristic features. We present a patient showing AGEP associated with azathioprine hypersensitivity. To our knowledge, this is the first reported case of this association. [ABSTRACT FROM AUTHOR]

The article presents a case of syphilis in a 38-year-old male patient. The article discusses the historical background of the disease. The article discusses the causative factors of the disease and alerts medical practitioners of the reappearance of syphilis, which was considered a disease of the past.

Presents a case of sebaceous adenoma in a family with a history of Muir-Torre Syndrome (MTS). Case presentation for a 46-year-old man with a small keratoacanthoma-like lesion on the neck; Histopathological findings; Description of MTS as a rare autosomal dominant, cancer-associated genodermatosis; Requirement for initial and periodic examination for both skin tumors and internal malignancy.

Presents a letter to the editor about amlodipine.

Presents a letter to the editor regarding the application of wet-wrap therapy in atopic eczema.

Presents a letter to the editor commenting on extensive plaque psoriasis successfully treated with adalimumab.

Presents a letter to the editor commenting on extensive plaque psoriasis successfully treated with adalimumab.

The article informs that a 53-year-old Caucasian female presented with a 3-week history of multiple, raised, tender, erythematous papules and plaques on her trunk and upper limbs. Some lesions had resolved to leave hyperpigmentation. Her general practitioner had treated her initially with chlorpheniramine followed by a course of phenoxymethyl penicillin with no effect. Following this she received prednisolone 30 mg OD for 1 week. Neutrophilic eccrine hidradenitis is a rare condition with a highly variable clinical presentation. Lesions range from erythematous papules to indurated nodules and plaques of varying sizes. There may be associated pigmentary or purpuric change. The lesions are usually asymptomatic, but may be pruritic or tender. The commonest site of involvement is the trunk and upper limbs. There is often an associated fever.

Presents a letter to the editor focusing on the treatment of a patient suffering from bullous pemphigoid.

Comments on the local regulations of private forests in the U.S. Stability of the regulations; Emphasis on ethical and stewardship-based forestry; Rationale for the proliferation of local ordinances.

A response by L. K. Cerveny and his colleagues to a letter to the editor about their article "Forest Service Interdisciplinary Teams: Size, Composition, and Leader Characteristics" in the June 2011 issue is presented.

The article focuses on the legislative bills formulated which relate to forests care in Virginia. Information from a 2005 tally of forest-related country and city ordinances in Virginia shows that the number of ordinances has increased from 44 in 1992 to 377 in 2005. Most of these forest-related ordinances emphasized the problem on erosion and sediment control, prescribed fire, forestry in floodplains and wetlands, timber harvesting and pesticides. Almost all local governments have regulated forestry. Meanwhile, the study focuses on the inconsistency of regulatory standards between municipalities, possible arguments with state mandates and more.

Focuses on the national policy of the Society of American Foresters for forest management in the U.S. Challenges of public land management; Impacts of local-level issues of national import on private forestry practices; Evaluation of competing scientific forestry documents.

Advises members of the Society of American Foresters on how to deal with environmental groups. Recognition of the self-interest of environmental groups; Building of professional and cooperative relationships with selected environmental groups.