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Undifferentiated pleomorphic sarcoma (UPS) and malignant peripheral nerve sheath tumor (MPNST) are aggressive soft tissue sarcomas that do not respond well to current treatment modalities. The limited availability of UPS and MPNST cell lines makes it challenging to identify potential therapeutic targets in a laboratory setting. Understanding the urgent need for improved treatments for these tumors and the limited cellular models led us to generate additional cell lines to study these rare cancers further. Patient-derived tumors were used to establish 5 new UPS models, including one radiation-associated UPS—UPS060.1, UPS271.1, UPS511, UPS0103, and RIS620—and 3 new models of MPNST—MPNST007, MPNST3813E, and MPNST4970. This study examined the utility of the new cell lines as sarcoma models by assessing tumorigenic potential and mutation status for known sarcoma-related genes. All the cell lines formed colonies and migrated in vitro. The in vivo tumorigenic potential of each cell line was determined by either subcutaneous injection of cells or implantation of tumor tissue into immunocompromised mice. UPS060.1, UPS271.1, and UPS511 cells formed tumors in mice upon subcutaneous injection. UPS0103 and RIS620 tumor implants formed tumors in vivo, as did MPNST007 and MPNST3813E tumor implants. Mutation analysis of a panel of genes frequently mutated in sarcomas showed that two of the three MPNST cell lines had NF1 mutations. Two of the three MPNST cell lines had mutations in polycomb repressive complex 2 members. These new cellular models provide the scientific community with powerful tools for detailed studies of sarcomagenesis and investigate novel therapies for UPS and MPNST.

Background Various means to facilit ate accurate biopsy site identification have been proposed. Objective To determine the accuracy of biopsy site identification by using photographs taken with a patient's digital device by a dermatologist versus professional medical photography. Methods Photographs of circled biopsy sites were taken with personal digital devices by the principal investigator (PI). Another set of photographs was taken by a professional photographer. Secondary photographs were taken of the biopsy site location pointed to by the staff and PI on the basis of the personal digital device image and professional medical photography, respectively. On the basis of secondary photographs, 2 independent dermatologists determined whether the skin biopsy locations pointed out by the staff were consistent with the ones pointed out by PI. Results Per dermatologist A, the staff correctly identified all 53 biopsy sites. Per dermatologist B, the staff were correct on 51 of 53 observations. Dermatologist C, the final arbiter, concurred with dermatologist A on the 2 cases in which dermatologist B was not certain of the location of the biopsy site. Limitations The mean interval from initial biopsy to reidentification of the site was 36.2 days. Conclusion Utilizing patients' personal digital devices is a cost-effective, Health Insurance Portability and Accountability Act–compliant, and readily available means to identify skin biopsy sites.

Background The high prevalence of poor quality essential medicines in low and middle income countries (LMIC) presents considerable risks in terms of both health outcomes and economic cost. Oxytocin injection, the gold standard therapy for management of postpartum haemorrhage (PPH), presents a particular challenge in this area. Recent studies in India, Nigeria and DRC have identified product failure rates, in terms of low drug content, to be 41%, 74% and 80% respectively. Ethiopia bears a high burden of PPH with over 40% of maternal deaths being directly attributed to haemorrhagic causes. This study assessed the quality of oxytocin injection at points in the public and private supply chains to support national efforts to address PPH in Ethiopia. # Methods This study sampled oxytocin injection ampoules from 45 sites across Oromia, Afar regions and the administrative area of Addis Ababa. This included points along the public supply chain from the national point of entry for supplies through regional hubs to points of use (public and private facilities) in urban and rural areas. Collected samples were stored under refrigerated conditions until analysis for oxytocin content, known degradation products and microbiological quality. # Results Ninety-six percent of ampoules passed all tests, while two samples (4%) contained less than the specified oxytocin content. Both samples were collected from rural facilities in Afar, a remote, poorly resourced region with a very hot climate. All supplies collected were sourced from European stringent regulatory approved (SRA) suppliers and, where storage conditions could be determined, approximately 95% of samples were stored in the refrigerator at the time of collection. # Conclusions The study indicates that oxytocin injection in the selected regions is generally of high quality and being stored appropriately. The failed samples detected in Afar suggest challenges remain around maintenance of refrigerated storage in least resourced settings. These findings contrast with recent results in other African countries and support the joint World Health Organization (WHO)/United Nations Children Fund/United Nations Population Fund statement that the availability of high quality oxytocin injection at the point of use is dependent on procurement of supplies from manufacturers approved by WHO or SRAs and storage at 2-8°C throughout the supply chain.

The aim of this study was to isolate and optimize the growth conditions of thermophilic microorganism from hot springs. The isolation was conducted by using the mineral salt basal medium supplemented with 0.6% yeast extract at 50oC. Totally, 33 isolates of thermophilic microorganism were isolated from hot springs at Truong Xuan (Khanh Hoa province) and Binh Chau (Ba Ria - Vung Tau province). The effects of temperature (45 - 80oC), pH (pH 6 - 9) and carbon sources (malate, pyruvate, acetate, glucose, fructose, or carbon dioxide) on the growth of isolates were examined. In addition, the isolate morphology was also investigated by Gram and spore staining. The isolated thermophilic microorganism showed the diversity in colony morphology and color appearance. Most of them were rod shaped, spore-forming and most grew well at 50oC and pH 7. The highest growth of all isolates was observed under malate, glucose, or fructose, as an organic carbon source and unable to use carbon dioxide. Six out of 33 thermophilic microorganism isolates (namely BM7, BS5, NS1, NS3, NS4, and NW6) grew rapidly under high temperatures from 50 - 55oC and their morphology characteristics showed high similarity to Bacillus sp. The study evidenced the polymorphic diversity of thermophiles in the geothermal hot spring ecosystems.

Adult-type granulosa cell tumors of the ovary (aGCTs) are rare gynecologic malignancies that exhibit a high frequency of somatic FOXL2 c.C402G (p.Cys134Trp) mutation. Treatment of relapsed aGCT remains a significant clinical challenge. Here we show, using whole-exome and cancer gene panel sequencing of 79 aGCTs from two independent cohorts, that truncating mutation of the histone lysine methyltransferase gene KMT2D (also known as MLL2) is a recurrent somatic event in aGCT. Mono-allelic KMT2D-truncating mutations are more frequent in recurrent (10/44, 23%) compared with primary (1/35, 3%) aGCTs (p = 0.02, two-sided Fisher’s exact test). IHC detects additional non-KMT2D-mutated aGCTs with loss of nuclear KMT2D expression, suggesting that non-genetic KMT2D inactivation may occur in this tumor type. These findings identify KMT2D inactivation as a novel driver event in aGCTs and suggest that mutation of this gene may increase the risk of disease recurrence., Adult-type granulosa cell tumors of the ovary (aGCTs) are rare and recurrence is difficult to treat. Here, the authors observe in aGCT a novel recurrent somatic truncating mutation of KMT2D, more frequent in recurrent aGCT, and also non-genetic loss of KMT2D expression.

Background Mohs micrographic surgery (MMS) is a highly effective process that requires consistent accuracy in resection, mapping, and histologic interpretation. Although the general sequence in MMS is similar, there are numerous variations among Mohs surgeons as to how this process is performed. Objective This article aims to review the process of MMS, with the intent to identify and mitigate the potential errors at each step. Existing variations will be discussed and protocols offered to minimize error and optimize accuracy. Methods A Pubmed search was performed for publications on methods of tissue mapping, orienting, and processing in MMS. Results Our literature review highlights various techniques for tissue orientation, transfer, flattening, inking, mapping, and processing of later stages and multiple specimens. We discuss our system, which reduces error during tissue transfer, tissue identification in vivo and ex vivo, and tissue flattening. Furthermore, we discuss adaptations to increase the accuracy during reexcisions of subsequent Mohs layers. Conclusion Variations in MMS reflects the diverse training and creativity among Mohs surgeons. Unless potential errors are addressed, however, false negatives will occur and undermine the superior cure rate of MMS.

Objective.To determine the face, content, and construct validity of the Stages of Exercise Scale (SOES) in children with rheumatologic conditions [juvenile idiopathic arthritis (JIA) and juvenile dermatomyositis (JDM)], and if the validity of the SOES differs by disease type by comparing it with a disease control with a chronic respiratory illness [cystic fibrosis (CF)].Methods.Sixty-seven children and adolescents (43 female) ages 11 to 18 years with a diagnosis of either JDM (n = 15), JIA (n = 39), or CF (n = 13) completed the SOES; scales of sensibility, process of change, decisional balance, and self-efficacy; the Child Health Assessment Questionnaire; and patient/physician ratings of disease severity. Physical activity was measured by an accelerometer. Relationships among SOES and measured constructs were determined by ANOVA and with logistical modeling.Results.SOES, decisional balance, and self-efficacy as well as behavioral and cognitive processes from the process of change demonstrated significant differences across the staging subgroups. Disease groups did not significantly differ on the scoring across the SOES. Children and adolescents in higher stages participated in more minutes of vigorous physical activity compared with those in the lower stages.Conclusion.The SOES demonstrated good face, content, and construct validity in children and adolescents with rheumatic disease.

The paramedian forehead flap (PFF) is a well-established technique for reconstruction of large nasal defects. The literature has provided several technical advances and procedural nuances that expand the surgeon's options when performing this procedure.The objective is to provide procedural nuances, technical tips, and suggestions for improving flap outcomes. Specific techniques such as extending flap length below the orbital rim, avoiding terminal scalp hair inclusion in the flap design, restoring lining to full-thickness defects, and even flap dressings and wound care are detailed here. Of particular importance, the 3-staged turnover forehead flap for wounds requiring nasal lining, with delayed flap sculpting and cartilage graft placement, has revolutionized the conceptual approach to the most complicated nasal defects, and the technique is described in detail.This article includes the techniques and approaches from 3 different surgeons at 3 different institutions with 3 different training backgrounds, in an effort to provide a nuanced and broad overview of the subject matter.The PFF technique has been refined with increasing procedural variations and nuances in technique. The nasal reconstructive surgeon, armed with knowledge of these techniques, can approach each patient with a broad knowledge base and perform reconstruction with maximum success.

Cutaneous squamous cell carcinoma (cuSCC) comprises 15–20% of all skin cancers, accounting for over 700,000 cases in USA annually. Most cuSCC arise in association with a distinct precancerous lesion, the actinic keratosis (AK). To identify potential targets for molecularly targeted chemoprevention, here we perform integrated cross-species genomic analysis of cuSCC development through the preneoplastic AK stage using matched human samples and a solar ultraviolet radiation-driven Hairless mouse model. We identify the major transcriptional drivers of this progression sequence, showing that the key genomic changes in cuSCC development occur in the normal skin to AK transition. Our data validate the use of this ultraviolet radiation-driven mouse cuSCC model for cross-species analysis and demonstrate that cuSCC bears deep molecular similarities to multiple carcinogen-driven SCCs from diverse sites, suggesting that cuSCC may serve as an effective, accessible model for multiple SCC types and that common treatment and prevention strategies may be feasible., Cutaneous squamous cell of the skin is a common neoplasm that frequently arises from precancerous actinic keratoses. Here, the authors carry out genomic analysis on matched sets of human lesions and compare with those in ultraviolet treated mice and identify conserved drivers of tumour development.

Extramammary Paget's disease is a rare intra-epithelial malignancy that is occasionally associated with an invasive adenocarcinoma component as well as other secondary cancers. We investigated a consecutive series of patients referred for extramammary Paget's disease of the penis or scrotum at a single center in the contemporary era to determine the presence of secondary cancers and treatment outcomes.Between December 1990 and February 2009, 20 patients with extramammary Paget's disease of the scrotum and/or penis were seen. Patients were investigated with computerized tomography of the abdomen/pelvis, chest x-ray, cystoscopy, colonoscopy and serum prostate specific antigen measurement to rule out obvious secondary cancer. Clinical charts were reviewed with institutional review board approval. Mean followup of treated cases was 48 months (range 7 to 208).Patients were 50 to 86 years old with a history of symptoms of between 6 months and 10 years. Eight patients had invasive adenocarcinoma, of whom 2 died of the disease and 3 who had disease at 5, 7 and 40 months, respectively, were undergoing multimodal therapy. No patient with confirmed intra-epidermal disease only died of the disease. Invasive disease predicted nodal and metastatic progression.Surgical resection to achieve tumor-free margins resulted in durable relapse-free survival of patients with intra-epidermal extramammary Paget's disease alone. Extramammary Paget's disease with invasion was associated with regional metastatic progression. The latter scenario as well as failure to treat localized extramammary Paget's disease alone was associated with a fatal outcome. Systemic chemotherapy should be further explored in patients with invasive adenocarcinoma or lymph node positive disease.

Background Several research groups have demonstrated the non-invasive diagnostic potential of diffuse optical spectroscopy (DOS) and laser-induced fluorescence (LIF) techniques for early cancer detection. By combining both modalities, one can simultaneously measure quantitative parameters related to the morphology, function and biochemical composition of tissue and use them to diagnose malignancy. The objective of this study was to use a quantitative reflectance/fluorescence spectroscopic technique to determine the optical properties of normal skin and non-melanoma skin cancers and the ability to accurately classify them. An additional goal was to determine the ability of the technique to differentiate non-melanoma skin cancers from normal skin. Study Design The study comprised 48 lesions measured from 40 patients scheduled for a biopsy of suspected non-melanoma skin cancers. White light reflectance and laser-induced fluorescence spectra (wavelength range = 350–700 nm) were collected from each suspected lesion and adjacent clinically normal skin using a custom-built, optical fiber-based clinical instrument. After measurement, the skin sites were biopsied and categorized according to histopathology. Using a quantitative model, we extracted various optical parameters from the measured spectra that could be correlated to the physiological state of tissue. Results Scattering from cancerous lesions was significantly lower than normal skin for every lesion group, whereas absorption parameters were significantly higher. Using numerical cut-offs for our optical parameters, our clinical instrument could classify basal cell carcinomas with a sensitivity and specificity of 94% and 89%, respectively. Similarly, the instrument classified actinic keratoses and squamous cell carcinomas with a sensitivity of 100% and specificity of 50%. Conclusion The measured optical properties and fluorophore contributions of normal skin and non-melanoma skin cancers are significantly different from each other and correlate well with tissue pathology. A diagnostic algorithm that combines these extracted properties holds promise for the potential non-invasive diagnosis of skin cancer. Lasers Surg. Med. 42:876–887, 2010. © 2010 Wiley-Liss, Inc.

Dermatitis is a common side effect of radiation therapy (RT) whereas squamous cell carcinoma (SCC) is not. Management must include treatment options outside of RT, especially when cases are limited by extreme fibrosis. Here, we present a case in which a patient developed multiple SCC, severe radiation fibrosis, and limited neck mobility. This situation of increased risk for intubation required interdisciplinary coordination for proper therapeutic intervention, namely Mohs micrographic surgery to manage cutaneous lesions.

For some years, there has been interest in exploring the effects of high-fat and high-protein diets on the control of body weight. More recently, less extreme dieting paradigms have been studied, with a focus on the use of increased plant food components. This article reviews these diets from the standpoint of potential therapeutic use in cardiovascular risk reduction. We conducted a search of the literature published in 2008 and 2009 for studies assessing the effect of diet on body weight control, especially where there was an emphasis on differences in macronutrient profiles and food sources used (e.g., plant vs. animal). No clear picture emerged on the ideal macronutrient profile for weight loss and cardiovascular disease risk factor reduction. However, in general, the use of more plant food-based approaches had the greatest effect in reducing cardiovascular disease risk factors, including blood lipids and blood pressure. Alterations in the proportion of protein and fat intakes gave inconsistent effects on body weight reduction.

Nuts appear to have a marked effect in cohort studies in reducing the risk of coronary heart disease (CHD), but their demonstrated ability to lower cholesterol can only explain a proportion of the reduction in risk. Our aim was to assess whether improvement in carbohydrate metabolism provides a further explanation for the effect of nuts in reducing CHD. The effects of whole almonds, taken as snacks, were compared with the effects of low saturated fat (

Prompted by current dietary recommendations for the control of serum cholesterol to new targets to reduce the risk of coronary heart disease (CHD), and by the CHD risk reduction claims made for certain foods or food components, studies are now being undertaken using combinations of cholesterol-lowering foods in one diet (eg, a dietary portfolio) rather than single foods to achieve more effective dietary control of serum cholesterol. This approach has increased the potential relevance of dietary therapy and may yield nutrition strategies that bridge the gap between what is regarded as a good diet and drug therapy.

To determine the effect on blood pressure of dietary advice to consume a combination of plant-based cholesterol-lowering foods (dietary portfolio).For 1 year, 66 hyperlipidemic subjects were prescribed diets high in plant sterols (1.0 g/1000 kcal), soy protein (22.5 g/1000 kcal), viscous fibers (10 g/1000 kcal) and almonds (22.5 g/1000 kcal). There was no control group. Seven-day diet record, blood pressure and body weight were monitored initially monthly and later at 2-monthly intervals throughout the study.Fifty subjects completed the 1-year study. When the last observation was carried forward for non-completers (n=9) or those who changed their blood pressure medications (n=7), a small mean reduction was seen in body weight 0.7+/-0.3 kg (P=0.036). The corresponding reductions from baseline in systolic and diastolic blood pressure at 1 year (n=66 subjects) were -4.2+/-1.3 mm Hg (P=0.002) and -2.3+/-0.7 mm Hg (P=0.001), respectively. Blood pressure reductions occurred within the first 2 weeks, with stable blood pressures 6 weeks before and 4 weeks after starting the diet. Diastolic blood pressure reduction was significantly related to weight change (r=0.30, n=50, P=0.036). Only compliance with almond intake advice related to blood pressure reduction (systolic: r=-0.34, n=50, P=0.017; diastolic: r=-0.29, n=50, P=0.041).A dietary portfolio of plant-based cholesterol-lowering foods reduced blood pressure significantly, related to almond intake. The dietary portfolio approach of combining a range of cholesterol-lowering plant foods may benefit cardiovascular disease risk both by reducing serum lipids and also blood pressure.

A dietary portfolio of cholesterol-lowering ingredients has proved effective in reducing serum cholesterol. However, it is not known whether this dietary combination will also affect hematologic risk factors for coronary heart disease (CHD). Reductions in hematocrit and polymorphonuclear leukocytes have been reported to improve cardiovascular risk. We, therefore, report changes in hematological indices, which have been linked to cardiovascular health, in a 1-year assessment of subjects taking an effective dietary combination (portfolio) of cholesterol-lowering foods.For 12 months, 66 hyperlipidemic subjects were prescribed diets high in plant sterols (1.0 g/1000 kcal), soy protein (22.5 g/1000 kcal), viscous fibers (10 g/1000 kcal) and almonds (23 g/1000 kcal). Fifty-five subjects completed the study.Over the 1 year, data on completers indicated small but significant reductions in hemoglobin (-1.5+/-0.6 g/l, P=0.013), hematocrit (-0.007+/-0.002 l/l, P0.001), red cell number (-0.07+/-0.02 10(9)/l, P0.001) and neutrophils (-0.34+/-0.13 10(9)/l, P=0.014). Mean platelet volume was also increased (0.16+/-0.07 fl, P=0.033). The increase in red cell osmotic fragility (0.05+/-0.03 g/l, P=0.107) did not reach significance.These small changes in hematological indices after a cholesterol-lowering diet are in the direction, which would be predicted to reduce CHD risk. Further research is needed to clarify whether the changes observed will contribute directly or indirectly to cardiovascular benefits beyond those expected from reductions previously seen in serum lipids and blood pressure.

"Venous disease consists of a spectrum with significant medical and economic morbidities. For lack of exposure, however, it is a poorly understood subject. The evaluation and approach to diagnosing venous disease requires a firm understanding of venous anatomy and pathophysiology. With a targeted history and physical, and noninvasive testing, venous disease may be evaluated comprehensively."

BACKGROUND The island pedicle flap is a useful method of reconstruction in dermatologic surgery. Traditionally, the pedicle has been centrally and inferiorly based, with flap movements by rotation or advancement. With innovations, however, the flap is remarkably applicable to a variety of facial defects. OBJECTIVE Our purpose is to introduce modifications of the island pedicle flap, including (1) single lateral pedicle, (2) transposition, and (3) interpolation movements. METHODS Modifications of the island pedicle flap were applied in nine cases of cutaneous repair after Mohs micrographic surgery. Patient records and postoperative photographs were reviewed retrospectively. Both patients and other surgeons were asked to assess outcome variables. RESULTS Patients and physicians judged overall outcome as “excellent” or “good” in 100% and 90.7% of evaluated cases, respectively. CONCLUSIONS Variations of the island pedicle flap, including (1) single lateral pedicle, (2) transposition, and (3) interpolation movements, are viable options in the reconstruction of facial defects after Mohs micrographic surgery.

BACKGROUND. Dense infiltrates in association with squamous cell carcinoma (SCC) or basal cell carcinoma (BCC) in patients with underlying chronic lymphocytic leukemia (CLL) may complicate pathologic interpretation of histologic margins. OBJECTIVE. The study was conducted to determine the frequency of identifying dense inflammatory infiltrates in frozen histologic sections during Mohs operation for BCC or SCC in patients with CLL and organ-transplant recipients, to characterize the infiltrate (reactive versus leukemic) in CLL, and to estimate the subclinical tumor extension in patients with CLL, transplant recipients, and control subjects undergoing Mohs procedure. METHODS. Frozen sections of head and neck BCC and SCC obtained during Mohs procedures in patients with CLL, organ transplant recipients, and a control group were reviewed retrospectively. Biopsy specimens of CLL with dense infiltrates were assessed with immunohistochemical stains. Subclinical tumor extension (postoperative defect size minus preoperative tumor size) was evaluated in each group. RESULTS. Dense infiltrates were found in tumors of 20 of 55 patients with CLL (36%), 1 of 8 transplant recipients (13%), and 1 of 105 controls (1%). In patients with CLL, 75% of the dense infiltrates were B-cell leukemic. Compared with controls, the mean subclinical tumor extension was larger in patients with CLL (P 5 0.029) and in transplant recipients (P 5 0.55). CONCLUSION. Dense leukemic infiltrates associated with BCC or SCC in CLL may complicate pathologic interpretation of Mohs surgical histologic margins and may be associated with larger postoperative defects relative to preoperative clinical tumor appearance. In patients with CLL, as in transplant recipients, SCC seems more likely to develop than BCC.

Cutaneous surgeons cannot predict blood-thinner status by intraoperative visual inspection. Many surgeons believe they can discern whether a patient is taking an anticoagulant or a platelet inhibitor (blood thinner) by visual inspection of intraoperative oozing. However, there is little objective evidence to support this strongly held belief. The authors' objective was to determine whether visual inspection of intraoperative oozing during cutaneous surgery is accurate in identifying use of blood thinners. Blinded physician evaluators observed intraoperative oozing in 110 patients having cutaneous excisional surgery, rated the amount of oozing, and judged the likelihood that the patient was taking a blood-thinning agent. On the basis of the impressions of the most senior evaluator, 43 patients having used aspirin in the past 14 days or warfarin or vitamin E in the past 2 days, seven were judged as definitely or probably taking blood-thinning agents (sensitivity, 16.3 percent; 95 percent confidence interval, 6.8 to 30.7 percent). Of 67 patients who did not report recent use of a blood-thinning agent, just 11 were judged as definitely or probably taking blood-thinning agents (false-positive rate, 16.4 percent; 95 percent confidence interval, 8.5 to 27.5 percent). The level of training of the physicians doing the judging did not affect diagnostic sensitivity. Only 10 of the 110 patients (9.1 percent) were assessed as exhibiting excessive oozing, and of those, only four (40 percent) were actually taking a blood thinner. Results were similar when only patients who were taking aspirin or warfarin were analyzed. Thus, contrary to a commonly and strongly held belief, visual inspection of intraoperative oozing during cutaneous excisional surgery correlates poorly with blood-thinner use by patients. The data add further evidence that use of blood thinners does not have an objectively measurable adverse effect during cutaneous surgery.

Therapy for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) does not end with treatment of the initial lesion because almost 50% of patients with one nonmelanoma skin cancer (NMSC) develop another NMSC in the next 5 years. An integrated program of skin cancer awareness, sun protection, and prophylactic approaches is critical. The risk profile of the tumor influences which therapies and specialties will be involved. Most NMSCs may be treated with outpatient methods. Primary care physicians may treat low-risk tumors, but dermatologists specially trained in cutaneous oncology and a multidisciplinary team should manage high-risk lesions. Superficial BCC and SCC may be treated adequately with superficial modalities such as electrodesiccation and curettage (EDC) and cryotherapy. Topical 5-fluorouracil is effective for small in situ lesions. Invasive but low-risk lesions may be treated with EDC and cryotherapy provided that the tumor is limited to the papillary dermis, is not recurrent, and does not have high-risk features. High-risk tumors are best treated with excision and histologic examination or Mohs micrographic surgery (MMS). MMS is the therapeutic gold standard for all NMSCs in terms of cure rates, margin control, and tissue conservation. Because of its higher cost and specialized process, MMS is best reserved for specific indications.

BACKGROUND. Merkel cell carcinoma is an aggressive cutaneous neoplasm with a high propensity to metastasize to lymph nodes. OBJECTIVE. The objective of this study was to determine the prognostic significance of sentinel lymph node status in patients with Merkel cell carcinoma. METHODS. A meta-analysis of case series of patients with Merkel cell carcinoma managed with sentinel lymph node biopsy was performed. RESULTS. Forty of 60 patients (67%) had a biopsy-negative sentinel lymph node; 97% of this group had no recurrence at 7.3 months median follow-up. Twenty patients (33%) had a biopsy-positive sentinel lymph node; 33% of this group experienced local, regional, or systemic recurrence at 12 months median follow-up. Risk of recurrence or metastasis was 19-fold greater in biopsy-positive patients (odds ratio, 18.9; p = 0.005). None of 15 biopsy-positive patients who underwent therapeutic lymph node dissection experienced a regional recurrence; 3 of 4 who did not receive therapeutic lymphadenectomy experienced regional recurrence. CONCLUSION. Sentinel lymph node positivity is strongly predictive of a high short-term risk of recurrence or metastasis in patients with Merkel cell carcinoma. Therapeutic lymph node dissection appears effective in preventing short-term regional nodal recurrence. Aggressive adjuvant treatment should be considered for patients with positive sentinel lymph nodes.

SOLUTION We describe novel uses of a single-prong skin hook that will provide surgical assistance without the clutter. Traction is necessary for accurate skin incisions. Commonly, an assistant’s hand retracts the skin from the wound edges. Although helpful, it can clutter the field. Similar traction may be provided with a skin hook that is controlled by the surgeon’s nondominant hand (Fig 1). This hook traction works best for facial skin, where dermal thickness is minimal and the hook’s weight is able to provide the necessary traction.

Background: Pediatric patients undergoing dermatologic surgical procedures often experience high levels of anxiety. Oral midazolam is a short-acting benzodiazepine that can ameliorate procedure-related anxiety. Objective: Our purpose was to determine the safety and efficacy of oral midazolam as an adjuvant anxiolytic agent for pediatric patients undergoing dermatologic surgical procedures. Methods: A prospective series of pediatric patients undergoing dermatologic surgical procedures who received oral midazolam were monitored, and efficacy and complications were recorded. Results: Oral midazolam provided good to excellent anxiolytic effects in most pediatric patients undergoing painful dermatologic surgical procedures. Because midazolam does not provide analgesic effects, local anesthesia is necessary. Complications were uncommon and minor. Conclusion: Oral midazolam is an effective anxiolytic agent in pediatric patients undergoing dermatologic surgical procedures. (J Am Acad Dermatol 2001;45:105-8.)

BACKGROUND The success of Mohs micrographic surgery (MMS) is contingent on high-quality frozen tissue sections for histologic interpretation. Laboratory assistive personnel (LAP) are central to this process, but their training and tissue processing techniques are neither standardized nor certified for competence. OBJECTIVE To evaluate processes used to train and laboratory techniques practiced by LAP. Letters were mailed to Mohs surgeons with a Web link to an online survey for LAP to complete. RESULTS Response rate was 24%. Responders primarily received training on the job, but not from the surgeon. On-the-job training from other LAP was perceived to be the most helpful, and textbook to be the least helpful. On average, survey responders felt it took several months to become proficient. Wide variations in laboratory practice were noted for histology laboratory and Mohs tissue processing techniques and for quality assurance. Differences in training and practices were noted between certified and noncertified LAP. CONCLUSION Patient care may be compromised because of variable practice of laboratory techniques, quality assurance, and quality control. Standardization of LAP training, along with demonstration and maintenance of competency, may be necessary to ensure the integrity of the MMS technique.