Scripps Memorial Hospital

Speckled lentiginous nevus (SLN), also referred to as nevus spilus, is a common benign melanocytic neoplasm typically occurring as a small, café-au-lait-colored “speckled” patch studded with numerous darkly pigmented macules or papules. Herein, we present a unique case of SLN arising on the sole of the right foot in a young woman, which was reported to be gradually enlarging since a pregnancy two years prior. The lesion was removed by shave biopsy, and histopathology confirmed the diagnosis and ruled out atypical features. While SLN is quite common, the occurrence on acral skin is extremely rare. SLN is considered a mosaic RASopathy due to its embryological development through a postzygotic activating HRAS genetic variant. Although small lesions usually remain isolated, underlying SLN syndrome should be considered in extensive cases with associated neurologic or musculoskeletal abnormalities. Secondary melanocytic neoplasms commonly arise within SLN, but overall, small lesions carry a low risk of malignant transformation, and prophylactic surgical treatment is not necessary. We briefly discuss SLN occurring in special sites and report this novel case with a review of the literature on SLN.

Introduction: Loop diuretics are a first-line treatment for patients hospitalized with congestive HF, yet diuretic resistance affects 25-30% of patients and is a predictor of death, readmission, or renal complications. The addition of metolazone can help overcome resistance, however there is a lack of large-scale trials to establish clinical efficacy and safety of dual diuretic therapy. Our study aims to determine the effects of metolazone in combination with a loop diuretic on net urine output, weight change, absolute change in BUN, length of stay, in-hospital death and hospital readmissions. Methods: In the Scripps Health system, 10,713 chronic HF patients experienced a HF admission from June 2019 through June 2021. Of these, 9,755 patients received loop diuretics while hospitalized, and 958 received metolazone with loop diuretics. Patients were propensity-matched 1:1 based on age, sex, left ventricular ejection fraction, tricuspid valve regurgitation, glomerular filtration rate and blood urea nitrogen, leaving 309 matched patients in each group. The primary outcome was net urine output of the hospitalization. Secondary outcomes include net change in weight for the hospitalization, absolute change in BUN, 30-day readmissions, 90-day readmissions, length of stay and in-hospital deaths. Results: During HF admissions, adjunct metolazone with a loop diuretic was associated with a significantly larger net urine output (-5.6 L vs. -2.1 L, p < 0.0001), net weight change (-10.1 lbs vs. -3.9 lbs, p < 0.0001), and absolute change in BUN (38 mg/dL vs. 24.6 mg/dL, p < 0.0001) for the hospitalization compared to patients who adequately responded to loop diuretics in this patient population. Adjunct metolazone showed no difference in in-hospital deaths (8.7% vs. 8.7%, p > 0.9999) or 30-day readmissions (23.3% vs. 17.5%, p = 0.089), however, it was associated with a significantly higher 90-day readmission rate (33.98% vs. 26.21%, p = 0.044) and length of stay (IQR 5-16 days vs. 3-10 days, p < 0.0001). Conclusions: Adjunct metolazone use may be an effective strategy for this patient population with inadequate response to loop diuretics, keeping 30-day readmission rates and in-hospital mortality similar to patients who adequately respond to loop diuretics.

Following publication of the original article [1], the co-author “Nikolaos Pararas” has misspelled wrongly as “Nikolaos Parasas”. The original article has been corrected.

BackgroundInvestigating the context of trauma and acute care surgery, the article aims at understanding the factors that can enhance some ethical aspects, namely the importance of patient consent, the perceptiveness of the ethical role of the trauma leader, and the perceived importance of ethics as an educational subject.MethodsThe article employs an international questionnaire promoted by the World Society of Emergency Surgery.ResultsThrough the analysis of 402 fully filled questionnaires by surgeons from 72 different countries, the three main ethical topics are investigated through the lens of gender, membership of an academic or non-academic institution, an official trauma team, and a diverse group. In general terms, results highlight greater attention paid by surgeons belonging to academic institutions, official trauma teams, and diverse groups.ConclusionsOur results underline that some organizational factors (e.g., the fact that the team belongs to a university context or is more diverse) might lead to the development of a higher sensibility on ethical matters. Embracing cultural diversity forces trauma teams to deal with different mindsets. Organizations should, therefore, consider those elements in defining their organizational procedures.Level of evidenceTrauma and acute care teams work under tremendous pressure and complex circumstances, with their members needing to make ethical decisions quickly. The international survey allowed to shed light on how team assembly decisions might represent an opportunity to coordinate team member actions and increase performance.

The impact of injury mechanism on outcomes of pancreatic trauma has not been well studied, and current guidelines do not differentiate recommendations for blunt and penetrating injuries. The purpose of this study was to analyze interventions and outcomes as they relate to mechanism. We hypothesized that penetrating pancreatic trauma results in greater morbidity than blunt trauma because of more frequent operative exploration without imaging and thus more aggressive surgical management. Secondary analysis of a multicenter retrospective review of pancreatic injuries in patients 15 years and older from 2010 to 2018 was performed. Deaths within 24 hours of admission were excluded from analysis of the primary outcome, pancreas-related complications (PRCs). Data were analyzed by injury mechanism using various statistical tests where appropriate. Thirty-three centers reported on 1,240 patients (44% penetrating). Penetrating trauma patients were twice as likely to undergo resection (45% vs. 23%) and suffer PRCs (39% vs. 20%). However, differences varied widely based on injury grade and management. There were fewer resections and more nonoperative management in blunt grades I to III injury. Pancreas-related complications occurred in 40% of high-grade injuries with no difference between mechanisms and in 40% of patients after resection, regardless of mechanism or injury grade. High-grade pancreatic injury (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.55-3.67), penetrating injury (OR, 1.99; 95% CI, 1.31-3.05), and management in a low-volume center (i.e., five or fewer cases/year) (OR, 1.65; 95% CI, 1.16-2.35) were independent predictors of PRCs. Management of grades I to III, but not grades IV/V, pancreatic injuries varies based on mechanism. Penetrating injury is an independent risk factor for PRCs, but main pancreatic duct injury and resection are associated with high rates of PRCs regardless of the injury mechanism. Resection appears to offer better outcomes for grade IV/V injuries, and grade I and II injuries should be managed nonoperatively. Therapeutic/Care Management; Level III.

A urea paraformaldehyde polymer has been synthesized under optimum conditions, for use as a tanning agent. The characteristics and effects of this polymer as a tanning agent were investigated. The tensile strength, elongation at break, tear strength, scanning electron microscopy (SEM), shrinkage temperature, shrinkage area, putrefaction resistance and thermal gravimetric analysis (TGA) parameters were studied.