BCC by a board-certified dermatologist can be an efficient approach, with a high success rate and a low risk of negative outcomes. Invited Commentary | PRACTICE GAPS Immediate Curettage and Electrodessication Following Biopsy of Suspected Basal Cell Carcinoma at Initial VisitThis retrospective medical chart review attempts to establish the clinical value of performing a biopsy and treating a lesion suspected to be a basal cell carcinoma (BCC) with curettage and electrodessication (C & D) at first visit. The positive predictive value was 84% for lesions confirmed to be BCC on histologic confirmation. The success rate, defined as the proportion of lesions that were treated appropriately, was 95.8%.This study suggests that dermatologists are extremely accurate about clinically diagnosing lesions that are appropriately treated by same-day electrodessication and curettage. Diagnosis and treatment of BCC at the same office visit would improve clinical efficiency and practice outcomes. This would also allow for improved patient access to dermatological care, as appointment times would be more available for patients with suspicious lesions. The practice gap identified herein may be the predilection for practicing dermatologists to suspect skin cancer, biopsy it only, and then perform C & D at a later date. Many patients may not necessarily require surgical excision or Mohs micrographic surgery for treatment of all BCC lesions. This practice gap may exist because of current reimbursement strategies (ie, fee for service model; eg, the health care provider performs a skin biopsy at initial office visit to be followed by a procedure only at a subsequent office visit).Possible solutions to narrowing this gap may be an outcomes measure to confirm increased patient satisfaction and improved practice efficiency. Costs to the patient with the previous model include more than 1 office visit, with time away from work and travel to and from the physician's office. Considering our current environment of rising health care costs, an additional outcomes measure could be instituted to confirm the reduced cost incurred by academic and private practices of managing appropriate BCC lesions by C & D.Potential barriers to such a practice may be the perception that extending care into 2 office visits translates into more revenue for the health care provider. However, on deeper analysis, it may be financially more beneficial to include treatment in the initial office visit, thus providing more appointment slots for patients requiring skin cancer screening. Furthermore, histologic confirmation of all lesions treated by C & D and strict adherence to established guidelines of care may help alleviate any concerns on the part of the dermatologist. The caveat, however, is that established clinical guidelines for appropriate management of nonmelanoma skin cancer should be adhered to (eg, recurrent or morpheaform BCC should be treated with surgical excision or Mohs micrographic surgery, but patientcentered care should be included in this decision).T...

Pain control after total hip arthroplasty in sickle cell patients is challenging yet essential to prevent sickle cell crises or protracted hospital stays. We present a case of effective analgesia that lasted for weeks in a young opioid-tolerant female. This was achieved by the administration of glucocorticoids with different durations of action, dexamethasone sodium phosphate/methylprednisolone acetate, via a femoral/lateral femoral cutaneous nerve block placed preoperatively. Postoperatively, the patient's opioid demand was unchanged from her preoperative baseline. She met all the discharge requirements, including physical therapy targets, on postoperative day 2 and did not have any complications during the hospitalization.

BackgroundsThe aim of this study was to evaluate the utility of unilateral single injection thoracic paravertebral block (TPVB) with and without the addition of betamethasone for the acute pain management of patient’s undergoing laparoscopic cholecystectomy (LC).MethodsEligible patients were allocated randomly to three groups: (A) general anesthesia followed by surgeon infiltration at port sites with ropivacaine (n = 48), (B) general anesthesia after single injection TPVB at right T7-8 level with ropivacaine only, Ropi_TPVB (n = 43), and (C) general anesthesia after single injection TPVB with ropivacaine plus betamethasone, Ropi_Betamet_TPVB (n = 45). Primary outcome was TPVB duration assessed by the number of dermatomes at regular intervals up to 72 hours (h). Secondary outcomes included pain scores, analgesics consumption, and perioperative functional outcomes.ResultsThe addition of betamethasone to ropivacaine in TPVB resulted in similar onset but significantly slower block regression between 4 h and 72 h as compared to ropivacaine alone (P < 0.001). When compared to the surgeon infiltration group, Ropi_TPVB and Ropi_Betamet_TPVB group had significantly lower pain scores for 24 h and 48 h, respectively, P ≤ 0.001. Both TPVB groups had less frequency of analgesics administration for 72 h, P < 0.001, and earlier mobilization, P < 0.001.ConclusionsThe addition of betamethasone to TPVB significantly prolonged block duration as compared to local anesthetic alone. TPVB both with and without the addition of betamethasone resulted in better perioperative analgesia and improved functional status when compared to surgical site local anesthetic infiltration.