Behcet's Disease Presenting as Pancolonic Ulcerations in a Patient With Kikuchi-Fujimoto Disease: A Rare Gastrointestinal Manifestation.

Kikuchi-Fujimoto disease (KFD) is a rare and self-limiting disorder characterized by cervical lymphadenopathy and fever. In this report, we present a case of a 24-year-old man with known history of KFD who presented with lower gastrointestinal bleeding and acute blood loss anemia. Further evaluation with colonoscopy showed widespread ulcerations in the colon and terminal ileum with suspicion for Behcet's disease. Biopsy from the colonic mucosa and ileocecal valve demonstrated focal ulcer with cryptitis and lymphoid aggregates that can be seen in Behcet's syndrome; however, it lacks specificity and Behcet's disease is a clinical diagnosis. This case emphasizes the importance of including gastrointestinal bleeding as a potential manifestation due to Behcet's disease in patients diagnosed with KFD.

A Fork in the Road: An Unusual Case of Duodenal-Cecal Fistula Due to a Chronic Foreign Body.

A duodenal-cecal fistula is characterized as an unnatural connection between the duodenum and cecum. Here, we present the case of a 40-year-old male with unintentional weight loss and a history of foreign body ingestion a few years prior. Computerized tomography (CT) small bowel enterography showed a linear soft tissue tract extending from the inferior aspect of the distal duodenum to the cecum. Ultimately, a diagnosis of duodenal-cecal fistula was made following esophagogastroduodenoscopy (EGD) revealing a fistula in the third part of the duodenum. A duodenal-cecal fistula secondary to foreign body ingestion is rare, with surgical intervention or endoscopic fibrin glue closure being potential treatment modalities if the fistula fails to close spontaneously. Duodenal-cecal fistulas are generally seen secondary to malignancies of the duodenum or colon, peptic ulcers, or inflammatory bowel disease. However, a duodenal-cecal fistula due to a foreign body is rare, thus highlighting the importance of keeping a broad differential, as appropriate in the clinical context.

Exploring the Protective Role of Aspirin Use in Mitigating Colorectal Cancer (CRC) Metastasis: A Nationwide Analysis (2016 to 2020).

Despite advancements in treatment strategies, the mortality from colorectal cancer (CRC) remains high. Evidence suggests that aspirin (ASA) may have a protective effect on CRC incidence and metastasis through various mechanisms. The 2016 to 2020 National Inpatient Sample was used to identify adult patients (age above 18 y) with the principal diagnosis of CRC. Patients were stratified into 2 groups based on ASA use. The outcomes studied were in-hospital mortality and rates of total, gastrointestinal (GI), non-GI, and lymphoid metastasis. A multivariate logistic regression analysis was performed to evaluate the impact of ASA use on outcomes after adjusting for patient demographics, comorbidities, and the Elixhauser Comorbidity Index (ECI). Of the 814,270 patients, 88,620 (10.8%) used ASA, with the majority being aged above 65 years (78%), male (57%), white (77.6%), and had Medicare insurance (74.5%). There was a higher prevalence of Diabetes mellitus, Hypertension, Chronic pulmonary disease, Coronary artery disease, Chronic kidney disease, Chronic heart failure, Obesity, and Smoking among aspirin users than among non-ASA users. Patients who used ASA had a lower prevalence of total (47.3% vs. 32.5%, P<0.001), GI (22.2% vs. 32.4%, P<0.001), non-GI (9.9% vs. 15.3%, P<0.001), and lymphoid (9.3% vs. 10.9%, P<0.001) metastasis compared with those who did not use ASA. After adjusting for confounding factors, patients with ASA use had lower odds of total (aOR: 0.75, 95% CI: 0.72-0.78, P<0.001), GI (aOR: 0.74, 95% CI: 0.71-0.77, P<0.001), non-GI (aOR: 0.72, 95% CI: 0.68-0.77, P<0.1), and statistically insignificant odds of lymphoid (aOR: 0.95, 95% CI: 0.90-1.00, P=0.098) metastasis. The use of ASA is associated with a decrease in the prevalence of metastasis among individuals diagnosed with CRC, but additional studies are required to elucidate the mechanism and duration of therapy needed to be effective.

A Rare Case of Delayed Presentation of Acute Midgut Volvulus in an Adolescent.

Intestinal malrotation is primarily diagnosed in the neonatal period, when symptoms typically first appear. In contrast, occurrences in adults are quite uncommon. Adult cases are less frequently reported, often because the condition remains asymptomatic or presents with nonspecific symptoms that can delay diagnosis. Intestinal malrotation in adults can show a range of symptoms, from acute bowel obstruction to vague and chronic symptoms, often leading to a delay in the diagnosis compared to children. Patients with this condition present a distinctive challenge for surgeons regarding diagnosis and treatment, especially in acute situations. This study presents a rare case of a 16-year-old boy who came with chief complaints of acute abdominal pain and multiple episodes of bilious vomiting. The patient underwent an emergency laparoscopy converted to an open Ladd's procedure. During surgery, the duodenum, small intestine, cecum, and appendix were discovered to be abnormally positioned, and the transverse colon and mesentery were twisted along with the superior mesenteric artery and superior mesenteric vein, with the presence of classical Ladd's bands confirming preoperative CT findings of midgut volvulus. The patient tolerated the procedure well, with no intraoperative complications. Acute midgut volvulus is rare in adults and older children. Still, the differential diagnosis should be kept in mind in patients with pain in the abdomen and multiple episodes of bilious vomiting in cases with an uncertain diagnosis to plan proper management and avoid intraoperative surprises. Early detection, accurate imaging methods, and prompt intervention can mitigate complications that could increase morbidity and mortality.

Outcomes of emergency surgical intervention for complications in the cardiac catheterization laboratory.

Background: In today's era, cardiac catheterization procedures are becoming increasingly safe, but they are still fraught with complications. We aimed to study the outcomes of patients who underwent emergency surgical intervention for complications in the cardiac catheterization laboratory. Methods: A retrospective analysis of patients who required emergency surgical management following a complication in the cardiac catheterization laboratory in our institute from July 2017 to July 2022 was done. Result: A total of 57 patients out of a total of 52,326 patients (0.1%) were included. The average age of presentation was 10.4 years. Congenital heart disease (CHD) constituted the majority of the cases (28/57-49.1%), coronary artery disease (CAD) constituted 19.3% (11/57), and rheumatic heart disease (RHD) constituted 8.8% (5/57) of the cases. Apart from this, 22.80% patients (13/57) were grouped together in the miscellaneous group. In total, 76.9% (10/13) of these patients had pericardial effusion and they developed a right ventricular (RV) rent following an attempted pigtail drainage. Also, one patient each had a RV rent following an attempted permanent pacemaker implantation for heart block and an endocardial biopsy respectively. One patient had a left bronchial rupture following thoracic endovascular aortic repair (TEVAR) for descending thoracic aorta (DTA) aneurysm. Thirty-day mortality was 7% (4/57), and the mean time of shifting the patients from the catheterization laboratory to the operating room was 8.3 h. Conclusion: Cardiac catheterization procedures have become increasingly safe, but complications can still occur, for which the cardiac surgeon should be briefed in a Heart Team meeting before taking up such cases. Even though these complications form a small percentage, the cardiologist should exercise some caution in attempting cases which could have a relatively easier surgical correction.

Hidden Dangers of Frailty: Higher Mortality, Complications and Costs in Acute Pancreatitis.

BACKGROUND: Frailty is a clinically recognizable state of increased vulnerability due to age-related decline in reserve and function across multiple physiologic systems that compromises the ability to cope with acute stress. As frailty is being identified as an important risk factor in outcomes of gastrointestinal pathologies, we aimed to assess outcomes in patients with acute pancreatitis within this cohort. METHOD: We conducted a retrospective study using the Nationwide Inpatient Sample (NIS) database. ICD-10 codes were used to inquire for patients admitted with acute pancreatitis between September 2015 through 2017. ICD-10 codes corresponding to the Hospital Frailty Risk Score (HFRS) were used to divide the study sample into 2 cohorts: low risk (< 5 points) and intermediate or high risk (> 5 points). To calculate the points, we fitted a logistic regression model that included membership of the frail group as the binary dependent variable (frail vs. non-frail) and the set of ICD-10 codes as binary predictor variables (1 = present, 0 = absent for each code). To simplify the calculation and interpretation, we multiplied regression coefficients by five to create a points system, so that a certain number of points are awarded for each ICD-10 code and added together to create the final frailty risk score. Multivariate regression analysis was performed to find adjusted mortality. RESULTS: Out of a total of 1,267,744 patients admitted with acute pancreatitis, 728,953 (57.5%) were identified as intermediate and high risk (> 5 points) (study cohort) and 538,781 (42.5%) as low risk (< 5 points). The mean age in the study cohort was 64.8 ± 12.6 and that in the low-risk group was 58.6 ± 9.5. Most of the patients in both groups were males and Caucasians; Medicare was the predominant insurance provider. A majority of the admissions in both groups were in an urban teaching hospital and were emergency. (Table 1). The primary outcome was in-hospital mortality which was significantly higher in the study cohort as compared to the low-risk group (4.3% vs. 2.5%, p < 0.0001). The age-adjusted Odds ratio of mortality was 1.72(95% CI (Confidence Interval) 1.65-1.80, p < 0.05). When compared between the two groups; median length of stay (6 vs. 4); hospitalization cost ($14,412 vs. $10,193), disposition to a skilled nursing facility (SNF) (17.1% vs. 8.6%) and need for home health care (HHC) was significantly higher in the study cohort. Complications like septicemia, septic shock, and acute kidney injury were also higher in the study group (Table 2). Table 1 Baseline demographics of the cohort Characteristics Acute pancreatitis with High HES Frailty score (> 5, intermediate + high) Acute pancreatitis with low HES Frailty score (< 5) P-value N = 1,267,744 N = 728,953 (57.5%) N = 538,781 (42.5%) Age  Mean years (Mean ± SD) 64.8 ± 12.6 58.6 ± 9.5 < 0.001 Gender < 0.001  Male 59.1% 52.3%  Female 40.9% 47.7% *Missing-475 Age groups < 0.001  18-44 3.7% 14.3%  45-64 48% 52.9%  65-84 32.2% 28.7%  ≥ 85 16.1% 4.1% Race < 0.001  Caucasians 67.4% 61.9%  African Americans 9.6% 16.8%  Others 23% 21.3% *Missing-10 Insurance type < 0.001  Medicare 40.9% 36.3%  Medicaid 17.2% 24.3%  Private 31.8% 27.9%  Other 9.9% 11.4% *Missing-75 Active smoking 32.7% 37.9% 0.005 Biliary Stone 36.2% 16.7% < 0.001 Admission Type < 0.001  Emergent 93.7% 94.3%  Elective 6.3% 5.7% *Missing-2880 Hospital ownership/control < 0.001  Rural 7.8% 10%  Urban nonteaching 26.3% 26.6%  Urban teaching 65.9% 63.4% Table 2 Outcomes Outcomes Acute pancreatitis with High HES Frailty score (> 5, intermediate + high) Acute pancreatitis with low HES Frailty score (< 5) P-value In-hospital mortality *Missing-920 4.3% 2.5% < .0001 1.72(1.65-1.80) < .0001 Length of stay, days (Median,IQR) 6(3-8) 4(2-6) < .0001 Total hospitalization cost, $ (Median,IQR) 14,412(8843-20,216) 10,193(6840-13,842) < .0001 In-Hospital Complications  ARDS 0.4% 0.3% 0.08  Ventilator dependence respiratory failure 0.23% 0.29% 0.25  Septicemia 15.2% 9.6% < .0001  Septic Shock 6.1% 2.9% < .0001  AKI 24.8% 14.9% < .0001 Disposition < .0001  Discharge to home 58.9% 74.9%  Transfer other: includes  Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), and another type of facility 17.1% 8.6%  Home health care 11.5% 8.1%  Against medical advice (AMA) 1.6% 3.4% *Missing-920 CONCLUSION: Using frailty as a construct to identify those who are at greater risk for adverse outcomes, can help formulate interventions to target individualized reversible factors to improve outcomes in patients with acute pancreatitis. Future large-scale prospective studies are warranted to understand the dynamic and longitudinal relationship between pancreatitis and frailty.

Association of Metabolic Syndrome Components and Colonic Diverticulosis in the Very Elderly: A Tertiary Health Network Study.

Introduction There is scarce data about the association of metabolic syndrome (MetS) or its components with the development of colonic diverticulosis (CD) in the elderly. We aim to determine the association of MetS and its components with CD in the elderly aged ≥75 years. Methods We conducted a retrospective chart review at St. Luke's University Health Network to identify patients who underwent a colonoscopy between 2011 and 2020. We collected data on patient demographics, comorbidities, and colonoscopy findings. Statistical analyses were conducted to compute means and frequencies of patient characteristics and rates of CD, as well as to test for associations between potential risk factors and the presence of CD.  Results A total of 1239 patients were included with a median age of 80 years, 57.6% females, 89.5% Caucasians, 72.9% with CD, and 66.7% having a left-sided disease. On bivariate analysis, the older age group (p=0.02), Caucasian ethnicity (p=0.01), and hypertension (p=0.04) were found to be significant risk factors for developing CD. Multivariate regression analysis showed older age group and hypertension (OR=1.47, 95% CI: 1.66-2.02, p=0.02) were major risk factors. A significant proportion of patients with left-sided disease had Caucasian ethnicity (p<0.001), while female gender, obesity, and iron deficiency anemia were also seen more frequently, although without statistical significance.  Conclusion In the elderly (>75 years old), our study found hypertension to be associated with an increased risk of CD, while impaired fasting glucose (IFG) was protective. Most patients exhibited isolated left-sided diverticulosis, with pan-diverticulosis associated with higher proportions of adverse health indicators, including American Society of Anesthesiologists (ASA) score ≥3, IFG, hypertriglyceridemia, hypertension, and hypothyroidism. Further research with larger sample sizes in similar age groups is needed to expand upon these findings.

The Practice of Obtaining a Chest Radiograph in Pediatric Patients Presenting With Their First Episode of Wheezing: A Survey of Resident Physicians.

A chest radiograph (CXR) is not routinely indicated in children presenting with their first episode of wheezing; however, it continues to be overused. A survey was distributed electronically to determine what trainees are taught and their current practice of obtaining a CXR in children presenting with their first episode of wheezing and the factors that influence this practice. Of the 1513 trainees who completed surveys, 35.3% (535/1513) reported that they were taught that pediatric patients presenting with their first episode of wheezing should be evaluated with a CXR. In all, 22.01% (333/1513) indicated that they would always obtain a CXR in these patients, and 13.75% (208/1513) would always obtain a CXR under a certain age (4 weeks to 12 years, median of 2 years). Our study identifies a target audience that would benefit from education to decrease the overuse of CXRs in children.

Foreign body reaction toward hydrophilic polymer at the site of endovascular procedure: A report of two cases.

Hydrophilic polymer-coated devices have been increasingly utilized for various endovascular procedures, however not been without adverse effects. We report two cases of subacute cutaneous lesions on the neck encountered in our dermatology clinic. Histopathologic findings were significant for a nodular aggregate of epithelioid histiocytes and lymphocytes with numerous foreign body giant cells in the dermis. The granulomatous infiltrate was associated with an amorphous basophilic non-polarizable material. Further chart review reveals both patients receiving a central venous procedure in the past, thus attributing the hydrophilic polymers as the likely source of the foreign material found at the insertion site. Our cases contrast to the more commonly reported distal embolization by these hydrophilic polymer layers. We suspect the incidence of retained hydrophilic polymer at the site of prior endovascular procedures may be underreported in the literature with the more inconspicuous presentations. Therefore, retained foreign material should be considered by both treating physicians and dermatopathologists in presenting cases of lesions that occur at common sites of endovascular procedures.

Noninvasive Assessment of Epidermal Genomic Markers of UV Exposure in Skin.

The measurement of UV-induced DNA damage as a dosimeter of exposure and predictor of skin cancer risk has been proposed by multiple groups. Although UV-induced mutations and adducts are present in normal-appearing UV-exposed epidermis, sampling normal nonlesional skin requires noninvasive methods to extract epidermal DNA for analysis. Here, we demonstrate the feasibility of such an approach, termed surfactant-based tissue acquisition for molecular profiling. Sampling in patients was performed using a felt-tip pen soaked in a mixture of surfactants (Brij-30/N-decyl-N,N-dimethyl-3-ammonio-1-propanesulfonate). In mice, we show that the epidermis can be selectively removed without scarring, with complete healing within 2 weeks. We exposed hairless mice to low-dose UV radiation over a period of 3 months and serially sampled them through up to 2 months following the cessation of UV exposure, observing a progressive increase in a UV signature mutational burden. To test whether surfactant-based tissue acquisition for molecular profiling could be applied to human patients, samples were collected from sun-exposed and sun-protected areas, which were then subjected to high-depth targeted exome sequencing. Extensive UV-driven mosaicism and substantially increased mutational loads in sun-exposed versus sun-protected areas were observed, suggesting that genomic measures, as an integrated readout of DNA damage, repair, and clonal expansion, may be informative markers of UV exposure.

Effect of in-office samples on dermatologists' prescribing habits: a retrospective review.

The relationship between physicians and pharmaceutical companies has caused the medical community to question the degree to which pharmaceutical interactions and incentives can influence physicians' prescribing habits. Our study aimed to analyze whether a change in institutional policy that restricted the availability of in-office samples for patients resulted in any measurable change in the prescribing habits of faculty physicians in the Department of Dermatology and Cutaneous Surgery at the University of South Florida (USF)(Tampa, Florida). Medical records were retrospectively reviewed for common dermatology diagnoses-acne vulgaris, atopic dermatitis, onychomycosis, psoriasis, and rosacea-before and after the pharmaceutical policy changes, and the prescribed medications were recorded. These medications were then categorized as brand name, generic, and over-the-counter (OTC). Statistical analysis using a mixed effects ordinal logistic regression model accounting for baseline patient characteristics was conducted to determine if a difference in prescribing habits occurred.

The Practice of Obtaining a Chest X-Ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department: A Survey of Attending Physicians.

BACKGROUND: Routine use of chest X-ray (CXR) in pediatric patients presenting with their first episode of wheezing was recommended by many authors. Although recent studies conclude that a CXR is not routinely indicated in these children, there continues to be reports of overuse. OBJECTIVE: To examine the attitudes of practicing physicians in ordering CXRs in pediatric patients presenting with their first episode of wheezing to an emergency department (ED) and the factors that influence this practice by surveying ED physicians. METHODS: A survey targeting pediatric emergency medicine (PEM) and general emergency medicine attending physicians was distributed electronically to the nearly 3000 members of the PEM Brown listserve and the Pediatric Section of American College of Emergency Physicians listserve. The 14-item survey included closed ended and free text questions to assess the respondent's demographic characteristics, their belief and current practice of obtaining a CXR in pediatric patients presenting with their first episode of wheezing. Data were analyzed using descriptive statistics and χ test. RESULTS: Of the 537 attending physicians who participated, their primary residency training was: 42% pediatrics, 54% emergency medicine, and 4% other. Seventy-two percent of participating physicians supervise residents, 54% were board-eligible or -certified in PEM. Thirty percent (95% confidence interval [CI], 26-34) of participants indicated that they would always obtain a CXR in pediatric patients presenting with their first episode of wheezing. Eighty-one percent (95% CI, 75-87) of those who always obtain a CXR believe that it is the standard of care. Of the 376 physicians who do not always obtain a CXR, 18% (95% CI, 15-23) always obtain a CXR under certain age (2 weeks to 12 years, median of 1 year). Physicians who report a primary residency in pediatrics, who supervise residents, who were board-eligible or -certified in PEM, and who were practicing for greater than 5 years were less likely to obtain a CXR (P < 0.001, P < 0.001, P < 0.001, P = 0.001). CONCLUSIONS: In our study, a significant number of practicing ED physicians routinely obtain a CXR in children with their first episode of wheezing presenting to the ED. The factors influencing this practice are primary residency training, fellowship training, resident supervision, and years of independent practice. This identifies a target audience that would benefit from education to decrease the overuse of CXRs in children with wheezing.

Assessment of impact of a skin cancer education session on cosmetology students' knowledge and preparedness to assess future clients for skin lesions.

BACKGROUND: Approximately 50% of cutaneous melanomas go undetected by patient self-inspection, and lesions that go unnoticed are usually located on the scalp, head, and neck. Cosmetologists are able to examine areas difficult to see on self-inspection. OBJECTIVES: The purpose of this study was to design and conduct an educational skin cancer screening presentation for cosmetology students and assess preparedness to discuss skin cancer with future clients. METHODS: This cross-sectional study conducted and analyzed in 2017 assessed the efficacy of a skin cancer education presentation among cosmetology students. Students completed a pre-/poststyle quiz aimed at assessing skin cancer knowledge. The difference in pre- and postknowledge quiz was analyzed using paired samples t test. RESULTS: A total of 194 students from seven cosmetology schools participated. Before the presentation, 43.4% felt underprepared to check for unusual lesions on future clients while 17.7% felt some level of preparedness. After, 3% felt underprepared while 51% felt prepared. There was a statistically significant difference in the skin cancer knowledge quiz total score before (M = 7.87, SD = 1.493) and after (M = 9.23, SD = 1.037) the educational presentation (P < 0.0001). CONCLUSIONS: This study shows most cosmetology students in the Tampa Bay area appear to be interested in learning more about skin cancer and agree that curricula should include skin cancer topics. Results of this study were limited to the Tampa Bay area and may not represent national trends. However, skin cancer presentation and screening-related content could be included in cosmetology curricula to help better prepare cosmetologists to screen for suspicious skin lesions.

Rosacea Triggers: Alcohol and Smoking.

A variety of triggers are thought to exacerbate rosacea. A validated self-assessment tool and survey was used to study the relationship between rosacea severity and triggers. Subjects were adult patients with a clinical diagnosis of rosacea. Increased severity of disease was significantly associated with consumption of many alcoholic beverages in 1 day and employment at a job requiring extensive sun exposure. The authors' findings may inform physician counseling practices; patients may be provided with practical measures for managing their rosacea, such as limiting alcohol consumption over short periods of time and increasing sun protection, especially in the summer.

Prevalence of cutaneous viral infections in incident cutaneous squamous cell carcinoma detected among chronic lymphocytic leukemia and hematopoietic stem cell transplant patients.

The role of cutaneous viral infections in the development of non-melanoma skin cancer (NMSC), including cutaneous squamous cell carcinoma (SCC), among chronic lymphocytic leukemia (CLL) and blood and marrow transplant (BMT) patients is not established. CLL (n = 977) and BMT (n = 3587) patients treated at the Moffitt Cancer Center were included in a retrospective cohort study. Human papillomavirus (HPV) and human polyomavirus (HPyV) DNA were examined in a subset of incident SCC tumors. Five-year cumulative incidence of NMSC was 1.42% in both BMT (n = 31 NMSCs) and CLL (n = 18 NMSCs) cohorts. Of the nine SCC tumors examined from each cohort, 22.2% and 33.3% were positive for viral DNA in the transplant (HPV 65, MCV) and CLL (HPV 38, HPV 15, HPyV6) cohort, respectively. Enhanced skin cancer screening of BMT/CLL patients should be conducted to better capture incident NMSCs and examine the role of viral infections in these tumors.

Advanced Management of Severe Keloids.

Keloids negatively impact the health and quality of life of many affected dermatologic patients. Treating keloids is often difficult, and suboptimal responses are frequent. Fortunately, there are many treatment options available to the clinician that may lead to improved clinical outcomes. We present a review of currently available therapeutic options. Intralesional steroid injection remains the first-line treatment for keloids. Imiquimod, direct interferon therapy, or intralesional 5-flurouracil may alleviate the need for excessive corticosteroid therapy. Radiation and laser therapy are emerging therapeutic options that have demonstrated efficacy in reviewed studies. Given the unsatisfactory outcomes associated with pressure dressings, vitamin E, ablative laser, and surgical excision, these options should be avoided in keloid management. Further research is needed to evaluate the efficacy and recurrence associated with the reviewed therapeutics.

Use of the QIAGEN GeneReader NGS system for detection of KRAS mutations, validated by the QIAGEN Therascreen PCR kit and alternative NGS platform.

BACKGROUND: The detection of somatic mutations in primary tumors is critical for the understanding of cancer evolution and targeting therapy. Multiple technologies have been developed to enable the detection of such mutations. Next generation sequencing (NGS) is a new platform that is gradually becoming the technology of choice for genotyping cancer samples, owing to its ability to simultaneously interrogate many genomic loci at massively high efficiency and increasingly lower cost. However, multiple barriers still exist for its broader adoption in clinical research practice, such as fragmented workflow and complex bioinformatics analysis and interpretation. METHODS: We performed validation of the QIAGEN GeneReader NGS System using the QIAact Actionable Insights Tumor Panel, focusing on clinically meaningful mutations by using DNA extracted from formalin-fixed paraffin-embedded (FFPE) colorectal tissue with known KRAS mutations. The performance of the GeneReader was evaluated and compared to data generated from alternative technologies (PCR and pyrosequencing) as well as an alternative NGS platform. The results were further confirmed with Sanger sequencing. RESULTS: The data generated from the GeneReader achieved 100% concordance with reference technologies. Furthermore, the GeneReader workflow provides a truly integrated workflow, eliminating artifacts resulting from routine sample preparation; and providing up-to-date interpretation of test results. CONCLUSION: The GeneReader NGS system offers an effective and efficient method to identify somatic (KRAS) cancer mutations.

Chronic Tender Ulcers on the Calf and Both Forearms.

An elderly woman presented with a 3-month history of nonhealing, tender ulcers involving the right calf and both forearms. She denied any history of similar lesions or trauma. Two trials of oral antibiotics had led to no improvement. Her medical history was significant for rheumatoid arthritis treated with methotrexate, hydroxychloroquine, and prednisone. A review of clinical manifestations was otherwise negative for disease. Physical examination of the patient's right calf revealed two punched-out ulcers with central necrotic black eschars, underlying retiform purpuric pattern, and mild fibrinopurulent drainage (Figure 1). Similar lesions were present on her forearms (Figures 2 and 3). No other remarkable skin changes were noted. The differential diagnosis included polyarteritis nodosa, cutaneous necrosis secondary to antiphospholipid syndrome, cryoglobulinemic vasculitis, and an atypical presentation of pyoderma gangernosum.

Epidermal programmed cell death-ligand 1 expression in TEN associated with nivolumab therapy.

Nivolumab is a programmed cell death receptor-1 (PD-1) antibody used in the treatment of metastatic or unresectable melanoma. Cutaneous reactions are the most common adverse events reported with these agents and are rarely severe or life-threatening. Here we present a case report describing the clinicopathological findings of a patient with a fatal toxic epidermal necrolysis (TEN) eruption associated with use of nivolumab for treatment of metastatic melanoma. The patient developed a pruritic, morbiliform eruption, which slowly progressed over 3 months to a tender, exfoliative dermatosis. Histology initially showed interface dermatitis and subsequently revealed full thickness epidermal necrosis. The diagnosis of TEN was made. From initial biopsy to TEN presentation, there was an increase in the number of CD8+ lymphocytes within the dermal-epidermal junction and an increase of programmed death ligand 1 (PD-L1) expression in both lymphocytes and keratinocytes. Despite treatment with infliximab, high-dose steroids and intravenous immunoglobulin, the patient expired. Herein we describe what we believe is the second case of TEN associated with anti-PD1 therapy reported in the literature. Increased expression of PD-L1 by immunohistochemistry was observed as the eruption progressed to TEN. Early diagnosis and treatment is necessary in these fatal TEN reactions secondary to the anti-PD-1 antibody therapies.