A Rare Case of Extensive Basal Cell Carcinoma With Invasion of the Humerus: Excision and Immediate Reconstruction With Fibula Allograft, Plating, and Latissimus Dorsi Flap.

Basal cell carcinoma (BCC) is the most common skin cancer, and most of the reports have involved the head and neck, but it is rare for it to be highly invasive, with an invasion of long bone being extremely rare. A 73 year old woman presented with a giant BCC on her right arm. Magnetic resonance imaging suggested the involvement of the right humerus. Biopsy confirmed the nodular type of BCC. The patient underwent BCC excision including hemicortical humerus excision with fibula allograft and latissimus dorsi flap with a split-thickness skin graft. Excluding a transient radial nerve palsy, the patient's postoperative course was otherwise uncomplicated. Although BCC invasion into the long bone is extremely rare, the gold standard treatment is, as a rule, en bloc surgical resection with a wide variety of reconstructive techniques. This treatment is only possible through the collaboration of general surgery, orthopedics, and plastic surgery.

Operative Rib Fixation at a Rural Trauma Center.

INTRODUCTION: Operative rib fixation is becoming more common in the management of rib fractures, with studies showing benefits of surgery in decreasing time on mechanical ventilation, ICU and total hospital length of stay, and mortality. This paper will review the data from our institution to determine if these benefits were seen in our trauma population. METHODS: A retrospective review of the institution's trauma database was conducted, including operative patients (n = 36), control patients (nonoperative patients from October 2018 to October 2019, n = 207), and selected control patients based on similar injury severity score range as operative patients (n = 181). Data reviewed included time on mechanical ventilation, ICU and total hospital length of stay, and disposition at discharge, including mortalities. Operative complications were also reviewed. RESULTS: The operative group had a higher ISS compared to both controls, longer average time on mechanical ventilation, longer average ICU and total hospital length of stay, and a higher percentage of patients discharged to inpatient facilities. However, the operative group had lower mortality compared to the control groups. The operative group had 3 surgical site infections requiring readmission and hardware removal. DISCUSSION: Unlike other studies, our operative patients did not see improvements in time on mechanical ventilation, ICU and total hospital length of stay, or disposition at discharge, but did see a mortality benefit. Confounding factors include higher average ISS in the operative group, and over-sedation in the ICU. Data collection is ongoing, and refinements are being made to perioperative and ICU management to minimize these confounding variables.

Role of Serum Biomarkers in Early Detection of Non-Alcoholic Steatohepatitis and Fibrosis in West Virginian Children.

BACKGROUND: Obesity, an epidemic among West Virginia children, as well as insulin resistance (IR), is well-established contributors to nonalcoholic steatohepatitis (NASH). Progression of NASH can lead to hepatic fibrosis and cirrhosis, making early detection imperative. The standard for diagnosing NASH is histologically via liver biopsy, which is highly invasive and generally contraindicated in children. By studying serum biomarkers associated with NASH, we aim to identify high risk children who can benefit from a less invasive, alternative approach to the early detection of NASH. METHODS: Seventy one children were prospectively recruited and divided into 3 groups: normal weight without IR (control), obese without IR, and obese with IR. Serum samples were drawn for each patient and biomarker levels were assessed via ELISA kits. RESULTS: Obese without IR and obese with IR patients had significantly elevated levels of lipid metabolism and accumulation markers (FGF-21, NEFA, FATP5, ApoB), oxidative stress markers (dysfunctional HDL, 8-Isoprostane), inflammatory markers(dysfunctional HDL, CK-18) and apoptosis markers (CK-18) compared to control patients (p<0.02). Bilirubin (an antioxidant) was significantly decreased in the obese without IR and obese with IR patients compared to control (p<0.02). CONCLUSION: This study showed a correlation between obesity, IR, and biomarkers associated with NASH in pediatrics patients from West Virginia, with obese with IR patients showing the strongest correlation. These findings support the clinical application of these serum biomarkers as a less invasive method for early detection of NASH and hepatic fibrosis.

Systematic Review of Metabolic Syndrome Biomarkers: A Panel for Early Detection, Management, and Risk Stratification in the West Virginian Population.

INTRODUCTION: Metabolic syndrome represents a cluster of related metabolic abnormalities, including central obesity, hypertension, dyslipidemia, hyperglycemia, and insulin resistance, with central obesity and insulin resistance in particular recognized as causative factors. These metabolic derangements present significant risk factors for cardiovascular disease, which is commonly recognized as the primary clinical outcome, although other outcomes are possible. Metabolic syndrome is a progressive condition that encompasses a wide array of disorders with specific metabolic abnormalities presenting at different times. These abnormalities can be detected and monitored via serum biomarkers. This review will compile a list of promising biomarkers that are associated with metabolic syndrome and this panel can aid in early detection and management of metabolic syndrome in high risk populations, such as in West Virginia. METHODS: A literature review was conducted using PubMed, Science Direct, and Google Scholar to search for markers related to metabolic syndrome. Biomarkers searched included adipokines (leptin, adiponectin), neuropeptides (ghrelin), pro-inflammatory cytokines (IL-6, TNF-α), anti-inflammatory cytokines (IL-10), markers of antioxidant status (OxLDL, PON-1, uric acid), and prothrombic factors (PAI-1). RESULTS: According to the literature, the concentrations of pro-inflammatory cytokines (IL-6, TNF-α), markers of pro-oxidant status (OxLDL, uric acid), and prothrombic factors (PAI-1) were elevated in metabolic syndrome. Additionally, leptin concentrations were found to be elevated in metabolic syndrome as well, likely due to leptin resistance. In contrast, concentrations of anti-inflammatory cytokines (IL-10), ghrelin, adiponectin, and antioxidant factors (PON-1) were decreased in metabolic syndrome, and these decreases also correlated with specific disorders within the cluster. CONCLUSION: Based on the evidence presented within the literature, the aforementioned biomarkers correlate significantly with metabolic syndrome and could provide a minimally-invasive means for early detection and specific treatment of these disorders. Further research is encouraged to determine the efficacy of applying these biomarkers to diagnosis and treatment in a clinical setting.