The effect of mailed outreach on FIT completion among patients aged 45-50 in a safety net healthcare system.

PURPOSE: Colorectal cancer screening is recommended starting at age 45, but there has been little research on strategies to promote screening in patients younger than 50. METHODS: An outreach program quasi-randomly assigned patients aged 45-50 without recent fecal immunochemical test (FIT), colonoscopy or contraindications to screening to two intervention arms: electronic outreach with email and text (electronic outreach only) versus electronic outreach plus mailed outreach with FIT, an instructional letter and a prepaid return envelope (mailed + electronic outreach). In response to known disparities in screening uptake, all Black patients were assigned to receive mailed + electronic outreach. RESULTS: Among patients quasi-randomly assigned to an intervention (non-Black patients), the 180-day FIT completion rate was 18.8% in the electronic outreach only group (n = 1,318) and 25.0% in the mailed + electronic outreach group (n = 1,364) (difference 6.2% [95% CI 3.0, 9.4]). FIT completion was 16.6% among Black patients (n = 469), 8.4% (95% CI 4.1, 12.6) lower than among non-Black patients also assigned to mailed + electronic outreach. CONCLUSION: Among patients aged 45-50, mailed + electronic outreach had a greater effect on FIT completion than electronic outreach alone. Crossover between intervention groups likely lead to an underestimation of the effect of mailed outreach.

Electronic Coding for Abnormal Fecal Immunochemical Test Is Associated With Increased Colonoscopy Completion.

INTRODUCTION: We examined the utility of the International Classification of Disease, Tenth Revision (ICD-10) code, R19.5, for a positive or abnormal fecal immunochemical test (FIT) and its association with colonoscopy completion. METHODS: We identified all patients in a safety-net health system who underwent FITs from January 1, 2020, to August 31, 2021, and extracted the FIT date, FIT result, and ICD-10 code (R19.5) and colonoscopy procedures for each patient. RESULTS: FIT-positive patients who had an R19.5 designation within 90 days (n = 383) were significantly more likely than all other FIT-positive patients (n = 273) to complete a colonoscopy within 6 months (40.9% vs 16.8%, P <0.001). DISCUSSION: We found that less than two-thirds of patients had an ICD-10 code designated in their chart within 30 days of an abnormal FIT. When coding occurred in a timely manner, patients were more likely to complete their colonoscopy within 6 months.

Associations between actigraphy-measured sleep duration, continuity, and timing with mortality in the UK Biobank.

STUDY OBJECTIVES: To examine the associations between sleep duration, continuity, timing, and mortality using actigraphy among adults. METHODS: Data were from a cohort of 88 282 adults (40-69 years) in UK Biobank that wore a wrist-worn triaxial accelerometer for 7 days. Actigraphy data were processed to generate estimates of sleep duration and other sleep characteristics including wake after sleep onset (WASO), number of 5-minute awakenings, and midpoint for sleep onset/wake-up and the least active 5 hours (L5). Data were linked to mortality outcomes with follow-up to October 31, 2021. We implemented Cox models (hazard ratio, confidence intervals [HR, 95% CI]) to quantify sleep associations with mortality. Models were adjusted for demographics, lifestyle factors, and medical conditions. RESULTS: Over an average of 6.8 years 2973 deaths occurred (1700 cancer, 586 CVD deaths). Overall sleep duration was significantly associated with risk for all-cause (p < 0.01), cancer (p < 0.01), and CVD (p = 0.03) mortality. For example, when compared to sleep durations of 7.0 hrs/d, durations of 5 hrs/d were associated with a 29% higher risk for all-cause mortality (HR: 1.29 [1.09, 1.52]). WASO and number of awakenings were not associated with mortality. Individuals with L5 early or late midpoints (<2:30 or ≥ 3:30) had a ~20% higher risk for all-cause mortality, compared to those with intermediate L5 midpoints (3:00-3:29; p ≤ 0.01; e.g. HR ≥ 3:30: 1.19 [1.07, 1.32]). CONCLUSIONS: Shorter sleep duration and both early and late sleep timing were associated with a higher mortality risk. These findings reinforce the importance of public health efforts to promote healthy sleep patterns in adults.

Phytonanofabrication of iron oxide particles from the Acacia jacquemontii plant and their potential application for the removal of brilliant green and Congo red dye from wastewater.

Phytonanofabrication is one of the most promising areas that has drawn the attention of scientists worldwide due to its eco-friendly nature and biocompatibility. In the current investigation, we reported the phyto-assisted formation of iron oxide nanoparticles (IONPs) from a rare species of Acacia (Acacia jacquemontii). First, ethanolic extracts of the stem powder were analyzed by high-performance thin-layer chromatography (HPTLC) for the identification of phytochemicals in the stem sections of Acacia. Furthermore, IONPs were synthesized by a chemical co-precipitation method by using the stem extract. The phytonanofabricated iron oxide particles were investigated by UV-Vis spectroscopy, Fourier transform infrared (FTIR) spectroscopy, X-ray diffraction (XRD), field emission scanning electron microscopy (FESEM), and Energy-dispersive X-ray spectroscopy (EDS) for elemental analysis. HPTLC confirmed the presence of several phenols and terpenoids in the ethanolic extracts of the stem. UV-Vis spectroscopy exhibited an absorbance peak at 380 nm, indicating the formation of IONPs, while FTIR spectroscopy showed the typical bands for Fe-O in the range of 599-1,000 cm-1 in addition to several functional groups of organic molecules at 1,596 cm-1, 2,313 cm-1, and 3,573 cm-1. XRD exhibits the amorphous nature of IONPs with peaks at 30.7, 35.5, and 62.7 nm. The IONPs were spherical-shaped, whose size varies from 10 to 70 nm, as confirmed by FESEM. EDS exhibited the presence of Fe, O, C, and NaCl. Finally, the phytonanofabricated iron oxide particles were utilized for the removal of brilliant green (BG) and Congo red (CR) dye from the aqueous solution. The removal efficiency of BG dye was up to 54.28%, while that of Congo red dye was up to 36.72% in 120 min and 60 min, respectively. Furthermore, the effect of pH and contact time was also assessed on both the dyes, where CR exhibited maximum removal at acidic pH, i.e., 47.5%, while BG showed maximum removal at pH 10, i.e., 76.59%.

Life's Essential 8: Optimizing Health in Older Adults.

The population worldwide is getting older as a result of advances in public health, medicine, and technology. Older individuals are living longer with a higher prevalence of subclinical and clinical cardiovascular disease (CVD). In 2010, the American Heart Association introduced a list of key prevention targets, known as "Life's Simple 7" to increase CVD-free survival, longevity, and quality of life. In 2022, sleep health was added to expand the recommendations to "Life's Essential 8" (eat better, be more active, stop smoking, get adequate sleep, manage weight, manage cholesterol, manage blood pressure, and manage diabetes). These prevention targets are intended to apply regardless of chronologic age. During this same time, the understanding of aging biology and goals of care for older adults further enhanced the relevance of prevention across the range of functions. From a biological perspective, aging is a complex cellular process characterized by genomic instability, telomere attrition, loss of proteostasis, inflammation, deregulated nutrient-sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion, and altered intercellular communication. These aging hallmarks are triggered by and enhanced by traditional CVD risk factors leading to geriatric syndromes (eg, frailty, sarcopenia, functional limitation, and cognitive impairment) which complicate efforts toward prevention. Therefore, we review Life's Essential 8 through the lens of aging biology, geroscience, and geriatric precepts to guide clinicians taking care of older adults.

Future treatment of Diabetes - Tyrosine Kinase inhibitors.

Background: Diabetes mellitus (DM) is a group of metabolic disorders that have an increased risk of macro and micro-vascular complications due to lipid dysfunction. The present drug treatments for the management of DM either have numerous side effects or do not have long-lasting therapeutic effects. So it is essential to find a newer class of drug for DM treatment. Method: Broad information has been researched regarding Tyrosine kinase Inhibitors (TKIs) and their mechanism of action. They are proven for the management of various kinds of cancers. TKIs produce anti-hyperglycemic effects by acting on multiple targets such as c-Abl, Platelet-Derived Growth Factor Receptor (PDGFR), Vascular Endothelial Growth Factor Receptor (VEGFR), Epidermal Growth Factor Receptor (EGFR), and c-Kit. Result: This family of drugs blocks numerous tyrosine kinases by acting as a partial agonist of PPAR-γ receptors and results in an anti-diabetic effect by improving insulin sensitivity and glucose disposal rate. Conclusion: Therefore, it is said that TKI drugs will be great potential for the treatment of Diabetes. This review summarizes the possible targets of TKIs and TKIs being a potential drug class in the management of Diabetes mellitus.

Diagnostic Dilemma in a Case of Necrotizing Pneumonia With Negative Transbronchial Biopsy.

A 33-year-old male with a past medical history of asthma presented to the Emergency room with a three-day history of right-sided chest pain, productive cough with dark brown sputum, and shortness of breath. He was found to have right lower lobe consolidation consistent with acute pneumonia, and areas of non-homogenous density within the consolidation, suspicious of necrotizing pneumonia. Computed tomography (CT) of the chest with IV contrast revealed a large, irregular thick-walled cavitary mass involving the right middle lobe with surrounding ground glass cavitation. An extensive workup was negative, including a transbronchial biopsy. The case explains how a causative organism was detected.

Sclerostin antibody improves alveolar bone quality in the Hyp mouse model of X-Linked Hypophosphatemia (XLH).

X-linked hypophosphatemia (XLH) is a rare disease of elevated fibroblast growth factor 23 (FGF23) production that leads to hypophosphatemia and poor mineralization of bone and teeth. The clinical manifestations of XLH include a high prevalence of dental abscesses, likely driven by poorly formed structures of the dentoalveolar complex, including the alveolar bone, cementum, dentin, and periodontal ligament. Our previous studies have demonstrated that sclerostin antibody (Scl-Ab) treatment improves phosphate homeostasis, and increases bone mass, strength and mineralization in the Hyp mouse model of XLH. In the current study, we investigated whether Scl-Ab impacts the dentoalveolar structures of Hyp mice. Male and female wild-type and Hyp littermates were injected with 25 mg/kg of vehicle or Scl-Ab twice weekly beginning at 12 weeks of age and euthanized at 20 weeks of age. Scl-Ab increased alveolar bone mass in both male and female mice and alveolar tissue mineral density in the male mice. The positive effects of Scl-Ab were consistent with an increase in the fraction of active (non-phosphorylated) ß-catenin stained alveolar osteocytes. Scl-Ab had no effect on mineralized tissues of the tooth - dentin, enamel, acellular and cellular cementum. There was a non-significant trend toward increased periodontal ligament (PDL) attachment fraction within the Hyp mice. Additional PDL fibral structural parameters were not affected by Scl-Ab. The current study demonstrates that Scl-Ab can improve alveolar bone in the Hyp mouse model of XLH.

Recurrent Hydropneumothorax After COVID-19.

A 60-year-old male with a past medical history of heart failure with reduced ejection fraction, obstructive sleep apnea, atrial flutter, and hypertension initially presented to the emergency department with a chief complaint of shortness of breath. He was diagnosed with COVID-19-induced acute hypoxic respiratory failure. Before his presentation to the emergency department, he was treated with a brief course of hydroxychloroquine, azithromycin, and prednisone. His initial hospitalization was relatively uncomplicated. He then presented back to the emergency department approximately five months later with chief complaints of continued dyspnea and increased work of breathing. On this presentation, he was noted to have a right-sided pneumothorax with a moderate right-sided pleural effusion. The effusion was drained through CT (computed tomography)-guided catheter insertion. Pleural fluid culture and sensitivity were negative, and a cartridge-based nucleic acid amplification test (CBNAAT) was not performed. He was discharged a few days later to home. Over the next several weeks, the patient had recurrent admissions and chest tube placements for unresolving hydropneumothorax. He eventually had a right-sided posterolateral thoracotomy performed. The tissue sample from the thoracotomy was noted to have positive gram staining for fungal hyphae consistent with aspergillosis. This was initially considered a contaminant and not treated with antifungal medication. Unfortunately, after the thoracotomy, the patient continued to have complications including subcutaneous emphysema and recurring hydropneumothoraces. He was taken for another procedure after a repeat CT showed intercostal herniation of the pleura between the fifth and sixth ribs. The herniation was excised, and the pleura was repaired. This pleural tissue was then sent to pathology and noted to have non-caseating granulomas consistent with aspergillosis. At this time, the patient was started on voriconazole. After initiating this medication, the patient's last chest x-ray showed stable findings of his chronic disease process with no new or worsening hydropneumothorax.

Association of Accelerometer-Measured Physical Activity Level With Risks of Hospitalization for 25 Common Health Conditions in UK Adults.

Importance: Higher physical activity levels are associated with lower risks of cancer, cardiovascular disease, and diabetes, but associations with many common and less severe health conditions are not known. These conditions impose large health care burdens and reduce quality of life. Objectives: To investigate the association between accelerometer-measured physical activity and the subsequent risk of hospitalization for 25 common reasons for hospitalization and to estimate the proportion of these hospitalizations that might have been prevented if participants had higher levels of physical activity. Design, Setting, and Participants: This prospective cohort study used data from a subset of 81 717 UK Biobank participants aged 42 to 78 years. Participants wore an accelerometer for 1 week (between June 1, 2013, and December 23, 2015) and were followed up over a median (IQR) of 6.8 (6.2-7.3) years; follow-up for the current study ended in 2021 (exact date varied by location). Exposures: Mean total and intensity-specific accelerometer-measured physical activity. Main Outcomes and Measures: Hospitalization for the most common health conditions. Cox proportional hazards regression analysis was used to estimate hazard ratios (HRs) and 95% CIs for mean accelerometer-measured physical activity (per 1-SD increment) and risks of hospitalization for 25 conditions. Population-attributable risks were used to estimate the proportion of hospitalizations for each condition that might be prevented if participants increased their moderate to vigorous physical activity (MVPA) by 20 minutes per day. Results: Among 81 717 participants, the mean (SD) age at accelerometer assessment was 61.5 (7.9) years; 56.4% were female, and 97.0% self-identified as White. Higher levels of accelerometer-measured physical activity were associated with lower risks of hospitalization for 9 conditions: gallbladder disease (HR per 1 SD, 0.74; 95% CI, 0.69-0.79), urinary tract infections (HR per 1 SD, 0.76; 95% CI, 0.69-0.84), diabetes (HR per 1 SD, 0.79; 95% CI, 0.74-0.84), venous thromboembolism (HR per 1 SD, 0.82; 95% CI, 0.75-0.90), pneumonia (HR per 1 SD, 0.83; 95% CI, 0.77-0.89), ischemic stroke (HR per 1 SD, 0.85; 95% CI, 0.76-0.95), iron deficiency anemia (HR per 1 SD, 0.91; 95% CI, 0.84-0.98), diverticular disease (HR per 1 SD, 0.94; 95% CI, 0.90-0.99), and colon polyps (HR per 1 SD, 0.96; 95% CI, 0.94-0.99). Positive associations were observed between overall physical activity and carpal tunnel syndrome (HR per 1 SD, 1.28; 95% CI, 1.18-1.40), osteoarthritis (HR per 1 SD, 1.15; 95% CI, 1.10-1.19), and inguinal hernia (HR per 1 SD, 1.13; 95% CI, 1.07-1.19), which were primarily induced by light physical activity. Increasing MVPA by 20 minutes per day was associated with reductions in hospitalization ranging from 3.8% (95% CI, 1.8%-5.7%) for colon polyps to 23.0% (95% CI, 17.1%-28.9%) for diabetes. Conclusions and Relevance: In this cohort study of UK Biobank participants, those with higher physical activity levels had lower risks of hospitalization across a broad range of health conditions. These findings suggest that aiming to increase MVPA by 20 minutes per day may be a useful nonpharmaceutical intervention to reduce health care burdens and improve quality of life.

Bemoan My Collarbone: A Case of Costocondral Junction Syndrome Complicated by Methicillin Sensitive Staphylococcus aureus Sternoclavicular Osteomyelitis and Septic Arthritis.

A 35-year-old female with a past medical history of untreated Hepatitis-C, and a history of intravenous (IV) drug use initially presented to the emergency department with chief complaints of gradual worsening sharp, constant left-sided chest pain with no radiation starting three weeks before presentation. In the emergency department (ED), she was afebrile, normotensive, and tachycardia with 99% oxygen saturation on room air. A physical exam revealed a well-developed Caucasian female, alert and oriented with moderate distress. Respiratory exam with symmetrical bilateral excursions without wheezes, crackles, or rhonchi. On cardiovascular exam, she was tachycardic with a regular rhythm without murmurs, rubs, or gallops. There was a 2 x 2 cm tender erythematous swelling on the left sternal border inferior to the clavicle. The neck was supple and negative for Jugular Venous Distension (JVD). Neurologically grossly intact. Abnormal laboratory findings included leukocytosis with neutrophilic predominance. The patient received intravenous (IV) antibiotics with broad-spectrum vancomycin, cefepime, and azithromycin and underwent computed tomography angiography (CTA) chest, revealing a 26.8 mm x 26.5 mm left anterior subapical pleural-based pulmonary mass-like lesion with central hypoattenuation in surrounding ground-glass changes. Biopsy of the left subapical pulmonary lesion results showed chronic inflammatory infiltrate. Unfortunately, the patient left the hospital against medical advice after supportive care and pain control. Our patient's history of intravenous drug use and active Hepatitis-C infection were typical risk factors associated with invasive infections. In the clinical context, leukocytosis with hypo-attenuated pulmonary lesion should raise suspicion for septic emboli, localized abscess pocket, infection by atypical organisms, infective endocarditis, and malignancy which was considered upon initial assessment.

Surgical Treatment for Intrahepatic, Peri-Hilar, and Distal Cholangiocarcinoma: 20-Single Institutional Year Experience.

BACKGROUND: Surgical resection is the curative treatment for all subtypes of cholangiocarcinoma (CCA), including intrahepatic, hilar/peri-hilar, and distal. This study evaluates patients with CCA who underwent surgery and determines factors that impact their survival. METHODS: A retrospective cohort study was performed for patients who underwent surgical resection for CCA at our institution from 1995 to 2016. Demographics, operative variables between CCA tumors, and postoperative complications were analyzed. Predictors of overall and recurrence-free survival were determined via statistical analysis. RESULTS: A total of 170 patients with a mean age of 61 years old underwent surgical resection of intrahepatic (n = 64, 37.6%), hilar/peri-hilar (n = 75, 44.1%), and distal (n = 31, 18.2%) CCA. Operations performed included liver resections (n = 83, 48.8%), liver transplants (n = 56, 32.9%), and pancreaticoduodenectomies (n = 31, 18.2%). The overall survival rate at 1, 5, and 10 years was 81.1%, 32.4%, and 17.2%, respectively. Low pathological stage and negative resection margins were associated with lower recurrence and higher survival rates. Tumor location and the type of operation performed were not predictive of recurrence or OS in this cohort. DISCUSSION: This study shows that definitive surgical resection with negative margins can result in long-term survival even at 10 years. Small tumor size and low pathological stage are predictive of higher survival rates post-surgery, emphasizing the importance of early diagnosis and appropriate surgical treatment in achieving positive outcomes.

Role of MRCP to determine the etiological spectrum, level and degree of biliary obstruction in obstructive jaundice.

Context: Obstructive jaundice as a result of hepatocellular disease many a times is indistinguishable from jaundice due to extrahepatic biliary obstruction based on just clinical and biochemical examinations. It is one of the most frequent and grave form of hepatobiliary disease which may lead to complications like ascending cholangitis, malabsorption and hepatorenal syndrome, thus demanding urgent surgical intervention. Thus not only early diagnosis but also accurate identification of level and cause of obstruction is crucial in managing these patients. Aims: The aim of this study is to evaluate the role of MRCP in the determination of the etiological spectrum, to evaluate level and degree of biliary obstruction in cases of obstructive jaundice, and to correlate MRCP findings with surgical/histopathology/ERCP findings where possible. Methods and Material: It is an observational study done after the Institutional Ethics Committee (I.E.C.)- 2 approval. (IEC no: IEC/HMPCMCE/122/Faculty/8/186/20) Outdoor and indoor patients referred to radiodiagnosis department of Shree Krishna Hospital, Karamsad, for MRCP with clinical and laboratory parameters suggesting obstructive jaundice were included in the study. Patients less than 10 years of age, those with contraindications to MRI and patients with clinico-laboratory evidence of perihepatic/hepatic jaundice were excluded. Methodology: A total of 50 patients were included after taking an informed consent from each patient. Demographic data, clinical details were recorded and collated along with MRI findings. Descriptive statistics was used to explore MRI findings and findings were correlated with surgical/histopathology/ERCP findings whichever applicable. The MRI scan was performed with 5 mm thick axial T1W, T2W and STIR, 5 mm thick coronal T1W, T2W and STIR TRUFIS, Thin coronal T2 FS, Thick coronal T2 FS, T2W coronal respiratory trigger sequences, 3-5 mm thick T2 weighted Haste and 3D sequence. Statistical Analysis Used: Analysis was performed using STATA (14.2). Descriptive statistics was used of study population. Sensitivity and specificity value was used to compare the modality and individually calculated for various causative factors of jaundice. Results: Of the 50 patients, 9 had CBD stones, it is observed that MRCP has sensitivity and specificity of 100% and 100%, respectively, in detecting Bile duct stones, whereas sensitivity and specificity of ERCP was 87.5% each. About 11 patients had CBD strictures, which were seen as narrowing of CBD with upstream dilatation. It was observed in our study that the sensitivity of MRCP was 93% and specificity was 95% in detecting CBD strictures while ERCP had 100% sensitivity and specificity. About 12 patients had CBD tumor for sensitivity and specificity of MRCP and ERCP was 100%. Out of 50 patients, 36% had gall bladder stones in whom MRCP sensitivity and specificity was 88.89% and 100% and was found to comparable with ERCP. Only three patients in our study had ampullary carcinoma out of which the sensitivity and specificity came 100% for MRCP. One patient, in whom MRCP and HPE detected ampullary carcinoma, ERCP detected no ampullary carcinoma thus favoring MRCP. However, owing to inadequate study population results are inconclusive. There is significant difference between MRCP and ERCP accuracy rate in detection of ampullary carcinoma. Therefore, our study which is more in favor of MRCP. There were 78% patients who were detected with biliary duct dilatation in ERCP, which was equally detected in MRCP. Thus MRCP had 100% sensitivity and specificity in detecting biliary duct dilatation compared to ERCP. Pancreatic dilatation was detected in four patients and there were two patients who were detected with ampullary stones and its sensitivity, specificity came up to 100% compared to ERCP. Conclusion: Thus to conclude, MRCP has high sensitivity for CBD such as stones, strictures and malignancies therefore to avoid unnecessary diagnostic ERCP; in cases with suspicion (clinical/CBD-IHBR dilatation on USG) of choledocholithiasis/ampullary stone, MRCP is recommended.

Discrepancies in Work Relative Value Unit Assignment Based on Operative Time in Hand Surgery.

BACKGROUND: Work relative value units (wRVUs) are an intricate component of physician reimbursement determination in the United States. This paper assesses whether wRVUs appropriately consider operative time in hand surgery. METHODS: The 50 most common single Current Procedural Terminology code hand surgery cases were queried from the 2013 to 2018 National Surgical Quality Improvement Program database. The average assigned wRVUs and median operative times were calculated for each CPT. Linear regressions were calculated between operative time, wRVUs, and wRVUs per hour. Cases deviating the most from the expected wRVUs based on operative time were identified. RESULTS: In all, 46 800 cases comprising the top 50 most common hand surgery procedures were identified. Among these cases, the median (range) assigned operative time was 62 minutes (18-110), wRVUs were 7.5 (3.5-18.0), and wRVUs per hour was 8.3 (4.9-14.2). There was a positive linear correlation between operative time and wRVUs (R2 = 0.60). Each additional operative hour was associated with an additional 6.3 wRVUs (P < .001). Based on this relationship, the assigned wRVUs for included cases ranged from 59.7% to 172.6% of expected. There was a weak negative relationship between wRVUs per hour and operative time (R2 = 0.25). Cases shorter than 1 hour had more wRVUs per hour than those longer than 1 hour (10.0 vs. 8.1, P = .003). However, this relationship disappeared when considering case turnover. CONCLUSION: This study suggests a moderately strong positive correlation between wRVUs and operative time in hand surgery. Yet, numerous outliers from this trend exist, suggesting some discrepancies in reimbursement.

Clear Cell Acanthoma with Malignant Cytologic Features: A Case Report and Review of the Literature.

Clear cell acanthoma (CCA) is classically considered a benign epidermal tumor, although rare case reports have described CCA with malignant features. Here, we present a case of a patient with a biopsy proven CCA that regrew post-biopsy and was subsequently completely excised. Histologic examination of the tumor in the excision specimen revealed malignant cytologic features that were not present in the initial biopsy. A review of the literature identified five additional cases of CCA with similar malignant cytologic features. On analysis, common histopathologic characteristics included cellular pleomorphism, increased nuclear-to-cytoplasmic ratio, prominent nucleoli, and atypical mitotic figures. We support the designation of atypical clear cell acanthoma for these entities with features of both CCA and significant cytologic atypia. As none of these cases exhibited clinically aggressive behavior, further study is warranted.

Orbital tuberculosis: a case report and update on the role of imaging in treatment.

Orbital tuberculosis is a manifestation of extra-pulmonary tuberculosis that is challenging to diagnose and treat. Here, we describe the pivotal role of serial imaging in the diagnosis and treatment of orbital tuberculosis. A 28-year-old male presented with recurrent right upper eyelid swelling and a supraduction deficit associated with a firm painless orbital mass, seen on initial computed tomography to be an extensive superomedial lesion producing mass effect. Biopsy revealed a tuberculosis-like granulomatous inflammation, which, coupled with a positive QuantiFERON gold test, led to empiric anti-tuberculin treatment. Serial radiologic imaging following initiation of treatment showed progressive reduction in mass size, supporting the diagnosis and determining the length of treatment. This rare case demonstrates the utility of serial radiologic exams in the diagnosis and treatment of orbital tuberculosis.

The Role of Runx2 in Microtubule Acetylation in Bone Metastatic Breast Cancer Cells.

Bone metastasis of breast cancer results in severe bone loss, fractures, and death. Crosstalk between breast cancer cells and bone resident cells promotes osteoclast activity and the release of growth factors from the bone matrix resulting in aggressive tumor growth and bone loss. We and others have shown that Runt-related transcription factor-2 (Runx2) promotes metastatic tumor growth-associated bone loss. Breast cancer cells also induce autophagy to survive metabolic stress at the metastatic site. Recently, we reported a Runx2-dependent increase in autophagy. In this study, to examine the underlying mechanisms of metastasis and tumor resistance to stress, we used a bone metastatic isogenic variant of breast cancer MDA-MB-231 cells isolated from a xenograft tumor mouse model of metastasis. Our results with immunofluorescence and biochemical approaches revealed that Runx2 promotes microtubule (MT) stability to facilitate autophagy. Stable MTs are critical for autophagosome trafficking and display increased acetylation at Lysine 40 of α-tubulin. Runx2 silencing decreases acetylated α-tubulin levels. The expression levels of HDAC6 and αTAT1, which serve to regulate the acetylation of α-tubulin, were not altered with Runx2 silencing. We found that HDAC6 interaction with α-tubulin is inhibited by Runt-related factor-2 (Runx2). We show that the expression of wild-type Runx2 can restore the acetylated polymer of MTs in Runx2 knockdown cells, while the C-terminal deletion mutant fails to rescue the polymer of MTs. Importantly, cellular stress, such as glucose starvation also increases the acetylation of α-tubulin. We found that the loss of Runx2 increases the sensitivity of breast cancer cells to MT-targeting agents. Overall, our results indicate a novel regulatory mechanism of microtubule acetylation and suggest that Runx2 and acetylated microtubules may serve as therapeutic targets for bone metastatic tumors.

Polypharmacy and Cardiovascular Diseases: Consideration for Older Adults and Women.

PURPOSE OF REVIEW: The intent of this review is to provide an update in polypharmacy in older adults and women with a focus on common determinants and strategies to mitigate polypharmacy. RECENT FINDINGS: Polypharmacy is becoming a critical focus in the management of cardiovascular diseases. It may emerge unintentionally while managing multimorbidity in older adults or in the vulnerable subgroup of patients, such as pregnant and lactating females. Clinicians should utilize several approaches such as deprescribing, sex-specific risk assessment, and encouraging healthy lifestyle to minimize inappropriate and unnecessary use of medications. A shared decision-making model along with coordination and collaboration among healthcare providers should be utilized in the selection and management of pharmacotherapies.

Relative Value Units and Operative Time in Plastic and Reconstructive Surgery.

BACKGROUND: Work relative value units (wRVUs) are linked to clinical reimbursements and physician compensation in the USA and thus should consider the time of the physician providing care. The primary goal of this study is to assess whether wRVUs appropriately consider operative time in plastic and reconstructive surgery. METHODS: The 2015-2018 National Surgical Quality Improvement Program was queried for the 50 most performed plastic surgery cases with assigned wRVUs and a recorded operative time. Linear regressions were used to assess the relationships between operative time, assigned wRVUs, and wRVUs per hour. The procedures with the highest and lowest assigned wRVUs relative to their operative time were identified. RESULTS: A total of 31,156 cases were included in this analysis. Among the 50 most performed procedures, the median (range) for assigned wRVUs was 10.0 (1.0-42.6), operative time was 61 min (21-441), and wRVUs per hour was 8.7 (2.2-16.2). There was a strong positive linear correlation between assigned wRVUs and median operative time (R2=0.78), with each additional operative hour being associated with an increase of 5.3 wRVUs (p<0.001). The procedures earning the most wRVUs relative to their operative times were breast reconstruction with other techniques and tissue expander placement in breast reconstruction. However, excisional debridements of the muscle/fascia and subcutaneous tissue had the lowest earned wRVUs relative to their operative times. CONCLUSION: Although wRVUs and operative time are correlated in plastic surgery, numerous outliers from this trend exist. This suggests that wRVUs may not be optimally assigned across the range of plastic surgery procedures.