Lymphovascular Invasion in Cutaneous Squamous Cell Carcinoma.

BACKGROUND: Although there is a large body of literature regarding risk stratification and outcomes for perineural invasion (PNI) in cutaneous squamous cell carcinoma (cSCC), there is a relative paucity of studies exploring the role of lymphovascular invasion (LVI) in cSCC and a lack of clear evidence-based guidelines for how to manage patients with these tumors. OBJECTIVE: This article is intended to review the available literature regarding LVI in cSCC and formulate evidence-based recommendations for clinical management. METHODS AND MATERIALS: A literature review was conducted using PubMed to find relevant articles relating to outcomes and management of primary cSCC with LVI. RESULTS: The available literature suggests that LVI is a major risk factor for poor outcomes and increased morbidity and mortality in cSCC. CONCLUSION: Lymphovascular invasion is a very high-risk feature that should place these tumors in the highest-risk category, and management of these tumors should be similar to that of squamous cell carcinoma with PNI.

Erythrasma.

This case report describes well-demarcated brown plaques with overlying fine scale in the bilateral axillae, inframammary folds, and inguinal folds and widespread coral-red fluorescence.

Integrative Conjugative Elements (ICEs) of the SXT/R391 family drive adaptation and evolution in γ-Proteobacteria.

Integrative Conjugative Elements (ICEs) are mosaics containing functional modules allowing maintenance by site-specific integration and excision into and from the host genome and conjugative transfer to a specific host range. Many ICEs encode a range of adaptive functions that aid bacterial survival and evolution in a range of niches. ICEs from the SXT/R391 family are found in γ-Proteobacteria. Over 100 members have undergone epidemiological and molecular characterization allowing insight into their diversity and function. Comparative analysis of SXT/R391 elements from a wide geographic distribution has revealed conservation of key functions, and the accumulation and evolution of adaptive genes. This evolution is associated with gene acquisition in conserved hotspots and variable regions within the SXT/R391 ICEs catalysed via element-encoded recombinases. The elements can carry IS elements and transposons, and a mutagenic DNA polymerase, PolV, which are associated with their evolution. SXT/R391 ICEs isolated from different niches appear to have retained adaptive functions related to that specific niche; phage resistance determinants in ICEs carried by wastewater bacteria, antibiotic resistance determinants in clinical isolates and metal resistance determinants in bacteria recovered from polluted environments/ocean sediments. Many genes found in the element hotspots are undetermined and have few homologs in the nucleotide databases.

Long-term risk of reintervention after transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has surpassed surgical aortic valve replacement (SAVR) as the predominant mode of valve replacement for the treatment of severe aortic stenosis (AS). However, the long-term need for valvular reintervention after TAVR remains unknown. METHODS: Using data from the Medicare Fee for Service 100% dataset, all patients receiving TAVR between July 2011 and December 2020 were identified. Patients were categorized as receiving a valve reintervention (either surgical or transcatheter) or not using the appropriate International Classification of Diseases 10th Revision Procedure Coding System (ICD-10-PCS). A competing risk regression model was used to estimate the cumulative probability of valve reintervention. RESULTS: Of 230,644 TAVR patients were identified, of whom 1,880 received a reintervention. Patients receiving a reintervention were younger and more likely to be male. At 10 years, the crude rate of reintervention was 0.59% within a surviving cohort of 341 patients. After adjusting for the competing risk of death and other covariates, the adjusted cumulative incidence of reintervention at 10 years after TAVR was 1.63%. When the rate of reinterventions was compared between early (2011-2016) and later (2017-2020) time periods, the risk-adjusted rate of reintervention at 4 years had decreased over time (0.85% vs 0.51%). CONCLUSION: The 10-year risk of valve reintervention after TAVR is low and appears to be decreasing over time. Further research is necessary to determine the driving factors contributing to valve reintervention in the current era.

The Emergence of the Genus Comamonas as Important Opportunistic Pathogens.

Comamonas spp. are non-fermenting Gram-negative bacilli. They were first discovered in 1894, and since then, twenty-four species have been characterized. The natural habitat of these bacteria is soil, wastewater/sludge, fresh water such as ponds and rivers, and the animal intestinal microbiome. They were also isolated from industrial settings, such as activated sludge and polluted soil, and from the hospital environment and clinical samples, such as urine, pus, blood, feces, and kidney. Comamonas spp. are associated with environmental bioremediation and are considered an important environmental bacterium rather than a human pathogen. However, in the 1980s, they became a concern when several human infections associated with these species were reported. Here, the Comamonas genus was examined in terms of its members, identification techniques, and pathogenicity. Seventy-seven infection cases associated with these microorganisms that have been discussed in the literature were identified and investigated in this project. All relevant information regarding year of infection, country of origin, patient information such as age, sex, underlying medical conditions if any, type of infection caused by the Comamonas species, antibiotic susceptibility testing, treatment, and outcomes for the patient were extracted from case reports. The findings suggest that even though Comamonas spp. are thought of as being of low virulence, they have caused harmful health conditions in many healthy individuals and even death in patients with underlying conditions. Antimicrobial treatment of infections associated with these species, in general, was not very difficult; however, it can become an issue in the future because some strains are already resistant to different classes of antibiotics. Therefore, these pathogens should be considered of such importance that they should be included in the hospital screening programs.

Longitudinal outcomes in cryptogenic stroke patients with and without long-term cardiac monitoring for atrial fibrillation.

Background: Guidelines recommend a confirmed diagnosis of atrial fibrillation (AF) to initiate oral anticoagulation in cryptogenic stroke (CS) patients. However, the intermittent nature of AF can make detection challenging with intermittent short-term cardiac monitoring. Objective: The purpose of this retrospective cohort study was to examine post-CS utilization of cardiac monitoring and associated clinical outcomes. Methods: Adults with incident hospitalization for CS were identified in the Optum® claims database and assessed for cardiac monitoring received poststroke. Patient were stratified into those with a long-term insertable cardiac monitor (ICM) vs external cardiac monitor (ECM) only. The timing of ICM placement poststroke was treated as a time-dependent covariate. The clinical outcomes of interest were time to AF diagnosis, oral anticoagulation usage, and all-cause mortality. Results: A total of 12,994 patients met selection criteria for the analysis, of whom 1949 (15%) received an ICM and 11,045 (85%) received ECM only. In those who had received an ECM as their first monitoring modality, only 4.4% moved on to receive an ICM for longer-term monitoring. Use of ECM before ICM was associated with a longer time to AF diagnosis (median 336 vs 194 days). Compared to those with ECM only, ICM patients had a significantly lower rate of death (hazard ratio [HR] 0.70; P = .004), and faster time to AF diagnosis (HR 1.50; P <.0001) and anticoagulation initiation (HR 1.57; P <.0001) during follow-up of up to 5 years after CS. Conclusion: In a real-world study of CS patients, prolonged cardiac monitoring was associated with higher rates of AF detection and treatment, and higher odds of survival.

Contemporary Costs Associated With Transcatheter Versus Surgical Aortic Valve Replacement in Medicare Beneficiaries.

BACKGROUND: In patients with severe aortic stenosis, treatment with transcatheter aortic valve replacement (TAVR) has been shown to be cost-effective in the high-risk surgical population and cost-saving in the intermediate-risk population when compared with surgical aortic valve replacement (SAVR) in early pivotal clinical trials. Whether TAVR is associated with comparable or lower costs when compared with SAVR in contemporary clinical practice is unknown. METHODS: Using data from the Medicare Dataset Standard Analytic Files 5% Fee for Service database, patients receiving either TAVR or SAVR between 2016 and 2018 were identified. Patients were categorized as low, intermediate, or high mortality risk based on 2 validated indices-the Hospital Frailty Risk Score and the logEuroScore. Health care costs out to 1 year were compared between TAVR and SAVR among the low, intermediate, and high-risk groups, after adjustment for patient demographics. RESULTS: Nine thousand seven hundred forty-six patients were identified (4834 TAVR; 3760 SAVR) and included in the analysis. Patients receiving TAVR were older and more likely to be female. Index hospitalization costs were significantly lower with TAVR compared with SAVR across all risk strata (logEuroScore: low: $61 845 versus $68 986; intermediate: $64 658 versus $76 965; high: $65 594 versus $91 005; P<0.001 for all). Follow-up costs through 1 year were generally lower with TAVR and this difference was more pronounced in the low risk groups (logEuroScore: $9763 versus $14 073; Hospital Frailty Risk Score: $10 116 versus $12 880). Accordingly, cumulative 1-year costs were substantially lower with TAVR compared with SAVR. CONCLUSIONS: At 1 year, TAVR is associated with lower health care costs across all risk strata when compared with SAVR in contemporary practice. If long-term data continue to demonstrate similar clinical outcomes and valve durability with TAVR and SAVR, these findings suggest that TAVR may be the preferred treatment strategy for patients with aortic stenosis from an economic standpoint.

Use of iso-osmolar contrast media during endovascular revascularization is associated with a lower incidence of major adverse renal, cardiac, or limb events.

OBJECTIVE: We examined the association of iso-osmolar contrast media (IOCM) versus low-osmolar contrast media (LOCM) with major adverse renal, cardiovascular, or limb events in patients at high-risk of acute kidney injury (AKI) undergoing peripheral endovascular procedures. BACKGROUND: Procedural characteristics including iodinated contrast type and volume have been associated with adverse renal and cardiovascular outcomes in patients undergoing angiographic interventions. METHODS: Patients at high-risk of AKI, undergoing peripheral endovascular procedures were identified using the Premier Healthcare Database and separated into claudication and critical limb ischemia (CLI) cohorts. For each cohort, we compared IOCM versus LOCM for the primary endpoint of MARCE (major adverse renal or cardiovascular events) and secondary endpoints of major adverse renal events (MARE) and major adverse renal and limb events (MARLE). These outcomes were captured within the indexed hospitalization via adjusted multivariable regression analyses. RESULTS: Two procedure-based cohorts of high-risk patients were formed: claudication (N = 11,976) and CLI (N = 8713). Use of IOCM was associated with a significant absolute risk reduction (ARR) of 2.2% (p < 0.0001) for MARCE overall and in each cohort (claudication, 1.8%, p = 0.0070; CLI, 2.7%, p = 0.0054). The incidence of MARE and MARLE in the overall cohort was also lower with the use of IOCM: MARE (ARR = 1.4%, p = 0.0072) and MARLE (ARR = 2.0%, p = 0.0043). CONCLUSIONS: Using IOCM versus LOCM in patients at high-risk of adverse renal events undergoing peripheral endovascular procedures was independently associated with lower risk of MARCE, MARE, and MARLE.

The need for future coronary access following surgical or transcatheter aortic valve replacement.

The aim of the study was to estimate the percentage of Medicare patients needing coronary access for percutaneous coronary intervention (PCI) or coronary angiography following aortic valve replacement (AVR). Indications for TAVR have expanded to include younger and low-risk patients, raising the question of coronary access for future procedures. Medicare patients <80 years old with an AVR between 2011 and 2018 were included. Time-to-event analyses were conducted using Cox hazard models to estimate risk of coronary access up to 7 years after AVR. Model adjustments included age, sex, race, region, comorbidity, concomitant CABG, and smoking. A total of 13,469 Medicare patients (mean age 70.6) met inclusion criteria. Models estimated that 2.5% of patients at 1-year post-index and 17% at over 7 years would need coronary access. For patients who had SAVR (with or without CABG), estimates for coronary access were similar and over 15% after 6.5 years. For TAVR patients, with a previous PCI, 28% at 4.5 years required coronary access, which was higher than TAVR patients without a previous PCI. SAVR patients with and without CAD at baseline were similar; however, TAVR patients with CAD had a 22% rate of coronary access versus 7% for those without at 3 years. Approximately half of patients who needed coronary access returned to the same hospital as their initial AVR. Coronary access is required in a substantial portion of AVR patients especially those with PCI or a history of CAD undergoing TAVR. The need for coronary access may increase as transcatheter AVR becomes accessible to younger patients with a longer life expectancy.

Association of Iso-Osmolar vs Low-Osmolar Contrast Media With Major Adverse Renal or Cardiovascular Events in Patients at High Risk for Acute Kidney Injury Undergoing Endovascular Abdominal Aortic Aneurysm Repair.

OBJECTIVE: The purpose of this analysis was to examine the association of iso-osmolar contrast media (IOCM) vs low-osmolar contrast media (LOCM) with major adverse renal or cardiovascular events (MARCE) in patients at high risk of acute kidney injury (AKI), undergoing endovascular abdominal aortic aneurysm repair (EVAR). METHODS: Patients at high risk of AKI (defined as age ≥75 years, or one or more of the following comorbidities: diabetes, anemia, chronic kidney disease (CKD stages 1-4) or congestive heart failure), undergoing EVAR from September 2012 to June 2018 were identified using the Premier Hospital Database. We compared the primary endpoint of MARCE (composite of AKI, AKI requiring dialysis, acute myocardial infarction [AMI], stroke/transient ischemic attack [TIA], and death) with IOCM vs LOCM via adjusted multivariable regression analyses. RESULTS: Among 15,777 high-risk patients undergoing EVAR, the occurrence of in-hospital MARCE was 6.8%, including renal events (4.5%), AMI (0.8%), stroke/TIA (0.4%), and death (1.9%), IOCM was used in 7360 patients (47%). Multivariable modeling found IOCM was associated with 1.8% (95% confidence interval [CI], 0.4-3.3; P=.01) lower absolute risk for MARCE (23.9% relative risk reduction; 95% CI, 5.2%-44.2%). CONCLUSIONS: Use of IOCM vs LOCM in patients at high risk of AKI undergoing EVAR procedures was associated with a lower risk of MARCE. As prevention of AKI or cardiovascular events after EVAR procedures may lead to reduced morbidity and mortality, this finding may have important clinical implications and should be confirmed through randomized controlled clinical studies.

Psychodermatology fellowship: is it time?

The fields of dermatology and psychiatry have overlap in the patient populations and diseases they treat. However, there are not currently fellowship opportunities for dermatologists or psychiatrists specifically interested in gaining expertise in psychodermatology. We discuss the logistics of a one-year psychodermatology fellowship, open to residents after completing either dermatology or psychiatry residencies, and the potential benefits that it could bring to both dermatology and psychiatry training programs across the county.

On the bacteriostatic activity of hyaluronic acid composite films.

Biofilm-related infections and contamination of biomaterials are major problems in the clinic. These contaminations are frequently caused by Staphylococcus aureus and are a pressing issue for implantable devices, catheters, contact lenses, prostheses, and wound dressings. Strategies to decrease contamination and biofilm related infections are vital for the success of implantable biomaterials. In this context, hyaluronic acid (HA), a naturally derived carbohydrate polymer, known to be biocompatible, degradable, and immunomodulatory, has shown some antimicrobial activity effects. Due to its poor structural stability, crosslinking strategies, and the incorporation of reinforcing fibres in HA gels is required to produce tailored gels for varying applications. Whilst carbon-based reinforcing materials, such as carbon nanofibers (CNF), present some intrinsic antimicrobial activity related to their high surface area, herein, a crosslinking strategy to enhance the mechanical properties and regulate the rate of degradation of HA is presented. We utilise bis-(ß-isocyanatoethyl) disulphide (BIED) as the crosslinker with the gel reinforced using 0.25 wt% CNF. The effects of CNF and BIED on the structural, mechanical, thermal, and swelling behaviour are examined. These new HA derivatives exhibit excellent mechanical properties and are capable of withstanding physiological stresses in vivo. Antimicrobial activity of the HA derivatives were tested against Staphylococcus aureus and the results reveal antibacterial effect. These carbohydrate based materials have potential application on surfaces within clinical settings where staphylococcal contamination is currently an issue.

The Genus Ochrobactrum as Major Opportunistic Pathogens.

Ochrobactrum species are non-enteric, Gram-negative organisms that are closely related to the genus Brucella. Since the designation of the genus in 1988, several distinct species have now been characterised and implicated as opportunistic pathogens in multiple outbreaks. Here, we examine the genus, its members, diagnostic tools used for identification, data from recent Ochrobactrum whole genome sequencing and the pathogenicity associated with reported Ochrobactrum infections. This review identified 128 instances of Ochrobactrum spp. infections that have been discussed in the literature. These findings indicate that infection review programs should consider investigation of possible Ochrobactrum spp. outbreaks if these bacteria are clinically isolated in more than one patient and that Ochrobactrum spp. are more important pathogens than previously thought.

Antimicrobial enzymatic biofuel cells.

A compact antibiotic delivery system based on enzymatic biofuel cells was prepared, in which ampicillin was released when discharged in the presence of glucose and O2. The release of ampicillin was effective in inhibiting the growth of bacterium Escherichia coli as confirmed by ex situ and in situ release studies in culture media.