Characterizing the Microbiome of the Contracted Breast Capsule Using Next Generation Sequencing.

BACKGROUND: Recent work suggests that bacterial biofilms play a role in capsular contracture (CC). However, traditional culture techniques provide only a limited understanding of the bacterial communities present within the contracted breast. Next generation sequencing (NGS) represents an evolution of polymerase chain reaction technology that can sequence all DNA present in a given sample. OBJECTIVES: The aim of this study was to utilize NGS to characterize the bacterial microbiome of the capsule in patients with CC following cosmetic breast augmentation. METHODS: We evaluated 32 consecutive patients with Baker grade III or IV CC following augmentation mammoplasty. Specimens were obtained from all contracted breasts (n = 53) during capsulectomy. Tissue specimens from contracted capsules as well as intraoperative swabs of the breast capsule and implant surfaces were obtained. Samples were sent to MicroGenDX Laboratories (Lubbock, TX) for NGS. RESULTS: Specimens collected from 18 of 32 patients (56%) revealed the presence of microbial DNA. The total number of positive samples was 22 of 53 (42%). Sequencing identified a total of 120 unique bacterial species and 6 unique fungal species. Specimens with microbial DNA yielded a mean [standard deviation] of 8.27 [4.8] microbial species per patient. The most frequently isolated species were Escherichia coli (25% of all isolates), Diaphorobacter nitroreducens (12%), Cutibacterium acnes (12%), Staphylococcus epidermidis (11%), fungal species (7%), and Staphylococcus aureus (6%). CONCLUSIONS: NGS enables characterization of the bacterial ecosystem surrounding breast implants in unprecedented detail. This is a critical step towards understanding the role this microbiome plays in the development of CC.

NEDD9 stimulated MMP9 secretion is required for invadopodia formation in oral squamous cell carcinoma.

Neural precursor cell expressed developmentally downregulated 9 (NEDD9) is a component of the metastatic signatures of melanoma, breast cancer, glioblastoma, lung cancer and head and neck squamous cell carcinoma (HNSCC). Here we tested the efficacy of NEDD9's domains in stimulating matrix metalloproteinase (MMP) secretion and invadopodia formation in cells stably expressing various NEDD9 mutants. Replacement of the 13 YxxP motif substrate domain (SD) tyrosines and the C-terminal Y629 with phenylalanines (F14NEDD9) eliminated tyrosine phosphorylation, MMP9 secretion and loss of invadopodia formation. Mutation of the N-terminal SH3 domain Y12 to glutamic acid (Y12ENEDD9) or phenylalanine (Y12FNEDD9) reduced MMP9 secretion and inhibited invadopodia formation. SH3 domain deletion (∆SH3NEDD9) resulted in the loss of MMP9 secretion and a lack of invadopodia formation. The SH3-SD domain (SSNEDD9) construct exhibited tyrosine phosphorylation and stimulated MMP9 secretion, as did ∆CTNEDD9 which lacked the C-terminus (∆C-terminal; ∆CT). E13NEDD9 expression blocked MMP9 secretion and invadopodia formation. MICAL1 (molecule interacting with Cas-L1) silencing with a short hairpin RNA reduced MMP9 secretion, vimentin and E-cadherin levels while increasing N-cadherin and Rab6 levels, consistent with reduced invasive behavior. These findings indicate that NEDD9 SD phosphorylation and SH3 domain interactions are necessary for increasing MMP9 secretion and invadopodia formation.

Cutaneous Burn Injury Modulates Urinary Antimicrobial Peptide Responses and the Urinary Microbiome.

OBJECTIVES: Characterization of urinary bacterial microbiome and antimicrobial peptides after burn injury to identify potential mechanisms leading to urinary tract infections and associated morbidities in burn patients. DESIGN: Retrospective cohort study using human urine from control and burn subjects. SETTING: University research laboratory. PATIENTS: Burn patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Urine samples from catheterized burn patients were collected hourly for up to 40 hours. Control urine was collected from "healthy" volunteers. The urinary bacterial microbiome and antimicrobial peptide levels and activity were compared with patient outcomes. We observed a significant increase in urinary microbial diversity in burn patients versus controls, which positively correlated with a larger percent burn and with the development of urinary tract infection and sepsis postadmission, regardless of age or gender. Urinary psoriasin and ß-defensin antimicrobial peptide levels were significantly reduced in burn patients at 1 and 40 hours postadmission. We observed a shift in antimicrobial peptide hydrophobicity and activity between control and burn patients when urinary fractions were tested against Escherichia coli and Enterococcus faecalis urinary tract infection isolates. Furthermore, the antimicrobial peptide activity in burn patients was more effective against E. coli than E. faecalis. Urinary tract infection-positive burn patients with altered urinary antimicrobial peptide activity developed either an E. faecalis or Pseudomonas aeruginosa urinary tract infection, suggesting a role for urinary antimicrobial peptides in susceptibility to select uropathogens. CONCLUSIONS: Our data reveal potential links for urinary tract infection development and several morbidities in burn patients through alterations in the urinary microbiome and antimicrobial peptides. Overall, this study supports the concept that early assessment of urinary antimicrobial peptide responses and the bacterial microbiome may be used to predict susceptibility to urinary tract infections and sepsis in burn patients.

Burn Injury Alters Epidermal Cholinergic Mediators and Increases HMGB1 and Caspase 3 in Autologous Donor Skin and Burn Margin.

Burn wound healing complications, such as graft failure or infection, are a major source of morbidity and mortality in burn patients. The mechanisms by which local burn injury alters epidermal barrier function in autologous donor skin and surrounding burn margin are largely undefined. We hypothesized that defects in the epidermal cholinergic system may impair epidermal barrier function and innate immune responses. The objective was to identify alterations in the epidermal cholinergic pathway, and their downstream targets, associated with inflammation and cell death. We established that protein levels, but not gene expression, of the α7 nicotinic acetylcholine receptor (CHRNA7) were significantly reduced in both donor and burn margin skin. Furthermore, the gene and protein levels of an endogenous allosteric modulator of CHRNA7, secreted mammalian Ly-6/ urokinase-type plasminogen activator receptor-related protein-1, and acetylcholine were significantly elevated in donor and burn margin skin. As downstream proteins of inflammatory and cell death targets of nAChR activation, we found significant elevations in epidermal High Mobility Group Box Protein 1 and caspase 3 in donor and burn margin skin. Lastly, we employed a novel in vitro keratinocyte burn model to establish that burn injury influences the gene expression of these cholinergic mediators and their downstream targets. These results indicate that defects in cholinergic mediators and inflammatory/apoptotic molecules in donor and burn margin skin may directly contribute to graft failure or infection in burn patients.

Local Burn Injury Promotes Defects in the Epidermal Lipid and Antimicrobial Peptide Barriers in Human Autograft Skin and Burn Margin: Implications for Burn Wound Healing and Graft Survival.

Burn injury increases the risk of morbidity and mortality by promoting severe hemodynamic shock and risk for local or systemic infection. Graft failure due to poor wound healing or infection remains a significant problem for burn subjects. The mechanisms by which local burn injury compromises the epithelial antimicrobial barrier function in the burn margin, containing the elements necessary for healing of the burn site, and in distal unburned skin, which serves as potential donor tissue, are largely unknown. The objective of this study was to establish defects in epidermal barrier function in human donor skin and burn margin, to identify potential mechanisms that may lead to graft failure and/or impaired burn wound healing. In this study, we established that epidermal lipids and respective lipid synthesis enzymes were significantly reduced in both donor skin and burn margin. We further identified diverse changes in the gene expression and protein production of several candidate skin antimicrobial peptides (AMPs) in both donor skin and burn margin. These results also parallel changes in cutaneous AMP activity against common burn wound pathogens, aberrant production of epidermal proteases known to regulate barrier permeability and AMP activity, and greater production of proinflammatory cytokines known to be induced by AMPs. These findings suggest that impaired epidermal lipid and AMP regulation could contribute to graft failure and infectious complications in subjects with burn or other traumatic injury.

"Right place at the right time" impacts outcomes for acute intestinal obstruction.

BACKGROUND: The purpose of this study was to measure how the duration of nonoperative intervention for intestinal obstruction impacted patient outcomes and whether hospital characteristics influenced the timing of operative intervention. METHODS: The State Inpatient Database (Florida) of the Health Care Utilization Project and the Annual Survey database of the American Hospital Association were linked from 2006 to 2011. Included were patients ≥18 years of age with a primary diagnosis of intestinal obstruction. Patient factors included age, sex, socioeconomic factors, and comorbid conditions. RESULTS: A total of 116,195 patients met our inclusion criteria, and 43,079 underwent operative intervention (37.1%). Patients who required operative correction of the intestinal obstruction after the fifth day of hospitalization, compared with patients who underwent an operation on the day of admission, had increases in mortality (6.1% vs 1.8%, P < .001), complication rates (15.4% vs 4.0%, P < .001), and postoperative hospital stay (9 vs 5 days, P < .001). Patients cared for at a large teaching facility (with surgery residents) had increased odds of early operative intervention by 23% (odds ratio 1.23, [1.20-1.28]), whereas patients at low-volume hospitals had decreased odds of early intervention (odds ratio 0.88, [0.73-0.91]). CONCLUSION: Initial nonoperative treatment in patients with uncomplicated intestinal obstruction is an important strategy, but the odds of having an adverse event increase as intestinal obstruction is delayed. Importantly, the presence of surgery residents and increasing bed size are hospital characteristics associated with earlier operative intervention, suggesting a quality benefit for care at large teaching hospitals.

Dynamic Role of Host Stress Responses in Modulating the Cutaneous Microbiome: Implications for Wound Healing and Infection.

Significance: Humans are under constant bombardment by various stressors, including psychological anxiety and physiologic injury. Understanding how these stress responses influence the innate immune system and the skin microbiome remains elusive due to the complexity of the neuroimmune and stress response pathways. Both animal and human studies have provided critical information upon which to further elucidate the mechanisms by which mammalian stressors impair normal wound healing and/or promote chronic wound progression. Recent Advances: Development of high-throughput genomic and bioinformatic approaches has led to the discovery of both an epidermal and dermal microbiome with distinct characteristics. This technology is now being used to identify statistical correlations between specific microbiota profiles and clinical outcomes related to cutaneous wound healing and the response to pathogenic infection. Studies have also identified more prominent roles for typical skin commensal organisms in maintaining homeostasis and modulating inflammatory responses. Critical Issues: It is well-established that stress-induced factors, including catecholamines, acetylcholine, and glucocorticoids, increase the risk of impaired wound healing and susceptibility to infection. Despite the characterization of the cutaneous microbiome, little is known regarding the impact of these stress-induced molecules on the development and evolution of the cutaneous microbiome during wound healing. Future Directions: Further characterization of the mechanisms by which stress-induced molecules influence microbial proliferation and metabolism in wounds is necessary to identify altered microbial phenotypes that differentially influence host innate immune responses required for optimal healing. These mechanisms may yield beneficial as targets for manipulation of the microbiome to further benefit the host after cutaneous injury.

An analytic decision support tool for resident allocation.

BACKGROUND: Moving residents through an academic residency program is complicated by a number of factors. Across all residency programs the percentage of residents that leave for any reason is between 3.4% and 3.8%.(1) There are a number of residents that participate in research. To avoid discrepancies in the number of residents at the all levels, programs must either limit the number of residents that go into the lab, the number that return to clinical duties, or the number of interns to hire. Traditionally this process consists of random selection and trial and error with names on magnetic strips moved around a board. With the matrix that we have developed this process is optimized and aided by a Microsoft Excel macro (Microsoft Corp, Redmond, Washington). METHODS: We suggest that a residency program would have the same number of residents at each residency stage of clinical practice, as well as a steady number of residents at each research stage. The program consists of 2 phases, in the first phase, an Excel sheet called the "Brain Sheet," there are simple formulas that we have prepared to determine the number of interns to recruit, residents in the research phase, and residents that advance to the next stage of training. The second phase of the program, the macro, then takes the list of current resident names along with the residency level they are in, and according to the formulas allocates them to the relevant stages for future years, creating a resident matrix. RESULTS: Our macro for resident allocation would maximize the time of residency program administrators by simplifying the movement of residents through the program. It would also provide a tool for planning the number of new interns to recruit and program expansion. CONCLUSIONS: The application of our macro illustrates that analytical techniques can be used to minimize the time spent and avoid the trial and error while planning resident movement in a program.

Healthcare provider attitudes towards the problem list in an electronic health record: a mixed-methods qualitative study.

BACKGROUND: The problem list is a key part of the electronic health record (EHR) that allows practitioners to see a patient's diagnoses and health issues. Yet, as the content of the problem list largely represents the subjective decisions of those who edit it, patients' problem lists are often unreliable when shared across practitioners. The lack of standards for how the problem list is compiled in the EHR limits its effectiveness in improving patient care, particularly as a resource for clinical decision support and population management tools. The purpose of this study is to discover practitioner opinions towards the problem list and the logic behind their decisions during clinical situations. MATERIALS AND METHODS: An observational cross-sectional study was conducted at two major Boston teaching hospitals. Practitioners' opinions about the problem list were collected through both in-person interviews and an online questionnaire. Questions were framed using vignettes of clinical scenarios asking practitioners about their preferred actions towards the problem list. RESULTS: These data confirmed prior research that practitioners differ in their opinions over managing the problem list, but in most responses to a questionnaire, there was a common approach among the relative majority of respondents. Further, basic demographic characteristics of providers (age, medical experience, etc.) did not appear to strongly affect attitudes towards the problem list. CONCLUSION: The results supported the premise that policies and EHR tools are needed to bring about a common approach. Further, the findings helped identify what issues might benefit the most from a defined policy and the level of restriction a problem list policy should place on the addition of different types of information.

Development of cerebral metastasis after medical and surgical treatment of anal squamous cell carcinoma.

Squamous cell carcinoma of the anus is a relatively uncommon GI malignancy. When it does occur, it metastasizes in only a small minority of patients. Spread of anal squamous cell carcinoma to the brain is exceedingly rare, and has been previously reported only three times in the medical literature. We report the case of a 67 year old male who was diagnosed on presentation with a poorly differentiated anal squamous cell carcinoma that already had a solitary metastasis to the liver. While the tumors were initially responsive to chemoradiotherapy, the patient's primary and liver lesions recurred. The patient then underwent synchronous abdominoperineal resection for the primary lesion and a liver lobectomy for the metastasis. Soon thereafter, the patient developed focal neurologic symptoms and was found to have an intracranial lesion that on biopsy demonstrated metastatic squamous cell carcinoma. This case highlights the fact that patients with a previous history of anal squamous cell carcinoma can occasionally develop cerebral metastasis. Furthermore, cerebral metastases from anal squamous cell carcinoma portend a dismal prognosis even in the face of aggressive medical and surgical therapy.