A novel case of NKX3.1-positive metastatic cutaneous prostate cancer.

Prostate carcinoma is the most common non-dermatological malignancy in men and only second to lung cancer as the leading cause of cancer related deaths in America. Moreover, metastasis to the skin is even more uncommon following apparently successful treatment of a preexisting prostate cancer. We present an 87-year-old man previously diagnosed with prostate cancer treated with brachytherapy, who presented with a metastatic prostate adenocarcinoma of the scalp mimicking a basal cell carcinoma. Herein, we present a patient with an NKX 3.1 positive cutaneous metastatic prostate carcinoma identified through NKX3.1 stain rather than the typical PSA/PSAP stain.

A case of leprosy in central Florida.

Hansen disease, also known as leprosy, is a chronic granulomatous infectious disease that is caused by Mycobacterium leprae. We report an unusual case of a 65-year-old man who presented with multiple anesthetic, annular, erythematous, scaly plaques with a raised border without any known exposures to leprosy. Histologic examination revealed a perineural lymphohistiocytic infiltrate and rare bacilli demonstrated on Fite staining. After confirmation with polymerase chain reaction (PCR) and consultation with the National Hansen's Disease Program (Baton Rouge, Louisiana), the patient was placed on a regimen of rifampicin 600 mg once monthly and dapsone 100 mg once daily for 6 months, which showed considerable improvement. This case demonstrates the identification of leprosy in central Florida, a region that is not known to be endemic to the disease. Leprosy, however rare, must be part of a practitioner's differential diagnosis even without history of traditional exposures.

Development of a bedside scoring system for predicting a first recurrence of Clostridium difficile-associated diarrhea.

PURPOSE: A scoring system for identifying patients at high or low risk for recurrent Clostridium difficile-associated diarrhea (CDAD) is described. METHODS: A retrospective cohort study was performed using data on adults with CDAD admitted to a 3-hospital system from 2009 to 2014. The primary endpoint was the rate of recurrent CDAD within 60 days of clinical cure of CDAD. Risk factors for CDAD recurrence were identified, and a risk prediction tool was developed using multivariate logistic regression. RESULTS: The CDAD cure rate in the study cohort (n = 340) was 92.3%; the 60-day recurrence rate was 16.9%. Five factors were significantly associated with high recurrence risk: presence of CDAD at admission, body temperature of >37.8 °C at admission, leukocytosis, nosocomial CDAD, and abdominal distention on CDAD presentation. From that information a risk prediction tool, the CDAD "recurrence score," was developed (1 point is assigned for each factor present, for a maximum score of 5). Validation testing of the recurrence score indicated an area under the receiver operating characteristic curve of 0.72 (95% confidence interval, 0.65-0.80). A score of ≥2 had a negative predictive value of 91%, while a score of ≥4 had a positive predictive value of 70%. CONCLUSION: If externally validated in future studies, a tool for predicting the risk of recurrent CDAD using data readily available at the time of presentation could allow clinicians to identify patients at high risk for recurrence, address modifiable risk factors, and select tailored treatments to improve patient outcomes.

Prolonged oral antibiotic suppression in osteomyelitis and associated outcomes in a Veterans population.

OBJECTIVE: Prolonged oral antimicrobial suppression has been suggested as an alternative treatment for patients with prosthetic joint infections who are unable or unwilling to undergo surgical intervention; however, little data exists for utilizing this approach in patients with chronic osteomyelitis and no artificial hardware. METHODS: We retrospectively reviewed the medical records of all patients over a 5-year time frame who were treated with chronic oral antibiotic suppression for osteomyelitis and who had no artificial hardware. Clinical outcomes, risk factors for treatment failure, and adverse drug reactions were evaluated. RESULTS: A total of 20 patients were included for evaluation, of which 12 (60%) were able to achieve successful suppression of disease for a mean duration of 778 ± 408 days after discontinuation. Diabetic patients were found to be at higher risk for treatment failure (p = 0.0281). We also identified a high rate of adverse events (25%) attributable to suppressive medications. Despite elevated inflammatory markers contributing to the decision to initiate antibiotic suppression in the majority of patients, few were able to achieve normal values throughout suppressive therapy. CONCLUSION: Further randomized, controlled studies are needed to determine the utility of antibiotic suppression. However, prolonged oral antibiotic suppression may be a reasonable last-line treatment alternative for chronic osteomyelitis, even in the absence of artificial hardware, for patients who are unwilling or unable to undergo optimal surgical intervention.

Clinical and economic outcomes of a prospective antimicrobial stewardship program.

PURPOSE: A pre-post analysis of an antimicrobial stewardship program (ASP) involving the use of data-mining software to prospectively identify cases for ASP intervention was conducted. METHODS: The investigators evaluated clinical outcomes and cost metrics before and after implementation of the ASP, which entailed daily physician review of summary reports on all adult inpatients receiving antimicrobial therapy. The primary outcome measures were annual antimicrobial expenditures and rates of infections due to common nosocomial pathogens; secondary outcome measures included patient survival and length of stay (LOS) in cases involving the indicator diagnoses of pneumonia and abdominal sepsis. RESULTS: Antimicrobial expenditures, which had increased by an average of 14.4% annually in the years preceding ASP implementation, decreased by 9.75% in the first year of the program and remained relatively stable in subsequent years, with overall cumulative cost savings estimated at $1.7 million. Rates of nosocomial infections involving Clostridium difficile, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci all decreased after ASP implementation. A pre-post comparison of survival and LOS in patients with pneumonia (n = 2186) or abdominal sepsis (n = 225) showed no significant differences in those outcomes in either patient group, possibly due to the hospital's initiation of other, concurrent infection-control programs during the study period. CONCLUSION: A prospective collaborative ASP employed automated reports to efficiently identify key data for ASP review. After ASP implementation, antimicrobial expenditures and rates of nosocomial infections caused by resistant pathogens dropped without significant changes in patient survival, LOS, and readmissions for the two studied illness categories.

Signet ring cell perianal paget disease: loss of MUC2 expression and loss of signet ring cell morphology associated with invasive disease.

Perianal Paget disease (PPD) is a rare and heterogeneous neoplasm in which underlying associated adenocarcinoma is a frequent comorbidity. Previous attempts have been made to define the cells of origin of this neoplasm and delineate the discriminating immunohistochemical (IHC) signature of primary versus secondary disease. We report a case of PPD in a 32-year-old male, that displays an unusual multiclonal immunostaining pattern with focal loss of MUC2 expression and simultaneous phenotypic loss of signet ring cell morphology associated with invasive disease. We postulate that our case captures the transition from PPD to invasive carcinoma. The loss of MUC2 positivity seen in this case could be relevant to biopsies of PPD in which no areas of invasion are initially found, and consequently a more thorough pathologic evaluation for invasive disease should be undertaken in cases with MUC2 negativity. Despite promising IHC staining patterns in individual case reports, PPD remains a heterogeneous entity. The specific IHC signature of primary versus secondary disease remains difficult to define due to the small number of cases reported in the literature and additional studies are needed. Therefore, in addition to a case's microscopic findings including IHC studies, distinguishing individual cases of primary from secondary PPD requires clinical correlation.

Engagement and retention: measuring breadth and depth of participant use of an online intervention.

BACKGROUND: The Internet provides us with tools (user metrics or paradata) to evaluate how users interact with online interventions. Analysis of these paradata can lead to design improvements. OBJECTIVE: The objective was to explore the qualities of online participant engagement in an online intervention. We analyzed the paradata in a randomized controlled trial of alternative versions of an online intervention designed to promote consumption of fruit and vegetables. METHODS: Volunteers were randomized to 1 of 3 study arms involving several online sessions. We created 2 indirect measures of breadth and depth to measure different dimensions and dynamics of program engagement based on factor analysis of paradata measures of Web pages visited and time spent online with the intervention materials. Multiple regression was used to assess influence of engagement on retention and change in dietary intake. RESULTS: Baseline surveys were completed by 2513 enrolled participants. Of these, 86.3% (n = 2168) completed the follow-up surveys at 3 months, 79.6% (n = 2027) at 6 months, and 79.4% (n = 1995) at 12 months. The 2 tailored intervention arms exhibited significantly more engagement than the untailored arm (P < .01). Breadth and depth measures of engagement were significantly associated with completion of follow-up surveys (odds ratios [OR] = 4.11 and 2.12, respectively, both P values < .001). The breadth measure of engagement was also significantly positively associated with a key study outcome, the mean increase in fruit and vegetable consumption (P < .001). CONCLUSIONS: By exploring participants' exposures to online interventions, paradata are valuable in explaining the effects of tailoring in increasing participant engagement in the intervention. Controlling for intervention arm, greater engagement is also associated with retention of participants and positive change in a key outcome of the intervention, dietary change. This paper demonstrates the utility of paradata capture and analysis for evaluating online health interventions. TRIAL REGISTRATION: NCT00169312; http://clinicaltrials.gov/ct2/show/NCT00169312 (Archived by WebCite at http://www.webcitation.org/5u8sSr0Ty).