The Clinical Significance of Aspergillus Detected in Lower-Respiratory-Tract Samples of Critically Ill COVID-19-Positive Patients.

Objective: Critically ill patients with acute respiratory distress syndrome (ARDS) due to viral infection are at risk for secondary complications, including invasive aspergillosis. Our study aimed to characterize the clinical significance and outcome of Aspergillus species isolated from lower-respiratory-tract samples of critically ill OVID-19 patients at a single center. Design: We conducted a retrospective cohort study to evaluate the characteristics of patients with COVID-19 and aspergillus isolated from the lower respiratory tract and to identify predictors of outcomes in this population. Setting: The setting was a single-center hospital system within the metropolitan Detroit region. Results: The prevalence of Aspergillus isolated in hospitalized COVID-19 patients was 1.18% (30/2461 patients), and it was 4.6% in critically ill ICU patients with COVID-19. Probable COVID-19-associated invasive pulmonary aspergillosis (CAPA) was found in 21 critically ill patients, and 9 cases were classified as colonization. The in-hospital mortality of critically ill patients with CAPA and those with aspergillus colonization were high but not significantly different (76% vs. 67%, p = 1.00). Furthermore, the in-hospital mortality for ICU patients with or without Aspergillus isolated was not significantly different 73.3% vs. 64.5%, respectively (OR 1.53, CI 0.64-4.06, p = 0.43). In patients in whom Aspergillus was isolated, antifungal therapy (p = 0.035, OR 12.3, CI 1.74-252); vasopressors (0.016, OR 10.6, CI 1.75-81.8); and a higher mSOFA score (p = 0.043, OR 1.29 CI 1.03-1.72) were associated with a worse outcome. In a multivariable model adjusting for other significant variables, FiO2 was the only variable associated with in-hospital mortality in patients in whom Aspergillus was isolated (OR 1.07, 95% CI 1.01-1.27). Conclusions: The isolation of Aspergillus from lower-respiratory-tract samples of critically ill patients with COVID-19 is associated with high mortality. It is important to have a low threshold for superimposed infections such as CAPA in critically ill patients with COVID-19.

Hemophagocytic Lymphohistiocytosis Following Skin and Soft Tissue Infection in a Patient With Human Immunodeficiency Virus.

Hemophagocytic lymphohistiocytosis (HLH) is a systemic inflammatory syndrome of inappropriate immune cell activation which can be rapidly fatal if not recognized and treated. Here we discuss a case of a 26-year-old male with HIV on antiretroviral therapy who presented with sepsis secondary to soft tissue infection and ultimately progressed to multi-organ dysfunction despite broad-spectrum antibiotics and an improvement in soft tissue infection. Continued fever and pancytopenia without an explanation found during additional infectious and rheumatologic testing eventually led to bone marrow biopsy and laboratory criteria consistent with HLH. Although pancytopenia is a common finding in patients with HIV, here it marked a more rapidly progressing and fatal disease, HLH. Here we highlight the difficulty in identifying and diagnosing this rare condition, including a discussion of the characteristics, outcomes, underlying etiologies, and treatment of HLH in patients with HIV.

Inflammation markers on benign breast biopsy are associated with risk of invasive breast cancer in African American women.

PURPOSE: Markers of inflammation, including crown-like structures of the breast (CLS-B) and infiltrating lymphocytes (IL), have been identified in breast tissue and associated with increased risk of breast cancer (BrCa), however most of this work has been performed in primarily non-Hispanic white women. Here, we examined whether CLS-B and IL are associated with invasive BrCa in African American (AA) women. METHODS: We assessed breast biopsies from three 5-year age-matched groups: BrCa-free AA women (50 Volunteer) from the Komen Normal Tissue Bank (KTB) and AA women with a clinically-indicated biopsy diagnosed with benign breast disease (BBD) from our Detroit cohort who developed BrCa (55 BBD-cancer) or did not develop BrCa (47 BBD only, year of biopsy matched to BBD-cancer). Mean adipocyte diameter and total adipose area were estimated from digital images using the Adiposoft plugin from ImageJ. Associations between CLS-B, IL, and BrCa among KTB and Detroit biopsies were assessed using multivariable multinomial and conditional logistic regression models. RESULTS: Among all biopsies, Volunteer and BBD only biopsies did not harbor CLS-B or IL at significantly different rates after adjusting for logarithm of adipocyte area, adipocyte diameter, and BMI. Among clinically-indicated BBD biopsies, BBD-cancer biopsies were more likely to exhibit CLS-B (odds ratio (OR) = 3.36, 95% Confidence Interval (CI): 1.33-8.48) or IL (OR = 4.95, 95% CI 1.76-13.9) than BBD only biopsies after adjusting for total adipocyte area, adipocyte diameter, proliferative disease, and BMI. CONCLUSIONS: CLS-B and IL may serve as histological markers of BrCa risk in benign breast biopsies from AA women.

APOBEC3 enzymes mediate efficacy of cisplatin and are epistatic with base excision repair and mismatch repair in platinum response.

Identifying the mechanisms mediating cisplatin response is essential for improving patient response. Previous research has identified base excision repair (BER) and mismatch repair (MMR) activity in sensitizing cells to cisplatin. Cisplatin forms DNA adducts including interstrand cross-links (ICLs) that distort the DNA helix, forcing adjacent cytosines to become extrahelical. These extrahelical cytosines provide a substrate for cytosine deaminases. Herein, we show that APOBEC3 (A3) enzymes are capable of deaminating the extrahelical cytosines to uracils and sensitizing breast cancer cells to cisplatin. Knockdown of A3s results in resistance to cisplatin and induction of A3 expression in cells with low A3 expression increases sensitivity to cisplatin. We show that the actions of A3s are epistatic with BER and MMR. We propose that A3-induced cytosine deamination to uracil at cisplatin ICLs results in repair of uracils by BER, which blocks ICL DNA repair and enhances cisplatin efficacy and improves breast cancer outcomes.

Outcomes of an Online Virtual Boot Camp to Prepare Fourth-Year Medical Students for a Successful Transition to Internship.

Introduction Changes in medical education and health care delivery have limited the ability of fourth-year medical students to perform the role of an intern prior to graduating from medical school. To address this issue, many schools have instituted residency preparation courses (sometimes referred to as boot camps) particularly for students entering surgical fields. Courses for students entering nonprocedural fields are less common and most assess increases in self-reported confidence without providing objective evidence of a gain in knowledge or skills improvement. Materials and Methods We used a Plan, Do, Study, Act (PDSA) model to develop and pilot cycle 1 of a nonprocedural internship preparation elective in 2019. Feedback was used to refine the course and map sessions to core competencies outlined by the Accreditation Council of Graduate Medical Education (ACGME) for PDSA cycle 2. The curriculum was adapted for remote synchronous delivery due to the coronavirus pandemic in spring 2020 using a combination of didactic lectures containing embedded polls and case-based role play responses using a chat box. Students completed anonymous surveys assessing self-perceived levels of confidence, as well as an objective comprehensive assessment after course completion. Results A total of 89 students participated in the course. Pre-session confidence was lowest for transfusion medicine, handling pages from nursing while on call, and knowledge of the role of a chief resident. A statistically significant increase in median scores for self-reported knowledge or confidence was seen in all sessions. The percentage of students reporting that they were either confident or extremely confident also increased significantly after each session (p<0.001 for all). All sessions analyzed were rated as useful or extremely useful by more than half of the students, and 94% of the students scored 70% or higher on the comprehensive course assessment. Conclusions An online virtual synchronous boot camp increased students' confidence in handling common topics encountered during residency and demonstrated an appropriate gain in knowledge using a comprehensive assessment. We were able to adapt our curriculum to a remote model and will likely keep several sessions in an online format in the future.

HPV induction of APOBEC3 enzymes mediate overall survival and response to cisplatin in head and neck cancer.

Human papillomavirus (HPV) is associated with the development of head and neck squamous cell carcinomas (HNSC). Cisplatin is used to treat HNSC and induces DNA adducts including interstrand crosslinks (ICLs). Previous reports have shown that HPV positive HNSC patients respond better to cisplatin therapy. Our previous reports highlight that loss of base excision repair (BER) and mismatch repair (MMR) results in cisplatin resistance. Of importance, uracil DNA glycosylase (UNG) is required to initiate the BER response to cisplatin treatment and maintain drug sensitivity. These previous results highlight that specific cytidine deaminases could play an important role in the cisplatin response by activating the BER pathway to mediate drug sensitivity. The APOBEC3 (A3) family of cytidine deaminases are enzymes that restrict HPV as part of the immune defense to viral infection. In this study, the Cancer Genome Atlas (TCGA) HNSC data were used to assess the association between the expression of the seven proteins in the A3 cytidine deaminase family, HPV-status and survival outcomes. Higher A3 G expression in HPV-positive tumors corresponds with better overall survival (OS) (HR 0.33, 95 % CI 0.11-0.93, p = 0.04). FaDu and Scc-25 HNSC cell lines were used to assess alterations in A3, BER and MMR expression in response to cisplatin. We demonstrate that A3, Polß, and MSH6 knockdown in HNSC cells results in resistance to cisplatin and carboplatin as well as an increase in the rate of ICL removal in FaDu and Scc-25 HNSC cells. Our results suggest that A3s activate BER in HNSC, mediate repair of cisplatin ICLs and thereby, sensitize cells to cisplatin which likely contributes to the improved patient responses observed in HPV infected patients.

Breast fibroadenomas are not associated with increased breast cancer risk in an African American contemporary cohort of women with benign breast disease.

BACKGROUND: Fibroadenomas are common benign breast lesions, and studies of European American women indicate a persistent, increased risk of breast cancer after diagnosing a fibroadenoma on biopsy. This association has not been independently assessed in African American women, despite reports that these women are more likely to present with fibroadenomas. METHODS: The study cohort included 3853 African American women with a breast biopsy completed between 1997 and 2010 in metropolitan Detroit. Biopsies were microscopically reviewed for benign breast lesions, including fibroadenoma, proliferative disease, and atypia. Risk of breast cancer within the cohort was estimated using relative risk ratios and 95% CIs calculated using multivariable log-binomial regression. Relative risk of breast cancer in this cohort compared with African American women in the broader metropolitan Detroit population was estimated using standardized incidence ratios (SIRs). RESULTS: Fibroadenomas occurred more frequently in biopsies of younger women, and other types of benign breast lesions were less likely to occur when a fibroadenoma was present (p = 0.008 for lobular hyperplasia; all other p values < 0.01). Unlike women with other benign lesions (SIR, 1.41; 95% CI, 1.20, 1.66), women with fibroadenomas did not have an increased risk of developing breast cancer compared with the general population (SIR, 0.94; 95% CI, 0.75, 1.18). Biopsies that indicated a fibroadenoma were associated with a reduced risk of breast cancer after adjusting for age at biopsy, proliferation, and atypia (relative risk, 0.67; 95% CI, 0.48, 0.93) compared with biopsies without a fibroadenoma. CONCLUSIONS: These findings have important implications for breast cancer risk models and clinical assessment, particularly among African American women, in whom fibroadenomas are common.