Rapid development of squamous cell carcinoma at a split-thickness skin graft donor site.

The development of a Marjolin ulcer at the site of a split-thickness skin graft donor site is exceptionally rare. Here we describe the rapid development of squamous cell carcinoma at a split-thickness skin graft donor site in the setting of severe burn. We present a case of a 52-year-old male with no past medical history who presented with a 24% total body surface area burn caused by a flash flame. Four months after his initial excision and grafting, he presented for revision of a burn scar with an additional complaint of a rapidly developing skin lesion at his donor site, which arose over 2 weeks. The lesion was excised en bloc and found to be invasive squamous cell carcinoma. There are 5 previous cases of squamous cell carcinoma development at the site of split-thickness skin harvest in the setting of severe burn. While the typical Marjolin ulcer has a latency period of up to 30 years, lesions that arise in split-thickness skin graft donor sites appear to have a rapid onset of weeks to months. Squamous cell carcinoma at the site of split-thickness skin grafting is an uncommon but important sequelae of burn care.

Healthcare Utilization Among Infants Discharged From the Neonatal Intensive Care Unit: A Descriptive Cost Analysis.

The cost of readmissions of neonatal intensive care unit (NICU) graduates within 6 months and a year of their life is well-studied. However, the cost of readmissions within 90 days of NICU discharge is unknown. This study's objective was to estimate the overall and mean cost of healthcare use for unplanned hospital visits of NICU graduates within 90 days of discharge A retrospective review of all infants discharged between 1/1/2017 and 03/31/2017 from a large hospital system NICUs was conducted. All unplanned hospital visits (readmissions or stand-alone emergency department (ED) visits) occurring within 90 days post NICU discharge were included. The total and mean cost of unplanned hospital visits were computed and adjusted to 2021 US dollars. The total cost was estimated to be $785 804 with a mean of $1898 per patient. Hospital readmissions accounted for 98% ($768 718) of the total costs and ED visits for 2% ($17 086). The mean cost per readmission and stand-alone ED visit were $25 624 and $475 respectively. The highest mean total cost of unplanned hospital readmission was noted in extremely low birth weight infants ($25 295). Interventions targeted to reduce hospital readmissions after NICU discharge have the potential to significantly reduce healthcare costs for this patient population.

Clinical and Lifestyle-Related Prognostic Indicators among Esophageal Adenocarcinoma Patients Receiving Treatment at a Comprehensive Cancer Center.

PURPOSE: The incidence of esophageal adenocarcinoma (EAC) has risen substantially in recent decades, while the average 5-year survival remains only ~20%. Disease stage and treatment are the strongest prognostic factors. The role of lifestyle factors in relation to survival remains uncertain, with a handful of studies to date investigating associations with obesity, smoking, physical activity, diet, or medications. METHODS: This study included patients diagnosed with primary adenocarcinoma of the esophagus, gastroesophageal junction, or cardia (N = 371) at Roswell Park Comprehensive Cancer Center between 2003 and 2019. Leveraging extensive data abstracted from electronic medical records, epidemiologic questionnaires, and a tumor registry, we analyzed clinical, behavioral, and environmental exposures and evaluated stage-specific associations with survival. Survival distributions were visualized using Kaplan-Meier curves. Cox proportional hazards regression models adjusted for age, sex, stage, treatment, and comorbidities were used to estimate the association between each exposure and all-cause or cancer-specific mortality. RESULTS: Among patients presenting with localized/regional tumors (stages I-III), current smoking was associated with increased overall mortality risk (HR = 2.5 [1.42-4.53], p = 0.002), while current physical activity was linked to reduced risk (HR = 0.58 [0.35-0.96], p = 0.035). Among patients with stage IV disease, individuals reporting pre-diagnostic use of statins (HR = 0.62 [0.42-0.92], p = 0.018) or NSAIDs (HR = 0.61 [0.42-0.91], p = 0.016) had improved overall survival. Exploratory analyses suggested that high pre-diagnostic dietary consumption of broccoli, carrots, and fiber correlated with prolonged overall survival in patients with localized/regional disease. CONCLUSION: Our data suggest that lifestyle exposures may be differentially associated with EAC survival based on disease stage. Future investigation of larger, diverse patient cohorts is essential to validate these findings. Our results may help inform the development of lifestyle-based interventions to improve EAC prognosis and quality of life.

Preoperative Opioids Associated With Increased Postoperative Opioid Use in Pediatric Appendicitis.

BACKGROUND: In light of current opioid-minimization efforts, we aimed to identify factors that predict postoperative opioid requirement in pediatric appendicitis patients. METHODS: A single-center retrospective cohort study was conducted of children (<18 y) who underwent laparoscopic appendectomy for acute appendicitis between January 1, 2018 and April 30, 2019. Patients who underwent open or interval appendectomies were excluded. The primary outcome was morphine milliequivalents (MMEs) per kilogram administered between 2 and 24 h after surgery. Multivariable analyses were performed to evaluate predictors of postoperative opioid use. Clinically sound covariates were chosen a priori: age, weight, simple versus complicated appendicitis, preoperative opioid administration, and receipt of regional or local anesthesia. RESULTS: Of 546 patients, 153 (28%) received postoperative opioids. Patients who received postoperative opioids had a longer median preadmission symptom duration (48 versus 24 h, P < 0.001) and were more likely to have complicated appendicitis (55% versus 21%, P < 0.001). Patients who received postoperative opioids were more likely to have received preoperative opioids (54% versus 31%, P < 0.001). Regional and local anesthesia use was similar between groups. Nearly all patients (99%) received intraoperative opioids. Each preoperative MME per kilogram that a patient received was associated with receipt of 0.29 additional MMEs per kilogram postoperatively (95% confidence interval, 0.19-0.40). CONCLUSIONS: Preoperative opioid administration was independently associated with increased postoperative opioid use in pediatric appendicitis. These findings suggest that preoperative opioids may potentiate increased postoperative pain. Limiting preoperative opioid exposure, through strategies such as multimodal analgesia, may be an important facet of efforts to reduce postoperative opioid use.

Use of Fecal Microbial Transplantation for Immune Checkpoint Inhibitor Colitis.

Immune checkpoint inhibitors (ICIs) can result in immune-related adverse events which require rapid identification and treatment. Gastrointestinal immune-related adverse events are among the most frequent and severe of these events. ICI colitis can be refractory to current therapies such as corticosteroids and biologic therapy. Fecal microbiota transplantation (FMT) is currently used in cases of recurrent Clostridioides difficile colitis. Many investigations are underway to test the utility of FMT for additional indications, including inflammatory bowel disease (IBD). We present a 71-year-old man with ICI colitis that was nonresponsive to currently defined management options and treated with benefit from FMT.

Pancreatic Adenocarcinoma, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology.

Ductal adenocarcinoma and its variants account for most pancreatic malignancies. High-quality multiphase imaging can help to preoperatively distinguish between patients eligible for resection with curative intent and those with unresectable disease. Systemic therapy is used in the neoadjuvant or adjuvant pancreatic cancer setting, as well as in the management of locally advanced unresectable and metastatic disease. Clinical trials are critical for making progress in treatment of pancreatic cancer. The NCCN Guidelines for Pancreatic Adenocarcinoma focus on diagnosis and treatment with systemic therapy, radiation therapy, and surgical resection.

Laparoscopic Intragastric Surgery With Endoscopic Assistance: A 2 Gastrostomy Approach With Multiple Applications.

PURPOSE: Laparoscopic intragastric resection is a surgical modality with acceptable oncologic outcomes for gastrointestinal stromal tumors and leiomyomas, particularly for masses located near the gastroesophageal junction (GEJ). We describe our technique of 2 gastrostomy laparoscopic, intragastric resection with endoscopic assistance. METHODS: We detail our technique and report a unique application of this versatile approach. RESULTS: Between December 2015 and July 2016, 4 patients underwent our combined technique of intragastric surgery. Complete resection was performed in the 2 patients who had gastrointestinal stromal tumors and 1 patient with a leiomyoma without complications. One patient had the unique diagnosis of gastritis cystica profunda. This mass could not be resected, but an effective Tru-cut core needle biopsy was obtained, and the mass was able to be diagnosed and decompressed. CONCLUSIONS: Our technique of 2 gastrostomy laparoscopic intragastric surgery is feasible and offers an effective oncologic approach for resection of tumors near the GEJ.

Primary pancreatic leiomyosarcoma with metastasis to the liver diagnosed by endoscopic ultrasound-guided fine needle aspiration and fine needle biopsy: A Case Report and Review of Literature.

Primary pancreatic leiomyosarcomas are rare tumors of the pancreas that are usually diagnosed after resection or by biopsy. One case in the literature has utilized endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology. We report a second case of a primary pancreatic leiomyosarcoma that yielded diagnostic material on EUS-FNA cytology. A 72-year-old female presented with 3-4 months of abdominal pain. A CT scan showed a large heterogeneous, lobulated pancreatic head and uncinate mass and multiple hypoattenuating liver lesions. An EUS-FNA was performed on one of the liver lesions with a 25-gauge needle, yielding an adequate sample with lesional cells. The initial read was a spindle cell neoplasm. A subsequent endoscopic ultrasound-guided fine needle biopsy with a 22-gauge needle was performed on the pancreatic head mass to rule out two primaries and to provide tissue for a mitotic index in the case of gastrointestinal tumor. Both the cell block of the EUS-FNA and the core biopsy were equally cellular and showed interlacing spindle cells that stained positive for SMA and negative for DOG-1, CD 117, and CD34. In addition, the core biopsy of the pancreas stained positive for Desmin. A diagnosis of a primary pancreatic leiomyosarcoma was made and the patient was started on systemic chemotherapy. Primary pancreatic leiomyosarcomas are rare pancreatic tumors that may yield diagnostic material by EUS-FNA with a 25-gauge needle. Diagn. Cytopathol. 2016;44:1070-1073. © 2016 Wiley Periodicals, Inc.

Pancreatic hepatoid carcinoma: a rare form of pancreatic neoplasm.

Primary pancreatic hepatoid carcinoma (PHC) is extremely rare, resembling hepatocellular carcinoma (HCC) in terms of morphology and immunohistochemical features. Hepatoid carcinoma can present in other organs, most noticeably in the stomach. PHC is present in two forms either a pure form like HCC or admixed with other histologic tumor components characteristic of the underlying primary site (endocrine tumors, ductal, or acinar adenocarcinomas). Here, we report a 69-year-old male patient with distal pancreatic mass incidentally found during a CT scan workup for a pulmonary nodule suspicious for metastatic prostate adenocarcinoma. We described the clinical, cytological, and histological finding and conducted a literature review.

Outcomes of endoscopic resection for high-grade dysplasia and esophageal cancer.

BACKGROUND: Endoscopic resection (ER) is an important advance in the management of esophageal tumors. It has been used successfully for superficial esophageal cancer and high-grade dysplasia (HGD) arising out of Barrett epithelium. METHODS: From a single institution within the Department of Surgery, patients who underwent ER for esophageal tumors between December 2001 and January 2012 were evaluated. Demographic, clinical, and pathologic variables were collected and reviewed. RESULTS: We identified 81 patients who underwent ER for esophageal lesions. Median patient age was 69 years, and the median follow-up was 3.25 years. In patients with HGD, at the time of last endoscopy, the complete eradication rate of HGD was 84 % and cancer-specific survival was 100 %. During surveillance, one patient developed an invasive carcinoma that required endoscopic therapy. Patients with T1a and negative deep margins on ER had a recurrence-free and cancer-specific survival of 100 %. There were seven patients with T1b and negative margins on ER. Three patients underwent esophagectomy; final pathology revealed no residual malignancy or lymph node metastasis. Two patients had definitive chemoradiation, and two patients were observed. To date, there has been no cancer recurrence. In all patients who underwent ER, there was one episode of bleeding that required endoscopic treatment and admission for observation. CONCLUSIONS: ER can be performed safely and can adequately stage and often treat patients with HGD and superficial cancers. Patients with HGD and T1a disease with negative margins are cured with ER alone. Observation and surveillance may be an option for select patients with low-risk, early submucosal disease (T1b) and negative margins.

Failure of centrosome migration causes a loss of motile cilia in talpid(3) mutants.

BACKGROUND: Loss of function mutations in the centrosomal protein TALPID3 (KIAA0586) cause a failure of primary cilia formation in animal models and are associated with defective Hedgehog signalling. It is unclear, however, if TALPID3 is required only for primary cilia formation or if it is essential for all ciliogenesis, including that of motile cilia in multiciliate cells. RESULTS: FOXJ1, a key regulator of multiciliate cell fate, is expressed in the dorsal neuroectoderm of the chicken forebrain and hindbrain at stage 20HH, in areas that will give rise to choroid plexuses in both wt and talpid(3) embryos. Wt ependymal cells of the prosencephalic choroid plexuses subsequently transition from exhibiting single short cilia to multiple long motile cilia at 29HH (E8). Primary cilia and long motile cilia were only rarely observed on talpid(3) ependymal cells. Electron microscopy determined that talpid(3) ependymal cells do develop multiple centrosomes in accordance with FOXJ1 expression, but these fail to migrate to the apical surface of ependymal cells although axoneme formation was sometimes observed. CONCLUSIONS: TALPID3, which normally localises to the proximal centrosome, is essential for centrosomal migration prior to ciliogenesis but is not directly required for de novo centriologenesis, multiciliated fate, or axoneme formation.

eChickAtlas: an introduction to the database.

The precise control of gene expression is critical in embryonic development. Quantitative assays, such as microarrays and RNA sequencing, provide gene expression levels for a large number of genes, but do not contain spatial information. In contrast, in situ methods, such as in situ hybridization and immunohistochemistry, provide spatial resolution, but poor quantification and can only reveal the expression of one, or very few genes at a time. Furthermore, the usual methods of documenting the results, by photographing whole mounts or sections, makes it very difficult to assess the three-dimensional (3D) relationships between expressing and nonexpressing cells. Optical projection tomography (OPT) can capture the full 3D expression pattern in a whole embryo at a reasonable level of resolution and at moderately high throughput. A large database containing spatio-temporal patterns of expression for the mouse (e-Mouse Atlas Project, EMAP, www.emouseatlas.org) has been created, incorporating 3D information. Like the mouse, the chick is an important model in developmental biology and translational studies. To facilitate comparisons between these important model organisms, we have created a 3D anatomical atlas, accompanied by an anatomical ontology of the chick embryo and a database of gene expression patterns during chick development. This database is publicly available (www.echickatlas.org).

Quality of colonoscopy withdrawal technique and variability in adenoma detection rates (with videos).

BACKGROUND: Studies suggest that endoscopist-related factors such as colonoscopy withdrawal time are important in determining the adenoma detection rate (ADR). OBJECTIVE: To determine the importance of withdrawal technique in differentiating among endoscopists with varying ADRs. DESIGN: Prospective, multicenter study. SETTING: Five academic tertiary-care medical centers. PARTICIPANTS: This study involved 11 gastroenterology faculty endoscopists. INTERVENTION: A retrospective review of screening colonoscopies was performed to categorize endoscopists into low, moderate, and high ADR groups. Video recordings were randomly obtained for each endoscopist on 20 (10 real, 10 sham) withdrawals during colonoscopies performed for average-risk colorectal cancer screening. Three blinded reviewers assigned withdrawal technique scores (total of 75 points) on 110 video recordings. A separate reviewer recorded withdrawal times. MAIN OUTCOME MEASUREMENTS: Withdrawal technique scores and withdrawal times. RESULTS: Mean (± standard deviation [SD]) withdrawal technique scores were higher in the moderate (62 ± 2.5) and high (59.5 ± 3) ADR groups compared with the low (40.8±3) ADR group (P = .002). Mean (± SD) withdrawal times were 6.3 ± 1.8 minutes (low ADR), 10.2 ± 1.5 minutes (moderate ADR), and 8.2 ± 1.8 minutes (high ADR) (P = .29). A comparison of the withdrawal times and technique scores of the two individual endoscopists with the lowest and highest ADRs did not find a significant difference in withdrawal times (6.6 ± 1.7 vs 7.4 ± 1.7 minutes) (P = .36) but did find a nearly 2-fold difference in technique scores (36.2 ± 9 vs 62.8 ± 9.9) (P = .0001). LIMITATIONS: Not adequately powered to detect small differences in withdrawal times. CONCLUSION: Withdrawal technique is an important indicator that differentiates between endoscopists with varying ADRs. It is possible that withdrawal technique is equal to, if not more important than, withdrawal time in determining ADRs.

Comparative analysis of 3D expression patterns of transcription factor genes and digit fate maps in the developing chick wing.

Hoxd13, Tbx2, Tbx3, Sall1 and Sall3 genes are candidates for encoding antero-posterior positional values in the developing chick wing and specifying digit identity. In order to build up a detailed profile of gene expression patterns in cell lineages that give rise to each of the digits over time, we compared 3 dimensional (3D) expression patterns of these genes during wing development and related them to digit fate maps. 3D gene expression data at stages 21, 24 and 27 spanning early bud to digital plate formation, captured from in situ hybridisation whole mounts using Optical Projection Tomography (OPT) were mapped to reference wing bud models. Grafts of wing bud tissue from GFP chicken embryos were used to fate map regions of the wing bud giving rise to each digit; 3D images of the grafts were captured using OPT and mapped on to the same models. Computational analysis of the combined computerised data revealed that Tbx2 and Tbx3 are expressed in digit 3 and 4 progenitors at all stages, consistent with encoding stable antero-posterior positional values established in the early bud; Hoxd13 and Sall1 expression is more dynamic, being associated with posterior digit 3 and 4 progenitors in the early bud but later becoming associated with anterior digit 2 progenitors in the digital plate. Sox9 expression in digit condensations lies within domains of digit progenitors defined by fate mapping; digit 3 condensations express Hoxd13 and Sall1, digit 4 condensations Hoxd13, Tbx3 and to a lesser extent Tbx2. Sall3 is only transiently expressed in digit 3 progenitors at stage 24 together with Sall1 and Hoxd13; then becomes excluded from the digital plate. These dynamic patterns of expression suggest that these genes may play different roles in digit identity either together or in combination at different stages including the digit condensation stage.