Impact of the Coronavirus Disease 2019 Pandemic on Antiretroviral Therapy Initiation and Care Delivery for People With Newly Diagnosed HIV in an Integrated Healthcare System.

The coronavirus disease 2019 (COVID-19) pandemic disrupted health systems. For patients newly diagnosed with human immunodeficiency virus, starting immediate antiretroviral therapy (ART) is recommended. For periods before and during the COVID-19 pandemic, Kaiser Permanente Northern California found similar rates of rapid ART initiation and time to viral suppression, concurrent with an increase in telemedicine.

Five-year outcomes of wide excision and Mohs micrographic surgery for primary lentigo maligna in an academic practice cohort.

BACKGROUND: Wide local excision with 5-mm margins is the standard of care for lentigo maligna (LM). Mohs micrographic surgery (MMS) is used increasingly to treat this tumor. OBJECTIVE: To study the authors' experience with these 2 approaches. MATERIALS AND METHODS: Primary LM cases treated at the authors' institution from January 1, 1995, through December 31, 2005, were studied retrospectively. Main outcome measures were recurrence and outcomes after treatment for recurrence. RESULTS: In total, 423 LM lesions were treated in 407 patients: 269 (64%) with wide excision and 154 (36%) with MMS. In the MMS group (primarily larger head and neck lesions with indistinct clinical margins), recurrence rates were 3 of 154 (1.9%). In the wide excision group (primarily smaller, nonhead and neck, or more distinct lesions), recurrence rates were 16 of 269 (5.9%). Each of the 16 recurrences was biopsy proven and treated surgically: 6 by standard excision and 10 by MMS. CONCLUSION: This follow-up study of LM surgical treatments shows excellent outcomes for wide excision and MMS. Because this is a nonrandomized retrospective study, no direct comparisons between the 2 treatments can be made. When recurrences occurred, repeat surgery, either standard excision or MMS, was usually sufficient to provide definitive cure.

Evaluation of gingival crevicular fluid levels of tissue plasminogen activator, plasminogen activator inhibitor 2, matrix metalloproteinase-3 and interleukin 1-ß in patients with different periodontal diseases.

OBJECTIVES: The purpose of this study was to evaluate the gingival crevicular fluid levels of interleukin-1beta (IL-1ß), matrix metalloproteinases-3 (MMP-3), tissue type plasminogen activator (t-PA) and plasminogen activator inhibitor 2 (PAI-2) in patients with chronic periodontitis, aggressive periodontitis (AgP) and healthy individuals (controls). MATERIAL AND METHODS: Systemically healthy (21 chronic periodontitis, 23 AgP and 20 controls) subjects were included in this study. Plaque index, gingival index, probing pocket depth and clinical attachment level were recorded and gingival crevicular fluid samples were collected. Assays for IL-1ß, MMP-3, t-PA and PAI-2 levels in gingival crevicular fluid were carried out by an enzyme-linked immunosorbent assay. The one-sample Kolmogorov-Smirnov test, Mann-Whitney U test and Spearman correlation coefficient were used for data analyses. RESULTS: Gingival crevicular fluid levels of t-PA and IL-1ß were significantly higher in chronic periodontitis and AgP groups than in the control group (p < 0.001). MMP-3 levels in gingival crevicular fluid were detected as significantly higher in the chronic periodontitis and AgP groups compared with the control group (p < 0.05). The t-PA/PAI-2 rate of patients with chronic periodontitis and AgP were significantly higher than the control group (p < 0.05). The positive correlations were found among the PAI-2, t-PA, IL-1ß and MMP-3 levels in gingival crevicular fluid. The volume of the gingival crevicular fluid correlated with all of the clinical parameters (p < 0.001). There were positive correlations between the gingival crevicular fluid levels of PAI-2 and the probing pocket depth and between gingival crevicular fluid levels of PAI-2 and the clinical attachment level (p < 0.01). Similarly, significant correlations were found between t-PA levels and probing pocket depth and between t-PA levels and clinical attachment level measurements (p < 0.001). CONCLUSION: The present data showed that gingival crevicular fluid levels of IL-1 ß, MMP-3 and t-PA increased in periodontal disease regardless of the periodontitis type and played a part in tissue destruction.

Increasing incidence of melanoma among middle-aged adults: an epidemiologic study in Olmsted County, Minnesota.

OBJECTIVE: To identify changes in the incidence of cutaneous melanoma over time in the fastest-growing segment of the US population-middle-aged adults. PATIENTS AND METHODS: By using the Rochester Epidemiology Project resource, we identified patients aged 40 to 60 years who had a first lifetime diagnosis of melanoma between January 1, 1970, and December 31, 2009, in Olmsted County, Minnesota. The incidence of melanoma and overall and disease-specific survival rates were compared by age, sex, year of diagnosis, and stage of disease. RESULTS: Between 1970 and 2009, age- and sex-adjusted incidence increased significantly over time (P<.001) from 7.9 to 60.0 per 100,000 person-years, with a 24-fold increase in women and a 4.5-fold increase in men. Although not significant (P=.06), the incidence of melanoma increased with age. Overall and disease-specific survival improved over time, with hazard ratios of 0.94 (P<.001) and 0.93 (P<.001) for each 1-year increase in the year of diagnosis, respectively. Each 1-year increase in the age at diagnosis was associated with an increased risk of death from any cause (hazard ratio, 1.07; P=.01) but was not significantly associated with disease-specific death (P=.98). Sex was not significantly associated with death from any cause (P=.81) or death from disease (P=.23). No patient with malignant melanoma in situ died from disease. Patients with stage II, III, and IV disease were more than 14 times more likely to die from disease than were patients with stage 0 or I disease (P<.001). CONCLUSION: The incidence of cutaneous melanoma among middle-aged adults increased over the past 4 decades, especially in middle-aged women, whereas mortality decreased.

Incidence of lentigo maligna in Olmsted County, Minnesota, 1970 to 2007.

BACKGROUND: The incidence of lentigo maligna (LM) may be increasing, but no population-based epidemiologic studies have been performed to our knowledge. OBJECTIVE: We sought to determine the incidence of LM in Olmsted County, Minnesota, along with overall and recurrence-free survival. METHODS: Using the Rochester Epidemiology Project, we identified all adult residents of Olmsted County, Minnesota, with a first lifetime diagnosis of LM between 1970 and 2007. Medical records were reviewed to determine demographic, clinical, and surgical data, and incidence and survival were calculated. RESULTS: Among 145 patients identified, median (range) age at diagnosis of LM was 70 (33-97) years. Treatment changed over time, with Mohs micrographic surgery becoming available after 1986. No patients died of LM; 5 had local recurrence. Estimated local recurrence-free survival at 5, 10, 15, and 20 years after diagnosis was 98%, 96%, 92%, and 92%, respectively. Overall age- and sex-adjusted incidence of LM among adults was 6.3 per 100,000 person-years, increasing from 2.2 between 1970 and 1989 to 13.7 between 2004 and 2007. LIMITATIONS: Retrospective study design and homogeneous population are limitations. CONCLUSION: The incidence of LM increased significantly among residents of Olmsted County, Minnesota, over an extended time frame, with incidence being significantly higher among men than women and increasing with age.

Three-dimensional volumetric computed tomographic scoring as an objective outcome measure for chronic rhinosinusitis: clinical correlations and comparison to Lund-Mackay scoring.

BACKGROUND: We aimed to test the hypothesis that three-dimensional (3D) volume-based scoring of computed tomography (CT) images of the paranasal sinuses was superior to Lund-Mackay CT scoring of disease severity in chronic rhinosinusitis (CRS). We determined correlation between changes in CT scores (using each scoring system) with changes in other measures of disease severity (symptoms, endoscopic scoring, and quality of life) in patients with CRS treated with triamcinolone. METHODS: The study group comprised 48 adult subjects with CRS. Baseline symptoms and quality of life were assessed. Endoscopy and CT scans were performed. Patients received a single systemic dose of intramuscular triamcinolone and were reevaluated 1 month later. Strengths of the correlations between changes in CT scores and changes in CRS signs and symptoms and quality of life were determined. RESULTS: We observed some variability in degree of improvement for the different symptom, endoscopic, and quality-of-life parameters after treatment. Improvement of parameters was significantly correlated with improvement in CT disease score using both CT scoring methods. However, volumetric CT scoring had greater correlation with these parameters than Lund-Mackay scoring. CONCLUSION: Volumetric scoring exhibited higher degree of correlation than Lund-Mackay scoring when comparing improvement in CT score with improvement in score for symptoms, endoscopic exam, and quality of life in this group of patients who received beneficial medical treatment for CRS.

Atypical generalized eruptive histiocytosis clonally related to chronic myelomonocytic leukemia with loss of Y chromosome.

Generalized eruptive histiocytosis, described in 1963 by Winklemann and Muller, is a reactive, self-healing form of non-Langerhans histiocytosis. Rare cases of atypical generalized eruptive histiocytosis have been reported in patients with hematopoietic malignancy, but the biological relationship between the two disorders is not known. We report an 84-year-old man with chronic myelomonocytic leukemia who presented with coalescing erythematous papules and plaques on the posterior neck, ear and lower lip, followed by development of blast crisis. Skin biopsy revealed a thick band-like dermal infiltrate of cells that exhibited morphologic features of macrophages or histiocytes and prominent elastolytic phagocytosis. These cells demonstrated a mature immunophenotype, expressing CD14 and CD68, with partial expression of CD13 but not CD1a, CD43, CD56, CD123, Langerin, or S-100 protein. Karyotype and fluorescence in situ hybridization analyses showed loss of the Y chromosome in bone marrow and skin specimens, providing evidence of a clonal relationship between the cutaneous eruption and the underlying chronic myelomonocytic leukemia. The presence of the same clone in skin and bone marrow specimens from our patient supports the possibility that atypical generalized eruptive histiocytosis is a marker for underlying hematopoietic malignancy. Discovery of additional cases may shed further light on the pathogenesis of this rare entity.

Increasing incidence of melanoma among young adults: an epidemiological study in Olmsted County, Minnesota.

OBJECTIVE: To identify the change in the incidence of cutaneous melanoma over time among young adults. PATIENTS AND METHODS: Using Rochester Epidemiology Project data, we identified patients aged 18 to 39 years who had a first lifetime diagnosis of melanoma from January 1, 1970, through December 31, 2009, in Olmsted County, Minnesota. Demographic and clinical information, including survival, was abstracted, and estimates of the incidence of melanoma and overall and disease-specific survival were generated. RESULTS: From 1970 to 2009, the incidence of melanoma increased by 8-fold among young women and 4-fold among young men. Overall and disease-specific survival seemed to improve over time; hazard ratios comparing year of diagnosis with mortality were 0.92 and 0.91, respectively. CONCLUSION: The incidence of cutaneous melanoma among young adults is rapidly increasing, especially among women. Continued close monitoring of this high-risk population is necessary.

The cutaneous manifestations of metastatic malignant melanoma.

Cutaneous metastases are common sequelae of primary malignant melanoma. Because patients with melanoma are examined frequently after diagnosis, it is important that dermatologists are aware of the range of findings that may represent metastatic disease. Many case reports and a few retrospective series have been published detailing the wide variety of clinical presentations of cutaneous metastatic melanoma. This article reviews the various manifestations of metastatic melanoma of the skin and oral mucous membranes and summarizes treatment options for metastatic disease.

Iatrogenic immunosuppression and cutaneous malignancy.

Patients with autoimmune and inflammatory conditions often receive long-term immunosuppressive therapy. Some of the largest patient populations with iatrogenic immunosuppression include patients who have received solid-organ transplants or who have rheumatoid arthritis or psoriasis. Although treatments improve patient outcomes, individuals with immunosuppression subsequently may have an increased risk of skin cancer, including squamous cell carcinoma, basal cell carcinoma, and malignant melanoma.

Incidence of cutaneous lupus erythematosus, 1965-2005: a population-based study.

OBJECTIVES: To assess trends in the cutaneous variants of lupus erythematosus (CLE) and to ascertain the incidence of CLE over the past 4 decades. DESIGN: Retrospective population-based study. SETTING: Community-based epidemiology project. PATIENTS: All Olmsted County, Minnesota, residents with any subtype of CLE between January 1965 and December 2005. MAIN OUTCOME MEASURES: Incidence of CLE and disease progression to systemic LE (SLE). RESULTS: A total of 156 patients with newly diagnosed CLE (100 females and 56 males) were identified between 1965 and 2005. The incidence rate (age and sex adjusted to the 2000 US white population) was 4.30 (95% confidence interval [CI], 3.62-4.98) per 100,000. The age- and sex-adjusted prevalence as of January 1, 2006, was 73.24 (95% CI, 58.29-88.19) per 100,000. Nineteen patients with CLE had disease progression to SLE: cumulative incidence at 20 years, 19%; mean (SD) length to progression, 8.2 (6.3) years. Compared with a previously reported incidence of 2.78 (95% CI, 2.08-3.49) per 100,000 for SLE among Rochester, Minnesota, residents in 1965 through 1992, the incidence of CLE in Rochester was 3.08 (95% CI, 2.32-3.83) per 100,000 in 1965 through 1992. CONCLUSIONS: The incidence of CLE is comparable to the published incidence of SLE. Our findings double the incidence of the root designation of the disease process known as LE (SLE and CLE).

Retrospective evaluation of patch testing before or after metal device implantation.

OBJECTIVE: To review the results of patch testing before or after metal device implantation. DESIGN: Retrospective medical chart review. SETTING: Tertiary care academic medical center. PATIENTS: All patients who underwent patch testing before or after metal device implantation. INTERVENTIONS: Patch testing. RESULTS: From January 1999 through March 2006, 44 patients underwent patch testing in conjunction with metal device implantation, 22 preoperatively and 22 postoperatively. The reason for preoperative patch testing was a history of allergy to metals. Five patients had positive results for a component of the proposed device. The reasons for postoperative patch testing were unexplained skin eruptions at the implantation site (13 patients), chronic joint pain (8 patients), and joint loosening (1 patient). None of the patients had positive patch test results to a component of the previously implanted device. CONCLUSIONS: Although the numbers of patients in this study were small, patch testing performed before metal device implantation was helpful in guiding the choice of device selected. Patch testing after implantation was of limited value.

Interleukin-1beta and thiobarbituric acid reactive substance (TBARS) levels after phase I periodontal therapy in patients with chronic periodontitis.

BACKGROUND: Interleukin-1beta (IL-1beta), a potent stimulator of bone resorption, has been implicated in the pathogenesis of periodontal tissue destruction. There is also a clearly defined and substantial role for free radicals or reactive oxygen species in periodontal destruction. The thiobarbituric acid reactive substances (TBARS) is a commonly applied test to measure free radical activity. The aims of this study were to investigate the amount of crevicular IL-1beta, tissue TBARS levels, and the clinical status of patients with advanced chronic periodontitis and the effect of phase I periodontal therapy on these clinical parameters and measurements. METHODS: Twenty-five chronic periodontitis and 25 healthy control (C) patients were selected for the study. Plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment level (CAL) were recorded from each sampling area. Gingival crevicular fluid (GCF) sampling and clinical index scores were recorded at the initial examination (IE) and 6 weeks after phase I periodontal therapy (APT). Assays for GCF IL-1beta were carried out by enzyme-linked immunosorbent assay (ELISA). Gingival tissue samples were obtained from sites requiring periodontal flap surgery due to unresolved pockets to determine the tissue TBARS levels. The paired-samples t test was used to compare the IL-1beta levels and clinical parameters between IE and APT. The independent-samples t test was used to determine the significance of all parameters between IE and C, and between APT and C. The correlation among the IL-1beta levels, clinical parameters, and tissue TBARS levels was analyzed using the Pearson correlation. RESULTS: The concentration of IL-1beta levels was not statistically different among IE, APT, and C groups, but the total amount of IL-1beta levels was statistically different among the 3 groups. While the levels of IL-1beta and the clinical parameters were reduced following phase I periodontal treatment, pretreatment IL-1beta, post-treatment IL-1beta, and TBARS levels were statistically higher in IE and APT groups than C specimens. Tissue TBARS levels in the APT group were statistically greater than controls. No correlations were noted between tissue TBARS levels and clinical parameters in the APT group. A positive statistical correlation was detected between the total IL-1beta and TBARS levels in the APT group. CONCLUSION: These data suggest that the levels of crevicular IL-1beta and gingival tissue TBARS are closely associated with periodontal status. This relationship may be valuable in treating and monitoring periodontal disease progression.

Evaluation of initial attachment of human gingival fibroblast cells to biodegradable membranes in vitro by light and scanning electron microscopy.

Guided tissue regeneration procedures using resorbable membranes have become accepted therapy for treating periodontal defects. Resorbable collagen and synthetic polylactide and polyglycolide copolymer membranes have been found to support regeneration and preclude the need for surgical removal. This study was undertaken to assess and compare the initial attachment of human gingival fibroblast cells to four collagen-based membranes (fascia lata, fascia temporalis, dura mater, and Type I bovine collagen) and a synthetic polylactic acid-based membrane (resolut). Human gingival fibroblasts were grown from explants of normal tissue obtained during surgical reduction of retromolar tissues. Membrane specimens were placed in separate culture wells and incubated with fibroblasts for one hour. The number of adherent cells was evaluated by light microscopy using an ocular grid system and detailed examination was performed by scanning electron microscopy. The results of evaluation by light microscopy indicated that initial cell attachment was significantly less in the polylactic acid-based membrane group than in the collagen-based membrane groups (P < 0.01). However, no significant differences were found among the collagen membrane groups in terms of fibroblast attachment (P > 0.01). Scanning electron microscopy examination of fibroblasts cultured directly on barrier membranes indicated that the collagen-based membranes appeared to facilitate cell attachment, whereas the polylactic acid-based membrane exhibited a morphology that was not conducive to attachment of human gingival fibroblasts. Based on these limited in vitro results, it appears that collagen-based membranes offer greater potential than polylactic acid-based membranes for guided tissue regeneration at surgical sites.

IL-6 levels in gingival crevicular fluid (GCF) from patients with non-insulin dependent diabetes mellitus (NIDDM), adult periodontitis and healthy subjects.

Cytokines play an important role in the pathology associated with chronic inflammatory diseases. One of these cytokines, interleukin 6 (IL-6) is a major mediator of the host response to tissue injury, infection and bone resorption. In the present study, gingival crevicular fluid (GCF) level of IL-6 was determined in patients with non-insulin dependent diabetes mellitus (NIDDM) with periodontitis, adult periodontitis, and healthy controls by use of an enzyme linked immunosorbent assay (ELISA). Twenty-four NIDDM patients with periodontitis, twenty-four adult periodontitis and twenty-four healthy controls were selected for the study. GCF sampling was performed on the vestibular aspects of maxillary incisors and canine teeth. Plaque index (PI), gingival index (GI), gingival bleeding time index (GBTI), probing depth (PD) and probing attachment levels (PAL) were recorded from each sampling area and also the entire dentition. NIDDM and adult periodontitis patients had numerous sites with radiographic evidence of alveolar bone resorption, loss of attachment and pocket depth greater than 3 mm. The mean GCF IL-6 level was 2.43 +/- 0.97 ng/ml in NIDDM patients, 1.31 +/- 0.92 ng/ml in adult periodontitis and 0.62 +/- 0.58 ng/ml in healthy subjects, respectively (p < 0.05). GCF IL-6 levels were markedly higher in NIDDM and adult periodontitis groups compared to the healthy controls. No correlation was found between GCF IL-6 levels and all clinical parameters. These findings suggested that GCF IL-6 levels were significantly higher in the area of inflammation and periodontal destruction locally. The high IL-6 levels in NIDDM patients might be due to different microbial flora in periodontal pockets and altered immune system. Future studies are needed to evaluate the complex interaction among IL-6 GCF levels, host response and local microbial environment in the NIDDM patients.

Combined use of root conditioning, fibrin-fibronectin system and a collagen membrane to treat a localized gingival recession: a 10-case report.

The purpose of this research was to evaluate the effectiveness of combined root surface conditioning with tetracycline HCI, fibrin sealing system, guided tissue regeneration procedure and coronal sliding flap application in the treatment of localized gingival recessions. The present study was conducted on 10 patients with localized facial recessions of at least 3mm. A trapezium-shaped flap was elevated apically to the margin of the bone dehiscence and the root surface was thoroughly scaled by hand instruments and burs. Tetracycline HCI (pH 1.9) solution was then topically applied for 5 minutes and the root surface thoroughly rinsed with sterile saline. A collagen membrane was trimmed and shaped to cover the entire root surface and later removed and a fibrin sealing system injected onto the root surface. Immediately membrane was placed again on the root surface without applying any pressure. The flap was sutured in the coronal position to completely cover the root surface and membrane. Control group patients were treated with only coronal sliding flap operation. Sutures were removed 10 days after surgery. Patients were clinically reevaluated 6 months postoperatively. The mean amount of root surface coverage obtained was similar in the test and control groups (test = 71.7%; control = 68.55%) but the clinical attachment gain (test = 4.21mm; control = 2.86mm) and pocket depth variations (test = 1.14mm reduction; control = 0.07mm reduction) differed significantly (P < 0.001). This study found promising healing of localized gingival recessions to result from a combined use of tetracycline HCI root demineralization, fibrin sealing system application, guided tissue regeneration procedure and coronal sliding flap operation.

An investigation of resorption and tissue reaction after subcutaneous implantation of collagen based membrane materials in rats.

This study was undertaken to assess histologically the response to collagen based membrane materials that might be used for guided tissue regeneration (GTR) procedures, using a subcutaneous model on the dorsal surface of the rat. The commercially available materials included absorbable type I bovine collagen barrier, fascia lata, fascia temporalis and dura mater membranes. In the study 20 Wistar rats were used 80 implant materials were placed under general anaesthesia. Animals were sacrificed 7, 14, 28 and 42 days post-implantation. The specimens were assessed histologically for the composition of the tissue surrounding the membranes, the types of cells in infiltrate and the degree of resorption. It was concluded that these membrane materials were well tolerated and were gradually resorbed. Light microscopic examination showed that the type I bovine collagen and fascia lata were resorbed faster but fascia temporalis and dura mater were resorbed more slowly at 42 days. In addition the resorption process was continuing and these materials were evident histologically at 42 days.

Verrucous carcinoma of skin.

Five different cases of verrucous proliferative lesions of skin are described and discussed. One of each developed in a chronic ulcer on a heel, in a scar on a lower leg, and on the penis, and two appeared in the region of the buttock in relation to chronic inflammatory sinuses. All these lesions showed morphological and clinical features of verrucous carcinoma which are described. It has been concluded that the variously named verrucous lesions in the literature (epithelioma cuniculatum, florid papillomatosis, giant cutaneous papilloma and papillomatosis cutis carcinoides), as well as our five cases represent a verrucous carcinoma which is a particular type of squamous cell carcinoma. This tumor develops typically in moist areas which are frequently sites of chronic inflammation. Despite the favorable prognosis, it is a potentially invasive tumor.