An Unusual Presentation of Recurrent Squamous Cell Carcinoma

Introduction: Cutaneous squamous cell carcinoma (cSCC) is the second most common type of skin cancer with excellent outcomes after surgical removal in most cases. However, local recurrence occurs in about 4.6% of cases and is a sign of aggressive biologic behavior. Here, we present a case of recurrent SCC with unusual clinical features. Case Presentation: A 65-year old male with past medical history of untreated prostate cancer and anal cancer status post chemoradiation presented with a nonhealing wound on the right lateral hip. He had previously undergone excision of a squamous cell carcinoma in this area, followed by Mohs surgery due to local recurrence. After both procedures, clear margins were noted histologically. On exam of the right hip there was a large wound with granulation tissue and grouped grey papules and vesicles coalescing into plaques along the posterior edge of the wound which were rapidly progressive. Due to the rapid spread and vesicular nature, infection was initially favored, but the patient did not improve despite treatment with antibiotics and antivirals. The lesion was subsequently biopsied showing moderately differentiated cSCC with high grade features. The patient refused palliative radiation, and cemiplimab, a PD-1 inhibitor, is being initiated. Discussion: Local recurrence is considered a high-risk feature for cSCC. The threshold for biopsy in cases of possible recurrent cSCC is low, especially given that the clinical presentation can vary, such as the unusual appearance in our case. A multidisciplinary approach is critical in the management of such patients to reduce morbidity and mortality.https://scholarlycommons.henryford.com/merf2020caserpt/1005/thumbnail.jp

Demographics and clinical presentations of 844 patients with light and dark skin types with polymorphous light eruption and chronic actinic dermatitis evaluated over 23 years

INTRODUCTION: Polymorphous light eruption (PMLE) and chronic actinic dermatitis (CAD) have been classically described in White individuals, although recent studies have reported higher prevalence in patients with dark skin types, particularly African Americans. OBJECTIVE: To evaluate for differences in demographic, and clinical features between persons with light and dark skin types who have PMLE and CAD. METHODS: Retrospective review of patients with PMLE and CAD who were diagnosed from January 1, 1998, through November 31, 2021, at a single academic dermatology center. RESULTS/DISCUSSION: A total of 844 patients (725 [85.9%] female; mean [SD] age of onset: 41.7 [16.9] years) were diagnosed with PMLE, and 60 patients (22 [36.6%] female; mean age, [SD]: 60.6 [10.6] years) of age at presentation, disease duration of 8.2 [7.3] years were diagnosed with CAD. Although just over 50% of the general clinic population was White, the prevalence of PMLE and CAD was significantly higher in dark-skinned individuals compared to light-skinned individuals (PMLE: 625 [74.0%] vs. 219 [25.9%], p value \u3c .001; CAD: 43 [71.6%] vs. 17 [28.3%], p value = .003) respectively. The pinpoint papular variant of PMLE (PP-PMLE) was predominantly seen in dark-skinned individuals. CONCLUSION: A substantial proportion of PMLE and CAD cases are present in dark-skinned individuals. PP-PMLE can be mistaken for lichen nitidus. As such, recognition of this entity is important for adequate evaluation and management of patients with PMLE

633 Comparison of soluble proteins from skin sections of acne and TCA induced postinflammatory hyperpigmentation and erythema

Postinflammatory hyperpigmentation (PIH) is an acquired hypermelanosis occurring after cutaneous inflammation or injury that can arise in all skin types, but more frequently affects skin-of-color. The differences in the ethology of PIH and Postinflammatory erythema (PIE) in skin of color were evaluated from soluble protein extracts collected from skin section samples, using Somascan protein kit1.3 k (n=5). The skin samples were collected from selected gluteal TCA-induced lesions and truncal acne pustules, of either PIH or PIE, at day 28 post initial evaluation. Differences between proteins (FDR\u3c0.05) from PIH and PIE were analyzed with STRING version 11.5 and analysis points toward involvement of JAK/STAT signaling pathway and enhanced IL17 signaling in PIH compared to PIE lesions (OSM, CSF3, IL10RA, IL12RB2, IL10RB, IL3, CSF2, IL17D, IL17F, IFNA2, IFNA10, CRLF2, IL5RA, TYK2, IL12RB1, PRLR, GHR). The involvement of JAK/STAT signaling pathway has been described for some chronic cutaneous inflammatory conditions and acne. A higher occurrence of dermal remodeling proteases and inhibitors were found in PIE (MMP1, MMP2, MMP7, TIMP2) indicating a dermal remodeling phase at the time of excision. Concurrently, elevated levels of IL-1β, and TGF-β (critical for triggering and continuing differentiation programs of naïve CD4+ T cells to IL-17 secreting Th17 cells) in PIH samples suggests continuing promotion of macrophage infiltration and sustained inflammation. In addition to MMP13 and MMP16, the protein Keap1 was found to be increased in the PIH samples. Keap1, a repressor of master cellular defense against oxidative and electrophilic stresses, has been reported to be involved in the imbalance of proteolysis that can lead towards premature aging and in a senescent phenotype of endothelial cells. The sustained inflammation with excess of Keap1 protein might contribute to an altered proteostasis and ethology of PIH

The Efficacy of Topical Hydrolyzed Psoralea corylifolia Extract in Treating Postinflammatory Hyperpigmentation

Background: Post-inflammatory hyperpigmentation (PIH) is common following resolution of acne. Purpose: The purpose of this study is to determine the treatment efficacy of Topical Hydrolyzed Psoralea Corylifolia extract (HPCE) on acne-induced PIH and TCA-induced PIH using a previously validated model.1Methods: A prospective, single-blinded, non-randomized study was conducted on 20 subjects with acne-induced PIH. Three acne-induced PIH areas on the face and three 35% TCA-induced PIH areas on the buttocks were analyzed. Subjects received topical HPCE [Unigen] and vehicle cream with instructions on twice daily application on two separate facial and gluteal lesions for 28 days; the third lesion served as a control. Clinical photography and Investigator Global Assessment (IGA) scores for hyperpigmentation were performed on days 0, 28, 35, 42, and 56 for all sites. Degree of improvement was defined as the change in the IGA score for hyperpigmentation between the first and last day of treatment. Results: For facial acne sites, one-way repeated measures ANOVA for degree of improvement as assessed by IGA analysis demonstrated a greater degree of improvement for product sites when compared to vehicle (1.9 times) and control (1.5 times); however, statistical significance was not reached. For TCA-induced PIH sites, there was a statistically significant degree of improvement for product treated sites compared to vehicle (9 times) and control (9 times). For both acne and TCA-induced PIH sites, Pearson correlation coefficient between time and IGA score for hyperpigmentation showed a strong and statistically significant (phttps://scholarlycommons.henryford.com/merf2019clinres/1010/thumbnail.jp

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030