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

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

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