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The impact of disparities at the intersection of multiple marginalized social identities is poorly understood in trauma. We sought to evaluate the joint effect of race, ethnicity, and sex on new functional limitations 6 to 12 months postinjury.Moderately to severely injured patients admitted to one of three Level I trauma centers were asked to complete a phone-based survey assessing functional outcomes 6 to 12 months postinjury. Multivariate adjusted regression analyses were used to compare functional limitations by race and ethnicity alone, sex alone, and the interaction between both race and ethnicity and sex. The joint disparity and its composition were calculated across race and sex strata.Included were 4,020 patients: 1,621 (40.3%) non-Hispanic White male patients, 1,566 (39%) non-Hispanic White female patients, 570 (14.2%) Black or Hispanic/Latinx male patients, and 263 (6.5%) Black or Hispanic/Latinx female patients (BHF). The risk-adjusted incidence of functional limitations was highest among BHF (50.6%) vs non-Hispanic White female patients (39.2%), non-Hispanic White male patients (35.8%), and Black or Hispanic male patients (34.6%; p0.001). In adjusted analysis, women (odds ratio 1.35 [95% CI 1.16 to 1.57]; p0.001) and Blacks or Hispanic patients (odds ratio 1.28 [95% CI 1.03 to 1.58]; p = 0.02) were more likely to have new functional limitations 6 to 12 months postinjury. When sex and race were analyzed together, BHF were more likely to have new functional limitations compared with non-Hispanic White male patients (odds ratio 2.12 [1.55 to 2.90]; p0.001), with 63.5% of this joint disparity being explained by the intersection of race and ethnicity and sex.More than half of the race and sex disparity in functional limitations experienced by BHF is explained by the unique experience of being both minority and a woman. Intermediate modifiable factors contributing to this intersectional disparity must be identified.

The aim of this study was to evaluate the Social Vulnerability Index (SVI) as a predictor of long-term outcomes after injury.The SVI is a measure used in emergency preparedness to identify need for resources in the event of a disaster or hazardous event, ranking each census tract on 15 demographic/social factors.Moderate-severely injured adult patients treated at 1 of 3 level-1 trauma centers were prospectively followed 6 to 14 months post-injury. These data were matched at the census tract level with overall SVI percentile rankings. Patients were stratified based on SVI quartiles, with the lowest quartile designated as low SVI, the middle 2 quartiles as average SVI, and the highest quartile as high SVI. Multivariable adjusted regression models were used to assess whether SVI was associated with long-term outcomes after injury.A total of 3153 patients were included [54% male, mean age 61.6 (SD = 21.6)]. The median overall SVI percentile rank was 35th (IQR: 16th-65th). compared to low SVI patients, high SVI patients were more likely to have new functional limitations [odds ratio (OR), 1.51; 95% confidence interval (CI), 1.19-1.92), to not have returned to work (OR, 2.01; 95% CI, 1.40-2.89), and to screen positive for post-traumatic stress disorder (OR, 1.56; 95% CI, 1.12-2.17). Similar results were obtained when comparing average with low SVI patients, with average SVI patients having significantly worse outcomes.The SVI has potential utility in predicting individuals at higher risk for adverse long-term outcomes after injury. This measure may be a useful needs assessment tool for clinicians and researchers in identifying communities that may benefit most from targeted prevention and intervention efforts.

Background: Routine genome-wide screening for cardiovascular disease risk may inform clinical decision-making. However, little is known about whether clinicians and patients would find such testing useful or acceptable within the context of a genomics-enabled learning health system. Methods: We conducted surveys with patients and their clinicians who were participating in the HeartCare Study, a precision cardiology care project that returned results from a next-generation sequencing panel of 158 genes associated with cardiovascular disease risk. Six weeks after return of results, we assessed patients’ and clinicians’ perceived utility and disutility of HeartCare, the effect of the test on clinical recommendations, and patients’ attitudes toward integration of research and clinical care. Results: Among 666 HeartCare patients with a result returned during the survey study period, 42.0% completed a full or partial survey. Patient-participants who completed a full survey (n=224) generally had positive perceptions of HeartCare independent of whether they received a positive or negative result. Most patient-participants considered genetic testing for cardiovascular disease risk to have more benefit than risk (88.3%) and agreed that it provided information that they wanted to know (81.2%), while most disagreed that the test caused them to feel confused (77.7%) or overwhelmed (78.0%). For 122 of their patients with positive results, clinicians (n=13) reported making changes in clinical care for 66.4% of patients, recommending changes in health behaviors for 36.9% of patients, and recommending to 33.6% of patients that their family members have clinical testing. Conclusions: Both patients and clinicians thought the HeartCare panel screen for cardiovascular disease risk provided information that was useful in terms of personal or health benefits to the patient and that informed clinical care without causing patients to be confused or overwhelmed. Further research is needed to assess perceptions of genome-wide screening among the US cardiology clinic population.

Objective Determine the proportion and characteristics of traumatic injury survivors who perceive a negative impact of the COVID-19 pandemic on their recovery and to define post-injury outcomes for this cohort. Background The COVID-19 pandemic has precipitated physical, psychological, and social stressors that may create a uniquely difficult recovery and reintegration environment for injured patients. Methods Adult (≥18 years) survivors of moderate-to-severe injury completed a survey 6-14 months post-injury during the COVID-19 pandemic. This survey queried individuals about the perceived impact of the COVID-19 pandemic on injury recovery and assessed post-injury functional and mental health outcomes. Regression models were built to identify factors associated with a perceived negative impact of the pandemic on injury recovery, and to define the relationship between these perceptions and long-term outcomes. Results Of 597 eligible trauma survivors who were contacted, 403 (67.5%) completed the survey. Twenty-nine percent reported that the COVID-19 pandemic negatively impacted their recovery and 24% reported difficulty accessing needed healthcare. Younger age, lower perceived-socioeconomic status (SES), extremity injury, and prior psychiatric illness were independently associated with negative perceived impact of the COVID-19 pandemic on injury recovery. In adjusted analyses, patients who reported a negative impact of the pandemic on their recovery were more likely to have new functional limitations, daily pain, lower physical and mental component scores of the SF-12 and to screen positive for PTSD and depression. Conclusions The COVID-19 pandemic is negatively impacting the recovery of trauma survivors. It is essential that we recognize the impact of the pandemic on injured patients while focusing on directed efforts to improve the long-term outcomes of this already at-risk population.

PURPOSE Violence continues to be a significant public health burden, but little is known about the long-term outcomes of these patients. Our goal was to determine the impact of violence-related trauma on long-term functional and psychosocial outcomes. METHODS We identified trauma patients with moderate to severe injuries (Injury Severity Score, ≥9) treated at one of three level 1 trauma centers. These patients were asked to complete a survey over the phone between 6 and 12 months after injury evaluating both functional and psychosocial outcomes (12-item Short Form Survey, Trauma Quality of Life, posttraumatic stress disorder [PTSD] screen, chronic pain, return to work). Patients were classified as having suffered a violent injury if the mechanism of injury was a stab, gunshot, or assault. Self-inflicted wounds were excluded. Adjusted logistic regression models were built to determine the association between a violent mechanism of injury and long-term outcomes. RESULTS A total of 1,050 moderate to severely injured patients were successfully followed, of whom 176 (16.8%) were victims of violence. For the victims of violence, mean age was 34.4 years (SD, 12.5 years), 85% were male, and 57.5% were Black; 30.7% reported newly needing help with at least one activity of daily living after the violence-related event. Fifty-nine (49.2%) of 120 patients who were working before their injury had not yet returned to work; 47.1% screened positive for PTSD, and 52.3% reported chronic pain. On multivariate analysis, a violent mechanism was significantly associated with PTSD (odds ratio, 2.57; 95% confidence interval, 1.59-4.17; p < 0.001) but not associated with chronic pain, return to work, or functional outcomes. CONCLUSION The physical and mental health burden after violence-related trauma is not insignificant. Further work is needed to identify intervention strategies and social support systems that may be beneficial to reduce this burden. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.

Objective Assess the prevalence of anxiety, depression, and posttraumatic stress disorder (PTSD) after injury and their association with long-term functional outcomes. Background Mental health disorders (MHD) after injury have been associated with worse long-term outcomes. However, prior studies almost exclusively focused on PTSD. Methods Trauma patients with an injury severity score ≥9 treated at 3 Level-I trauma centers were contacted 6-12 months post-injury to screen for anxiety (generalized anxiety disorder-7), depression (patient health questionnaire-8), PTSD (8Q-PCL-5), pain, and functional outcomes (trauma quality of life instrument, and short-form health survey)). Associations between mental and physical outcomes were established using adjusted multivariable logistic regression models. Results Of the 531 patients followed, 108 (20%) screened positive for any MHD: of those who screened positive for PTSD (7.9%, N = 42), all had co-morbid depression and/or anxiety. In contrast, 66 patients (12.4%) screened negative for PTSD but positive for depression and/or anxiety. Compared to patients with no MHD, patients who screened positive for PTSD were more likely to have chronic pain {odds ratio (OR): 8.79 [95% confidence interval (CI): 3.21, 24.08]}, functional limitations [OR: 7.99 (95% CI: 3.50, 18.25)] and reduced physical health [β: -9.3 (95% CI: -13.2, -5.3)]. Similarly, patients who screened positive for depression/anxiety (without PTSD) were more likely to have chronic pain [OR: 5.06 (95% CI: 2.49, 10.46)], functional limitations [OR: 2.20 (95% CI: 1.12, 4.32)] and reduced physical health [β: -5.1 (95% CI: -8.2, -2.0)] compared to those with no MHD. Conclusions The mental health burden after injury is significant and not limited to PTSD. Distinguishing among MHD and identifying symptom-clusters that overlap among these diagnoses, may help stratify risk of poor outcomes, and provide opportunities for more focused screening and treatment interventions.

As the COVID-19 pandemic persisted into the 2020 to 2021 academic year, there was a continued effect on graduate medical education trainees and graduating trainee job attainment. Our survey aims to investigate how the pandemic has continued to affect job search and attainment for pediatric gastroenterology fellows as well as to re-evaluate the pandemic's impact on pediatric gastroenterology fellow educational experiences.An anonymous survey was distributed to all North American pediatric gastroenterology fellows from May to June 2021. Survey questions included topics related to job search and fellowship training and were tailored to respondent year of training.Of 453 pediatric gastroenterology fellows in the 2020 to 2021 academic year, 158 fellows (35%) responded to the survey. Of graduating fellow respondents with job contracts, 74% reported willingness to make compromises in their job search, 76% reported accepting academic positions that were primary clinical, and 42% estimated staying at their accepted job for less than 5 years. When asked about the impact of COVID-19 on various aspects of fellowship education, a negative impact was reported in the following areas: 76% in research, 94% in clinical experience, 73% in procedural skills, and 84% in didactics.The COVID-19 pandemic continues to make a significant impact on pediatric gastroenterology fellowship education and the job attainment process. Regarding accepted job positions, we found substantial willingness to compromise, a shorter duration to stay at the job than expected, and minimal research focus. This raises concern regarding job preparedness and satisfaction as fellows complete their medical training.

Pigmented lesions of the nail unit are commonly encountered in the clinical setting. Yet, they often present a unique challenge to clinicians because of a broad differential diagnosis or unfamiliarity with clinical and histopathologic features. A wide variety of causes exist ranging from benign lesions such as subungual hemorrhage to malignant lesions such as subungual melanoma. Identifying the underlying cause is key to appropriate management and follow-up in these patients. Although emerging clinical tools such as dermoscopy can be very useful in evaluation of these lesions, histopathologic analysis remains the gold standard. In this review, we discuss and provide a summary of important clinical and histopathological concepts of pigmented lesions of the nail unit with special focus on longitudinal melanonychia, melanotic macule, melanocytic nevus, subungual melanoma, along with discussion of some nonmelanocytic lesions.

Abdominal pain, nausea, and vomiting are known gastrointestinal symptoms of symptomatic SARS-CoV-2 infection (COVID-19 disease) in pediatric patients.(1) There is little literature regarding pancreatitis in COVID-19. We describe a 16-year-old male diagnosed with acute pancreatitis in the setting of a SARS-COV-2 infection and associated fluid balance considerations.

OBJECTIVES Recent advances in medical and surgical management have led to improved long-term survival in children with intestinal failure. Yet, limited data exist on their neurodevelopmental and cognitive outcomes. The aim of the present study was to measure neurodevelopmental outcomes in children with intestinal failure. METHODS Children enrolled in a regional intestinal failure program underwent prospective neurodevelopmental and psychometric evaluation using a validated scoring tool. Cognitive impairment was defined as a mental developmental index

We describe the case of a 42-yr-old female patient with a 2-yr history of headache that has progressively worsened. Physical examination revealed no neurological deficit. Magnetic resonance imaging showed a large tumor of the left lesser sphenoid wing that enhanced with gadolinium and produced displacement of the midline and the Sylvian fissure. A thorough analysis of the origin of the tumor was done to establish the surgical strategy. With the patient positioned supine with the head slightly turned to the right side, fixed in a 3-pin head clamp, a pterional craniotomy was performed. Since the origin of the tumor is in the lesser wing an early extradural devascularization of the tumor was done with drilling out all the hyperostotic bone of the lesser sphenoid wing, including the lateral base of the anterior clinoid process. Intradural debulking and resection showed the effect of extradural devascularization with an important decrease in bleeding, allowing the total resection of the tumor. An immediate postop magnetic resonance showed a complete removal of the tumor. The patient presented a paresis of the oculomotor nerve that completely resolved in the 3-mo follow-up. In the following video illustration, we narrate this operative case and highlight the nuances of this approach.1 The patient has given assent and written consent for videos, images, or clinical or genetic information to be published.

Multidisciplinary decision making has been shown to be highly effective in various aspects of medicine, most notably with the concept of tumor boards and transplant committees.1 ,2 The most updated guidelines for percutaneous coronary intervention (PCI), published jointly by the American College of Cardiology Foundation, American Heart Association, and the Society for Cardiovascular Angiography and Interventions, assign a class IC recommendation for the use of a collaborative Heart Team approach in the treatment of patients with complex coronary artery disease (CAD).3 The guidelines assert that this recommendation is based on retrospective analyses showing that patients with complex CAD referred for revascularization based on a Heart Team consensus have improved mortality compared with patients merely assigned to a particular strategy in the context of their trial enrollment. Despite the suggestion of improved mortality in this retrospective comparison, the Heart Team approach has not been adopted widely in the current clinical practice of cardiovascular medicine. This multidisciplinary innovation remains in its infancy, and numerous questions remain about its practicality, feasibility, and efficacy. For several reasons, there remains significant variability in the care delivered to patients with complex CAD.4 Numerous reports show that although differences in patient characteristics may explain some of the variability in revascularization decisions, much of this variance is physician driven, such as practicing in a fee-for-service model or high-risk anatomy for low-volume operators.4,5 As emphasis grows on informed decision making and patient-centered care, a critical evaluation of these difficult questions will be essential to discovering whether there is a clinically meaningful effect of the Heart Team approach on patients with complex CAD. Although the longstanding use of tumor boards in the field of oncology represents a functioning model of interdisciplinary care on which the Heart Team may be based, it is critical …

Recent data have demonstrated improved survival in children with intestinal failure. We hypothesized that this trend would also be observed in children with ultrashort bowel syndrome.A prospective database from Seattle Children's Intestinal Failure Program was used to evaluate outcomes and morbidities of consecutive patients with 10 cm or less of small bowel enrolled in the program since 2005. Data are listed as median (range).Five patients were identified with a bowel length of 6 (1-10) cm and follow-up of 54 (43-61) months. All children have survived and are currently between 3.5 and 5.5 years of age. One patient underwent isolated intestinal transplantation and one patient is currently listed for intestinal transplantation. The transplanted child is fully enterally fed. The other patients remain at least partially dependent on parenteral nutrition. None of these patients have current evidence of parenteral nutrition-associated liver disease. Patients have required extensive care after referral to our program, including 18 (15-32) visits to the emergency room, 152 (114-273) days of inpatient care, and 6 (5-9) central line-associated blood stream infections.Long-term survival in children with ultrashort bowel length is possible after referral to an intestinal failure program, although extensive medical management is required. These children may be reasonable candidates for long-standing intestinal rehabilitation as a bridge to intestinal transplantation.

Patients who undergo colorectal surgery have up to a 30% chance of developing a surgical site infection postoperatively. Silverlon is a silver nylon dressing designed to prevent surgical site infections, but only anecdotal evidence has previously supported its efficacy.The aim of this study was to evaluate the effect of silver nylon dressings in patients undergoing colorectal surgery.We performed a prospective, randomized, controlled trial comparing a silver nylon dressing with gauze dressings in patients undergoing elective colorectal surgery.The study was performed at a university-based, tertiary referral center.We studied patients undergoing elective colorectal surgery with an abdominal skin incision of at least 3 cm.Patients were randomly assigned to receive either a silver nylon or a gauze dressing.The primary end point was surgical site infection occurring within 30 days of surgery.One hundred ten patients were enrolled in the study and were randomly assigned to 1 of 2 treatment groups. After a 30-day follow-up period, the incidence of surgical site infection was lower in the silver nylon group compared with the control group (13% vs 33%, P = .011). Twenty-five patients in the study developed superficial surgical site infections, 5 in the silver nylon group and 14 in the control group (P = .021). Two patients in the study group developed deep wound infections compared with 4 in the control group (P = .438). Multivariate analysis revealed that patients in the control group had a 3-fold increase in risk of infection compared with patients in the silver nylon group (P = .013).A limitation of this study is that the members of the surgical team were not blinded to the treatment groups.Silver nylon is safe and effective in preventing surgical site infection following colorectal surgery.

Acute decompensated heart failure (ADHF) is a common syndrome with diverse etiologies and precipitating factors, which is associated with significant morbidity and mortality. Tremendous resources are used in treating this syndrome, with few prospectively designed clinical trials to guide therapy. Patients suffering from ADHF are at increased risk for readmission to the hospital as well as an increased risk of death. Prompt identification and management of these patients can lead to shorter length of hospital stay, lower likelihood of readmission, and, perhaps, lower mortality. Initial treatment should target the relief of congestive symptoms. Intravenous loop diuretics are the mainstay of therapy, whereas ultrafiltration has emerged as a viable option in patients refractory to conventional treatment with diuretics. The safety and efficacy of nesiritide have been clarified in a recent large randomized trial, reassuring a favorable safety profile, but with modest improvement in short-term clinical outcomes. Thus, the preferred intravenous vasoactive medication has yet to be determined in large clinical trials, and positive inotropic agents should be reserved for patients with hemodynamic collapse. This article reviews the in-hospital assessment and management of ADHF.

Introduction: Focal impulse and rotor modulation (FIRM)-guided ablation targets localized sources that are thought to sustain AF. In previous reports, it has been shown that FIRM is effective in terminating or organizing AF. We sought to evaluate the acute success of FIRM in patients with persistent and LSP AF undergoing ablation in our centers. Methods: This was a multicenter prospective observational study. FIRM was performed alone or before conventional ablation. Rotors were ablated as confirmed by their absence during remapping and acute success was defined as AF termination, organization or slowing 10%. Results: 57 patients were enrolled (mean age 63 ± 10; 7% LSP). Rotors-only ablation was performed in 56% of patients, and preceded conventional ablation in 44%. There were no major periprocedural adverse events. No focal impulses were found, while rotors were present in all patients (3.9 ± 1.2 per patient; 66% in the LA). In the RA, the majority of rotors were in the lateral wall (53%) and in the septum (30%). In the LA, most of the rotors were in proximity of the pulmonary veins (48%), with the second most common locations being around the mitral annulus or in the septum (17% and 13% respectively). Mean procedural time for FIRM only procedures was 226 ± 52 minutes vs a median of 210 (168-240) minutes for FIRM + conventional ablation procedures (p = NS). Overall acute success was achieved in 35% of patients (3% AF termination, 16% AF organization, 16% AF slowing) with a mean RF time to complete FIRM ablation of 30 ± 15 minutes; no difference in acute success was found when comparing persistent to LSP patients (28% vs 50%; p = NS). Conventional ablation following FIRM did not significantly increase the rate of acute success (1 additional patient converted to sinus rhythm during pulmonary vein isolation). Conclusion: Rotors were present in all patients undergoing ablation for non-paroxysmal AF, most commonly the right atrial lateral wall, septum or around the pulmonary veins. Their ablation was not effective in obtaining AF organization/termination during the procedure.

Introduction: We sought to investigate the characteristics and outcomes of patients who underwent RF ablation of PM ventricular arrhythmias (VA) in our center. Results: 26 patients were included, median age was 66 years (16 to 85), 46% female, all with normal LVEF. PM VAs were PVCs in 68% patients, and PVC + VT in 32%. Site of origin was the LV infero-septal PM in 73%, LV antero-lateral PM in 15% and right ventricular RV septal PM in 12%. 46% of patients showed other VAs in addition to the one originating from the PMs; in 33% of these patients, additional VAs were 2 or more. These VAs were mostly PVCs (92%), localized in the LVOT (64% - 56 % in the basal LV and 44% in the aortic cusps) and the septal RVOT (36%). The only additional VT was fascicular. All the PMs and mappable additional VAs were ablated with RF energy through an irrigated catheter and the aid of ICE; a remote magnetic navigation system (RMS) was used in half of the procedures. In one case, PVC suppression required additional epicardial ablation. Major complications occurred in 2 patients (8%): 1 pericardial effusion (the patient underwent ablation of a crista terminalis premature atrial complex in the same procedure) and 1 pseudoaneurysm. Acute success (PM VA suppression/non-inducibility) was achieved in 96% of patients (the patient with pericardial effusion could be anticoagulated further and the procedure was stopped). After a median follow-up period of 8 (4-14) months, long-term success (no PM VT recurrence or PVC burden reduced by 80% off antiarrhythmic drugs) was 92% after a single procedure, 96% after repeat procedures. When considering additional VAs, the only recurrence was a parahisian RVOT PVC. No difference in acute or overall long-term success was observed when comparing RMS-guided vs standard procedures (respectively 92% vs 100 % and 100% vs 92%; P = NS). Conclusion: PM VAs are most commonly PVCs originating from the LV infero-septal PM and are frequently (48%) associated with an additional ventricular focus (LVOT > RVOT >> fascicular VT). RF ablation is safe and effective in eliminating or significantly reduce the burden of PM VAs, as well the extra-PM foci that are commonly encountered in this population. RMS guided ablation is not inferior to standard ablation in this subset of patients.

Aim To evaluate the biodistribution, internal radiation dosimetry and toxicity of the humanized MAb h-R3 labelled with 9 9 m Tc in humans. Methods Twenty-five patients with suspected epithelial-derived tumours were included in this study and divided into two groups: group I consisted of 10 patients who received 3mg/1110MBq (3mg/30mCi); and group II consisted of 15 patients who received 6mg/2220MBq (6 mg/60 mCi). Single photon emission computed tomography (SPECT) and planar images, and multiple blood and urine samples were collected up to 24 h after injection. Haematological parameters and adverse effects were classified according to the WHO criteria. Biodistribution, human anti-mouse antibody (HAMA) response and absorbed doses were estimated and reported. Results Liver, spleen, kidneys and heart were identified as source organs. Their higher uptakes were 53.3′6.4%ID, 2.0′1.4%ID, 9.8′4.3%ID and 2.8′0.9%ID, respectively. The urinary bladder and large intestine also had a significant uptake. The mean urinary excretion was around 22%ID. The liver received the highest absorbed doses followed by the kidneys and the urinary bladder wall. There were no haematological or biochemical abnormalities with clinical significance related to the product. No patient developed HAMA response. Preliminary analysis of clinical results showed a sensitivity of 76.5% and a specificity of 100%. Conclusions The results of this study suggest that 9 9 m Tc.h-R3 could be used in patients in a safe and effective way, for the diagnosis of epithelial-derived tumours at the two evaluated dose levels.

Objective The objective of this study was to determine why different criteria for response to treatment of bacterial vaginosis (BV) led to markedly different conclusions about treatment efficacy in a randomized trial comparing metronidazole gel versus metronidazole/nystatin ovules. Study We compared the impact of two treatment regimens on individual components of Amsel and Nugent criteria at follow-up visits 14, 42, and 104 days after initiating treatment. Results Compared with gel, ovules more effectively eliminated amines, clue cells, and Gardnerella, Prevotella, or Mobiluncus morphotypes from vaginal fluid, thus achieving cure based on "usual" criteria (absence of BV by Amsel or Nugent criteria), but did not more effectively restore Lactobacillus morphotypes or lower vaginal pH, thus not meeting Federal Drug Administration (FDA) criteria for cure. Conclusion Because early vaginal recolonization by lactobacilli was poor after both gel and ovules, FDA draft criteria for cure missed marked differences in treatment efficacies against Gardnerella, clue cells, and amines. Cure defined more "usually" may give more useful information.

Nevus sebaceus of Jadassohn is a hamartoma that combines epidermal, follicular, sebaceous, and apocrine gland abnormalities. Classically, several types of cutaneous neoplasms have been associated with this hamartoma, with basal cell carcinoma being the most frequently described malignancy. We studied a series of 155 examples of nevus sebaceus of Jadassohn with clinicopathologic correlation. Several histopathologic changes related to the age of the patients were found. In our series, we could not identify any cases of authentic basal cell carcinoma. In contrast, several examples of primitive follicular induction and of trichoblastomas were seen. Other cutaneous hamartomas, hyperplasias, and neoplasms found in our series of nevus sebaceus of Jadassohn included syringocystadenoma papilliferum, sebomatricoma, apocrine gland cyst, poroma, different histopathologic variants of warts (classic warts, tricholemmoma, and desmoplastic tricholemmoma), primitive follicular induction, and ductal induction. In our series, no examples of malignant neoplasms were identified. On the basis of these findings, the classically recommended treatment for this hamartoma, which consists of early excision to prevent the development of malignancy, seems to be inappropriate.

Bacterial translocation (BT) has been involved in the pathogenesis of spontaneous bacterial peritonitis (SBP) in experimental cirrhosis. Because malnutrition is a common feature in cirrhosis, the aim of this study was to evaluate the effect of nutrition on BT and SBP. We induced cirrhosis in 44 Sprague-Dawley rats by administration of oral CCl4, and, afterward, 26 animals were maintained with dietary restriction. Cultures of mesenteric lymph nodes (MLN), peripheral and portal blood, liver, and spleen were performed. SBP occurred in 48% of the rats with ascites, this being more frequent in the malnourished animals (80%) than in control rats (29%). BT appeared in all the rats with SBP (100%) but only in 57% without it. In the malnourished animals, the BT rate was 95%, while it was 30% in the control group. These results suggest that malnutrition increases the BT rate and the risk of developing SBP in experimental cirrhosis, and that BT is frequent in cirrhosis and may play a role in the development of SBP.

Bleomycin is a powerful antitumoral antibiotic whose utilization has been limited by pulmonary toxicity. At the Medical Oncology Department of the Hospital General de Mexico, SS, 17 patients with high-risk testicular cancer were treated with therapeutic regimens based on cisplatin and bleomycin in continuous infusion. The mean bleomycin dose was 813 mg. Adequate renal function was observed in all patients during and after chemotherapy. During a minimum 4-year follow-up period, no patient experienced pulmonary toxicity; 3 patients died due to tumoral progression. The remaining 14 patients are alive and none of them had shown x-ray abnormalities nor a significant reduction in pulmonary vital capacity (PVC) or carbon monoxide diffusion capacity (DLCO). Bleomycin in continuous infusion can be an appropriate alternative for reducing pulmonary toxic effects. Therefore, randomized controlled studies should be conducted in order to determine if this treatment regime could enhance the therapeutic index.

Three cases of basal cell carcinoma showing shadow cells within basaloid islands have been described using the term basal cell carcinoma with matrical differentiation for this histologic variant. We present four new cases of basal cell carcinoma with evidence of matrical differentiation. Unlike the cases previously published, these lesions showed nests of shadow cells either within the lobules of basaloid cells or forming nests in the stroma. We also noted the presence of a foreign body reaction and calcification. These neoplasms illustrate the capability of basal cell carcinoma to differentiate toward hair matrix cells. Basal cell carcinoma with matrical differentiation must be added to the uncommon variants of basal cell carcinoma showing adnexal differentiation. A parallel between the degrees of differentiation of the cutaneous sebaceous neoplasms with those showing matrical differentiation is proposed.