Anne M. Lachiewicz

Survival Differences Between Patients With Scalp or Neck Melanoma and Those With Melanoma of Other Sites in the Surveillance, Epidemiology, and End Results (SEER) Program

OBJECTIVE To compare the prognosis of patients with scalp or neck (scalp/neck) melanomas with that of patients with melanomas at other sites in a large, population-based national data set controlling for known prognostic factors. DESIGN Retrospective cohort study using US cancer registries that constitute the Surveillance, Epidemiology, and End Results 13 Registries (SEER-13) database. PATIENTS A total of 51 704 non-Hispanic white adults in the United States with a first invasive cutaneous melanoma reported during the period 1992 to 2003. MAIN OUTCOME MEASURES Kaplan-Meier survival estimates were used to compare melanoma-specific survival by anatomic site at 5 and 10 years. Multivariate Cox models were used to examine the hazard ratio (HR) of melanoma-specific death associated with scalp/neck melanoma compared with melanoma of the extremities after controlling for other variables. RESULTS The 5- and 10-year Kaplan-Meier survival probabilities for scalp/neck melanoma were 83.1% and 76.2%, respectively, compared with 92.1% and 88.7%, respectively, for melanoma of the other sites, including extremities, trunk, face, and ears (log-rank test; P < .001). In a multivariate Cox model, the patients with melanoma of the scalp/neck died of melanoma at 1.84 times (HR, 1.84; 95% confidence interval, 1.62-2.10) the rate of those with melanoma on the extremities, controlling for age, Breslow thickness, sex, and ulceration. Neither excluding cases of lentigo maligna and nodular melanoma nor controlling for lymph node involvement materially changed the HR for scalp/neck melanoma. CONCLUSIONS A notable survival difference remained between scalp/neck melanoma and melanoma of other sites even after adjustment for important prognostic factors. This finding has implications for screening and public health recommendations, and we urge physicians, physician assistants, nurses, and nurse practitioners to examine the scalp/neck carefully during routine skin examinations. Further studies are needed to understand the biological or environmental factors leading to survival differences by anatomic site.

Weight and Activity Change in Overweight and Obese Patients After Primary Total Knee Arthroplasty

Few studies have examined the effect of primary total knee arthroplasty on the weight and physical activity of overweight and obese patients in the United States. We conducted a prospective study of changes in mean weight, body mass index (BMI), and physical activity over 2 years in 188 consecutive overweight or obese patients. Weight, BMI, and physical activity, evaluated using the Lower Extremity Activity Scale (LEAS), were assessed preoperatively and at 1 and 2 years. At 2 years, no significant weight change was found (P = .80), but BMI increased by 0.46 kg/m(2) (P = .049). The LEAS score increased from preoperatively to 2 years (P < .001). Preoperative LEAS score was not associated with weight or BMI at 2 years. This finding has implications for patient expectations and preoperative counseling.

Solar UV exposure and mortality from skin tumors

Solar ultraviolet radiation (UVR) exposure is clearly associated with increased mortality from nonmelanoma skin cancer--usually squamous cell carcinoma. However, the association with cutaneous melanoma is unclear from the evidence in ecologic studies and the few analytic studies show that high levels of intermittent UV exposure prior to diagnosis are somehow associated with improved survival from melanoma. Understanding this conundrum is critical to present coherent public health messages and to improve the mortality rates from melanoma.

Muir-Torre syndrome

In this case report of Muir-Torre syndrome (MTS), we describe a 47-year-old man with a personal and family history of colon cancer and a personal history of keratoacanthoma who presented with a sebaceous carcinoma and, subsequently, had a cystic sebaceous tumor. Immunohistochemical examination of the patient’s colonic tumor, located proximal to the splenic flexure, revealed absence of MutL homolog (MLH)-1 protein.MTS is a rare genodermatosis defined clinically by the occurrence of a sebaceous neoplasm and an internal malignancy in the absence of other predisposing factors. Most patients present with sebaceous adenomas, but cystic sebaceous neoplasms have been reported as specific markers of MTS. Gastrointestinal and genitourinary cancers are the most common internal malignancies, with colorectal cancers often occurring at or proximal to the splenic flexure, contrary to most sporadic colorectal cancers. MTS is most frequently found as a variant of the autosomal dominant disorder hereditary non-polyposis colorectal cancer (HNPCC), with tumors demonstrating microsatellite instability and germline mutations in the DNA mismatch repair genes MutS homolog (MSH)-2 and MLH1. However, the distribution of gene mutations of patients with MTS is slightly different from that seen in all HNPCC families, and some cases of MTS arise spontaneously.Physicians should consider MTS in patients presenting with a sebaceous neoplasm, and immunohistochemical examination of tumors for MSH2 and MLH1 protein can be used as a screening test to identify patients with MTS. While the sebaceous and internal neoplasms of MTS are thought to follow a more indolent course than sporadic malignancies, patients with this disorder should be treated with standard therapies and carefully followed. Evidence indicates that for individuals with or at risk of MTS or HNPCC, colonoscopy every 1–2 years beginning at age 20–25 or 10 years younger than the youngest age at diagnosis in the family can be strongly recommended. Additionally, most experts believe that an annual history and physical examination, including a complete skin examination and urinalysis, as well as periodic endometrial sampling and/or transvaginal ultrasound for women, are worthwhile screening tests for these high-risk patients.

Healthcare-Associated Infections among Patients in a Large Burn Intensive Care Unit: Incidence and Pathogens, 2008–2012

Burn injuries are a common source of morbidity and mortality in the United States, with an estimated 450,000 burn injuries requiring medical treatment, 40,000 requiring hospitalization, and 3,400 deaths from burns annually in the United States. Patients with severe burns are at high risk for local and systemic infections. Furthermore, burn patients are immunosuppressed, as thermal injury results in less phagocytic activity and lymphokine production by macrophages. In recent years, multidrug-resistant (MDR) pathogens have become major contributors to morbidity and mortality in burn patients. Since only limited data are available on the incidence of both device- and nondevice-associated healthcare-associated infections (HAIs) in burn patients, we undertook this retrospective cohort analysis of patients admitted to our burn intensive care unit (ICU) from 2008 to 2012.

Nontuberculous mycobacterial infection after fractionated CO(2) laser resurfacing.

Nontuberculous mycobacteria are increasingly associated with cutaneous infections after cosmetic procedures. Fractionated CO2 resurfacing, a widely used technique for photorejuvenation, has been associated with a more favorable side effect profile than alternative procedures. We describe 2 cases of nontuberculous mycobacterial infection after treatment with a fractionated CO2 laser at a private clinic. Densely distributed erythematous papules and pustules developed within the treated area within 2 weeks of the laser procedure. Diagnosis was confirmed by histologic analysis and culture. Both infections responded to a 4-month course of a multidrug regimen. An environmental investigation of the clinic was performed, but no source of infection was found. The case isolates differed from each other and from isolates obtained from the clinic, suggesting that the infection was acquired by postprocedure exposure. Papules and pustules after fractionated CO2 resurfacing should raise the suspicion of nontuberculous mycobacterial infection.

Timeline of health care–associated infections and pathogens after burn injuries

BACKGROUND Infections are an important cause of morbidity and mortality after burn injuries. Here, we describe the time line of infections and pathogens after burns. METHODS A retrospective study was performed in a large tertiary care burn center from 2004-2013. Analyses were performed on health care-associated infections (HAIs) meeting Centers for Disease Control and Prevention criteria and on all positive cultures. Incidence rates per 1,000 days were calculated for specific HAI categories and pathogens and across hospitalization time (week 1, weeks 2-3, and week ≥4). RESULTS Among 5,524 patients, the median burn size was 4% of total body surface area (interquartile range, 2%-10%). Of the patients, 7% developed an HAI, of whom 33% had >1 HAI episode. Gram-positive bacteria were isolated earlier, and gram-negative bacteria were isolated later during hospitalization. Of 1,788 bacterial isolates, 44% met criteria for multidrug resistance, and 23% met criteria for extensive drug resistance. Bacteria tended to become increasingly resistant to antibiotics as time from admission increased. CONCLUSIONS We observed differences in infection type, pathogen, and antibiotic-resistant bacterium risk across time of hospitalization. These results may guide infection prevention in various stages of the postburn admission.

Adenovirus causing fever, upper respiratory infection, and allograft nephritis complicated by persistent asymptomatic viremia.

A 20‐year‐old woman, with renal transplant complicated by recurrence of focal segmental glomerulosclerosis and post‐transplant lymphoproliferative disorder, presented nearly 2 years after transplantation with fever, conjunctivitis, and sinus congestion. She was found to have severe adenovirus (ADV)‐induced granulomatous interstitial nephritis, confirmed by immunohistochemical staining for ADV in the renal biopsy, without urinary symptoms, hematuria, or laboratory evidence of a change in allograft function. Fever, upper respiratory tract symptoms, and evidence of adenoviral infection in the allograft resolved with decreased immunosuppression and treatment with cidofovir and intravenous immunoglobulin. Creatinine rose during treatment and remained elevated, possibly related to cidofovir nephrotoxicity. Despite therapy and continued reduction in immunosuppression, asymptomatic low‐level viremia persisted for a year. In renal transplant patients with ADV infection, allograft involvement should be highly suspected even without overt urinary symptoms or laboratory evidence of allograft dysfunction. Demonstration of allograft involvement may prompt alternative management that could limit continued allograft infection. No clear recommendations exist for management of asymptomatic ADV viremia in solid organ transplant patients.

Reduction in central line-associated bloodstream infections in patients with burns

2000 Enhanced education of medical staff regarding central lines; addition of 2% chlorhexidine plus 70% isopropyl alcohol for skin preparation to central line kits 2001 Mandatory training for nurses on IV line site care and maintenance 2003 Central line changes over a guidewire every 3 days with use of a new site every 6 days becomes standard practice; use of full body drape for line insertion and changes 2003–2005 Introduction of antibiotic-impregnated central venous catheters for all patients 2004 Enhanced nursing education on central line insertion and maintenance 2005 Customized catheter-insertion kits 2006 Universal glove and gown use for all patient encounters 2007 Implementation of the Institute for Healthcare Improvement bundle to prevent CLABSI 2009 Use of chlorhexidine patch at insertion site

Pseudomonas aeruginosa exoproducts determine antibiotic efficacy against Staphylococcus aureus

Chronic coinfections of Staphylococcus aureus and Pseudomonas aeruginosa frequently fail to respond to antibiotic treatment, leading to significant patient morbidity and mortality. Currently, the impact of interspecies interaction on S. aureus antibiotic susceptibility remains poorly understood. In this study, we utilize a panel of P. aeruginosa burn wound and cystic fibrosis (CF) lung isolates to demonstrate that P. aeruginosa alters S. aureus susceptibility to bactericidal antibiotics in a variable, strain-dependent manner and further identify 3 independent interactions responsible for antagonizing or potentiating antibiotic activity against S. aureus. We find that P. aeruginosa LasA endopeptidase potentiates lysis of S. aureus by vancomycin, rhamnolipids facilitate proton-motive force-independent tobramycin uptake, and 2-heptyl-4-hydroxyquinoline N-oxide (HQNO) induces multidrug tolerance in S. aureus through respiratory inhibition and reduction of cellular ATP. We find that the production of each of these factors varies between clinical isolates and corresponds to the capacity of each isolate to alter S. aureus antibiotic susceptibility. Furthermore, we demonstrate that vancomycin treatment of a S. aureus mouse burn infection is potentiated by the presence of a LasA-producing P. aeruginosa population. These findings demonstrate that antibiotic susceptibility is complex and dependent not only upon the genotype of the pathogen being targeted, but also on interactions with other microorganisms in the infection environment. Consideration of these interactions will improve the treatment of polymicrobial infections.