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Acid-fast bacilli staining for nonhealing ulcers: a case report of cutaneous Mycobacterium chelonae infection
No full textBACKGROUND: Cutaneous infections due to nontuberculous mycobacteria (NTM) are rare, and they can be challenging to treat, often requiring prolonged therapy with multiple antibiotics. Although recent literature challenges the idea of routine acid-fast bacilli (AFB) testing in diabetic foot infections, this report presents a case of Mycobacterium chelonae (M chelonae) infection in a patient with nonhealing ulceration.
CASE REPORT: A 64-year-old female with no history of immunocompromise and no recent surgical history presented with a rapidly growing ulceration despite appropriate antibiotic therapy based on routine aerobic culture results. After AFB cultures were obtained, she was found to have NTM infection with M chelonae, and the ulceration was healed without recurrence after treatment for 4 months with linezolid and clarithromycin.
CONCLUSION: This case highlights the potential inoculation of M chelonae, even in immunocompetent patients without known inoculation injury, and it highlights the value of AFB cultures in patients who do not progress with standard wound care therapies and routine aerobic cultures
Impact of an Interruptive Alert on the Number of Women Receiving CDC-Recommended Therapy for Trichomoniasis
No full textBackground: The 2021 Centers of Disease Control and Prevention (CDC) sexually transmitted infection treatment guidelines recommend a 7-day course of metronidazole or single-dose tinidazole for women with trichomoniasis due to improved patient outcomes compared with single-dose metronidazole therapy. A health system antimicrobial stewardship program implemented an interruptive electronic health record (EHR) alert to promote optimal trichomoniasis prescribing when nonrecommended treatment is ordered.
Objective: To determine the impact of an interruptive EHR alert on optimal trichomoniasis prescribing for women.
Methods: This was an institutional review board-approved, single pretest, posttest quasi-experiment of women ≥ 15 years with a microbiologically confirmed Trichomonas vaginalis infection from 10/2023 to 12/2023 (preintervention) and 10/2024 to 12/2024 (postintervention). An EHR alert was implemented 9/2024 that notifies prescribers that single-dose metronidazole 2 g is not recommended and suggests CDC-recommended treatments. The primary outcome was the proportion of single-dose metronidazole 2 g orders before and after EHR alert implementation. A secondary cross-sectional evaluation of all alerts triggered from 10/2024 to 12/2024 was performed and included the number of alerts, location of alert, and provider response.
Results: A total of 285 patients were included, 49.8% pre-intervention and 50.2% postintervention. Metronidazole 2 g was prescribed for 8.45% of pre-intervention and 2.80% of postintervention patients (P = 0.038). The clinical support alert fired 102 times for 75 patients during the 3-month postimplementation period. The alert was associated with a change in intended prescription to a metronidazole 7-day course in greater than 60% of patients over 3 months.
Conclusion: The implementation of an interruptive alert was associated with high acceptance and improved prescribing for women treated for trichomoniasis
Trends and disparities in palliative care utilization in advanced head and neck cancer hospitalizations
No full textBackground: Greater than 60% of Head and neck cancer (HNC) patients have advanced cancer at the time of presentation. They have unique physical and psychological symptoms due to the cancer\u27s anatomical location and multimodal treatment-related toxicities. Early integration of palliative care (PC) in their management can improve health-related quality of life. We examined the trends and predictors of PC utilization among hospitalized advanced HNC patients in the US. Methods: A retrospective longitudinal study was conducted using the NIS database (2008-2021). Using joinpoint regression and multivariable logistic regression, trends and factors associated with PC receipt were assessed. Results: The overall prevalence of palliative care utilization among 326,265 hospitalizations with advanced HNC was 11%. Over the period, palliative care utilizations increased from 3,651 to 16,982 per 100,000 advancedHNC admissions (p-trend,0.001) with an average annual percentage increase of 9.7%. Females with metastaticHNChad higher odds (Adjusted odds ratio (AOR): 1.11;95%CI: 1.04-1.19) of receiving palliative care compared to males. There was similar likelihood of utilizing palliative care across racial groups. Patients in teaching hospitals had 46% higher likelihood (AOR: 1.46; 95% CI: 1.33-1.60) of palliative care use in comparison to patients in non-teaching hospitals. Large hospitals had higher palliative care use compared to small hospitals (AOR: 1.12; 95% CI: 1.01- 1.25). Admissions in the south and west had higher likelihood of palliative care use relative to those in the North-east region. Patients covered by Medicaid had higher odds of palliative care receipt compared to those covered by Medicare. Relative to patients whohad a routine discharge home or with self-care, those discharged to facilities or with home health care were four-fold more likely (AOR: 4.35; 95% CI: 3.98-4.75) to receive palliative care. Those who died during hospitalization were also more likely to use palliative care (AOR: 21.4; 95% CI: 19.1-24.0). Nonelective admissions had higher likelihood of palliative care receipt relative to elective visits. Conclusions: Although palliative care utilization has improved over the years, it remains suboptimal. Tailored interventions addressing sociodemographic and hospital-level disparities will promote equitable access and meet the unique needs of this patient population
Genital cancer mortality in comorbid vs. non-comorbid populations: A nationwide trend analysis
No full textBackground: Genital cancers (GCs) remain a critical public health issue, with comorbidities such as hypertension (HTN) and diabetes significantly impacting outcomes. This study investigates comparative mortality trends in GCs with and without comorbid HTN and diabetes in U.S. adults aged 35 years and older. Methods: Data from 1999-2022 was extracted from the CDC WONDERdatabase. Age-adjusted mortality rates (AAMR) and annual percentage changes (APC) were calculated using Joinpoint regression. Results: Between 1999 and 2022, 277,938 GC deaths occurred with comorbid HTN and diabetes compared to 1,817,017 without these comorbidities. AAMRs for GCs with comorbidities increased significantly from 39.23 in 1999 to 68.34 in 2022, while AAMRs for GCs without comorbidities declined from 424.63 to 319.56. Men consistently had higher AAMRs thanwomen in both groups (Men: 96.01 vs Women: 25.57 and Men: 513.59 vs Women: 264.00). NH Blacks had the highest average APC for GCs both with (7.12) and without (-0.94) comorbidities, though the burden of GCs-related mortality was significantly lower without comorbidities. Mortality rates were highest in the 85+ age group in both cohorts. Geographical analysis revealed the highest overall AAMR in the Midwest, with 53.77 for GCs with comorbidities and 352.6 for those without. Non-metropolitan areas accounted for 20.4% of deaths (AAMR: 43.82 to 75.45; APC: 2.37) in GCs with comorbidities, while metropolitan areas accounted for 79.6% (AAMR: 38.18 to 62.25; APC: 2.08), both demonstrating increasing mortality. For GCs without comorbidities, non-metropolitan areas had 18.4% of deaths (AAMR: 444.8 to 346.76; APC: -1.36), and metropolitan areas had 81.6% (AAMR: 419.96 to 315.75; APC: -1.47), both showing a decline over time. Conclusions: Mortality trends for GCs with comorbid HTN and diabetes are rising, in stark contrast to declining trends for GCs without these comorbidities. Disparities by sex, race, age, and geography highlight the need for targeted interventions and equitable access to care, particularly for high-risk populations
ABCL-089: Masquerading as Breast Cancer: Rare Metastatic Peripheral T-Cell Lymphoma
No full textPeripheral T-cell lymphoma (PTCL) is a rare subtype of non-Hodgkin lymphoma that typically originates in the lymph nodes and rarely involves the breast. Here, we present a case in which PTCL not only originated in the breast but also mimicked an aggressive primary breast cancer—an exceptionally rare diagnosis, with only 18 documented cases in the literature. Patient: A 76-year-old debilitated female with diabetes, hypertension, and blindness from glaucoma presented after a mechanical fall. During evaluation, she reported a 3-week history of left breast pain with intermittent malodorous discharge. Years prior, a similar episode had resolved after incision and drainage and antibiotics for a presumed abscess. Results and Interventions: On examination, the breast was indurated without active discharge, although purulent and bloody drainage was observed in the emergency department. There was no lymphadenopathy or hepatosplenomegaly. Surgery attempted drainage unsuccessfully, prompting biopsy and oncology evaluation. Imaging added to the diagnostic dilemma. A recent mammogram was unremarkable. Noncontrast head computed tomography showed unchanged skull lucencies. However, brain MRI revealed new lytic calvarial lesions without brain involvement. Labs showed pancytopenia. Workup ruled out primary breast malignancy and multiple myeloma. Ultimately, immunohistochemistry showed a distinct but non-specific T-cell marker profile (BETAF1, CD8, TIA1, CD3, CD43, CD56, CD15, BCL2, GATA3, CD79a, c-MYC), leading to the diagnosis of PTCL-not otherwise specified (PTCL-NOS) with skull metastases and bone marrow infiltration. Outcome: Given the aggressive disease course, lack of defined treatment protocols, and poor prognosis, the patient opted for hospice care. Conclusions: This case illustrates several key challenges: • rare extranodal breast presentation. • clinical mimicry of primary breast carcinoma. • diagnostic confusion from lytic skull lesions and pancytopenia. • delayed diagnosis due to non-specific immunohistochemistry. • lack of data to guide management—only 4 of 18 known PTCLbreast cases involved metastasis. This case underscores the need for heightened suspicion in atypical breast lesions and highlights the diagnostic complexity and treatment uncertainty of rare extranodal lymphomas like PTCL
Temporal and regional mortality trends due to pulmonary embolism in female patients with genital cancers in the United States from 1999 to 2020
No full textBackground: The involvement of pulmonary vessels by tumor emboli has been described from different primary sites of malignancy. Pulmonary embolism (PE) is a severe and potentially fatal complication in patients with female genital cancers, including ovarian, cervical, uterine, and vulvar malignancies. These cancers, along with associated treatments such as major abdominal surgery, chemotherapy, and hormone therapy, significantly increase the risk of venous thromboembolism (VTE), including PE. While previous studies detail the advancements in cancer detection and treatment, temporal and regional trends of PE-related mortality among female genital cancer patients remain poorly characterized. Methods: This retrospective study analyzes national mortality data from the CDC WONDER database to assess mortality trends from 1999 to 2020 across different demographic subgroups in the United States. Patients with a known history of genital cancer were identified and PE related mortality data was retrieved. Age-adjusted mortality rates (AAMRs) per 100,000 individuals were calculated further stratified based on sex, age (15-64 years and.64 years), race and census region. Rstudio was used to perform t-test and Mann Kendall test. Results: From 1999 to 2020, a total of 13,692 deaths were reported in female genital cancer associated pulmonary embolism in the US (AAPC: 0.421 (95% CI: 0.414-0.428)). The AAMR has risen from 0.363 in 1999 to 0.590 in 2020, indicating a worsening trend over the study period (t: 0.680, p,0.001). AAMR varied greatly by region, with the Northeast having the highest AAMR (9.928). This was followed by the West (0.488), Midwest (0.43) and South (0.366). Black females had consistently higher AAMR than white females, with rates of 0.763 vs. 0.329 in 1999 and 0.976 vs. 0.523 in 2020, respectively. Females older than 65 years demonstrated a much higher total AAMR (1.506) compared to females between the ages of 15 and 65 (0.212) (p,0.001). Within the age group of 15-25 years, black females had higher AAMRs compared to white female (p,0.001). Black females of the age group .65 years demonstrated much higher mortality (total AAMR: 2.745) than white females of the same age group (1.419), and the highest AAMR overall (P,0.001). Conclusions: The analysis of AAMR for female genital cancer associated pulmonary embolism highlights a concerning disparity in this dangerous cancer related complication, particularly after 2015. This underscores the need for greater attention to be directed towards reproductive health and cancer related complications faced by black women and to address systematic inequalities in intervention and healthcare access. This can improve early detection and timely interventions in order to reduce mortality and improve outcomes for these patients
TCT-278 Interhospital Variation in Mechanical Circulatory Support Use for Acute Myocardial Infarction Complicated by Cardiogenic Shock
No full textBackground: Cardiogenic shock (CS) complicates acute myocardial infarction (AMI) and carries high mortality. Despite guidelines, selection between intra-aortic balloon pump (IABP) and percutaneous ventricular assist devices (PVAD) lacks standardization, potentially driving institutional practice variation. Methods: Using the 2019 Nationwide Readmissions Database, we analyzed 53,903 non-elective AMI-CS hospitalizations. Hierarchical regression quantified interhospital variation in IABP/PVAD use. Hospitals were stratified into high-IABP or high-PVAD (top decile of risk-adjusted use). Outcomes included escalation to ECMO/LVAD, length of stay (LOS), and costs. Results: Overall, 23.4% received IABP and 12.5% received PVAD. After risk adjustment, 13% (95% CI 11–14%) of IABP and 18% (15–20%) of PVAD variation was attributable to hospital-level differences. High-PVAD hospitals had higher PCI volume (median 257 vs. 204 cases/year, p=0.032) and were more often safety-net institutions (27.4% vs. 11.3%, p=0.023) than high-IABP hospitals. Patients at high-PVAD hospitals had lower adjusted risk of escalation to ECMO (RR 0.53; 95% CI 0.30–0.95) and LVAD (RR 0.28; 0.08–0.94). LOS (−0.16 days; −1.82 to 1.49) and costs (16,600 to $9,600) did not differ between hospital types. Conclusion: Significant interhospital variation exists in IABP/PVAD utilization for AMI-CS, driven partly by institutional factors like PCI volume and safety-net status. While escalation to advanced support was less frequent at PVAD-preferring centers, resource utilization was comparable. These findings highlight the need for evidence-based protocols to standardize MCS selection. Categories: CORONARY: Hemodynamic Support, Cardiogenic Shock and Cardiac Arres
21 years of tonsillar cancer mortality: Trends, disparities, and public health challenges
No full textBackground: Tonsillar squamous cell carcinoma (SCC), the most common oropharyngeal cancer, has shown increasing mortality trends despite declining traditional risk factors like tobacco use. Using CDC WONDER data from 1999 to 2020, this study examined demographic and geographic disparities in age-adjusted mortality rates (AAMRs) for individuals aged ≥25 years. Methods: Data was extracted from the CDC-WONDER database using ICD-code C09, specific to age-adjusted mortality rates (AAMR) due to tonsillar cancer per 100,000 population. Analysis was conducted using Joinpoint v5.3 to calculate average annual percent change (AAPC) and annual percent change (APC). Results: A total of 21,665 deaths were analyzed, revealing an overall AAMR increase from 0.42 in 1999 to 0.50 in 2020, with an AAPC of 1.16% (p,0.000001). The overall AAMR declined from 1999 to 2005 insignificantly, which was followed by an increase in AAMR with an APC of 1.84 (95% CI -0.60 to 4.77, p=0.05). Male mortality was significantly higher (AAMR: 0.75) than female (AAMR: 0.17) with a 2.78% annual increase (p=0.02). African Americans initially had the highest mortality, but rates declined (-1.96% AAPC, p=0.0004), while White populations experienced a significant rise (2.42% AAPC, p,0.000001). Mortality rates were highest among individuals aged 65-84 years and disproportionately affected rural areas (AAMR: 0.49) compared to urban areas (AAMR: 0.46). Geographic variability was notable, with rural and southern regions showing higher mortality. Maine had the highest AAMR of 0.67 (95% CI 0.57 to 0.78), while lowest AAMR was recorded in Utah (0.15 (95% CI 0.11 to 0.20)) from 1999 to 2020. Other states in the upper 90th percentile of tonsillar cancer related mortality included District of Columbia, Kentucky, Tennessee, Vermont and Washington whereas states in the lower 10th percentile included Alaska, Hawaii, New Jersey, New York and Rhode Island. The highest AAMR for tonsillar cancer was recorded in the Midwest (0.48, 95% CI 0.47 to 0.50), followed by the South (0.47,95% CI 0.46 to 0.48) and West regions (0.40 95% CI 0.39 to 0.41) with lowest in Northeast region (0.36, 95% CI 0.35 to 0.38). Conclusions: These findings highlight increasing tonsillar cancer mortality among males and Whites and persistent rural disparities. Public health interventions focusing on HPV vaccination, early detection, and addressing healthcare inequities are critical for mitigating these trends
NVL-330, a selective HER2 tyrosine kinase inhibitor, in patients with advanced or metastatic HER2-altered non-small cell lung cancer: The phase 1 HEROEX-1 study
No full textBackground: Oncogenic mutations and gene amplifications in the HER2 receptor tyrosine kinase are detected in approximately 2-4% and 1-5% of non-small cell lung cancers (NSCLC) in the US, respectively. Exon 20 insertion mutations (exon20ins) are the predominant HER2 mutations in NSCLC, and ∼50% of patients with HER2-mutant metastatic NSCLC develop brain metastases. The antibody drug conjugate (ADC) trastuzumab deruxtecan (T-DXd) has received FDA accelerated approval for HER2-mutant NSCLC, but no tyrosine kinase inhibitors (TKIs) are currently approved for this indication. NVL-330 is a novel, brain-penetrant, HER2-selective investigational TKI, designed to address the medical need of targeting HER2-mutant tumors, and treating brain metastases, while minimizing treatment related adverse events due to off-target inhibition of wild-type EGFR. Methods: HEROEX-1 (NCT06521554) is a first-inhuman, Phase 1a/1b trial. The Phase 1a dose escalation portion employs a Bayesian optimal interval design with a 3+3 run-in, followed by a Phase 1b dose expansion. The study population includes adult patients with advanced or metastatic NSCLC with a HER2 oncogenic mutation (Phase 1a/1b) or amplification (Phase 1a only) determined by local testing. Eligible patients must have received at least one prior systemic therapy including platinum-based chemotherapy with or without immunotherapy, or are unsuitable candidates for available therapies. Prior HER2-directed antibodies and HER2-directed ADCs are allowed. Prior HER2 TKIs are allowed in Phase 1a only. Patients will receive NVL-330 by oral administration once or twice daily. The primary objectives are to evaluate safety and tolerability, determine the recommended Phase 2 dose, and, if applicable, the maximum tolerated dose of NVL-330. Additional objectives include assessment of preliminary activity and characterization of the pharmacokinetic and pharmacodynamic profiles of NVL-330. Analyses will be performed to evaluate tumor and blood-based biomarkers of response and other relevant biomarkers. The study is open to accrual
The differential effect of stromal genes on gemcitabine/nab-paclitaxel (GN) and GN/cisplatin (GCN) outcomes in advanced pancreatic adenocarcinoma (aPDAC)
No full textBackground: GN is a front-line therapy for aPDAC. A Phase I/II study demonstrated that GCN has a higher overall response rate and median overall survival (mOS). Our previous study found no difference in outcomes among patients with DNA damage repair gene mutations; however, stromal gene expression correlated with mOS in patients receiving GCN. Here, we further evaluate differences in the outcomes with GCN and GN by site of biopsy. Methods: PDAC samples (n = 4,463) were analyzed by NGS (NextSeq/NovaSeq) or RNA (NovaSeq) (Caris Life Sciences, Phx, AZ). Expression of stromal and related genes (ACTA2, ADIRF, HAS2, IL-6, MMP-2, MMP-9, SPARC, STAT3, TBGB1, TGFB2, TGFBR3, IDO1, HLA-DRB4, VEGFB) from different biopsy sites [high expression (H) \u3e50% of RNA transcripts per million] was correlated with outcomes to GCN or GN. mOS was obtained from insurance claims and calculated from first treatment to last contact. The hazard ratio (HR) was calculated by the Cox proportional hazards model, and p-values were calculated using the log-rank test. Results: 4325 patients [primary biopsy (PT), n = 1,878; non-liver metastatic biopsy (N-LM), n = 818; Liver biopsy (LM), n = 1,629] received GN while 138 patients (PT, n = 45; N-LM, n = 28; LM, n = 65) received GCN. GCN was associated with longer mOS than GN [Δ: 5.2 months (m), HR: 0.76, 95% CI 0.63-0.92, p = 0.01]. GCN was associated with longer mOS compared to GN in LM (Δ: 5.6 m, HR: 0.66, 95% CI 0.50-0.87, p = 0.003), but it was not significant in PT (Δ: 4.6 m, p = 0.13) and N-LM (Δ: 4.4 m, p = 0.35). Median MMP2 (38.5 vs. 163.1 vs. 162.2), VEGFB (14.4 vs. 16.9 vs. 16.2) and TGFBR3 (11.4 vs. 15 vs. 16.4) expression were lower in LM compared to PT and N-LM while TGFB1 (41.6 vs. 34.5 vs. 39.8) and IL6 (1.61 vs. 1.19 vs. 1.41) expression were highest in LM (p\u3c0.05). In LM, IL6-H (Δ: -11 m, p = 0.037) and TGFB1-H (Δ: -5.9 m, p = 0.10) were associated with worse post-GCN survival compared to GN (p = 0.82 and p = 0.57). Whereas, in N-LM, TGFBR3-H trended towards longer post-GCN survival (Δ: 12 m, p = 0.18), while ADIRF-H trended towards shorter post-GCN survival (Δ: -12 m, p = 0.056) compared to GN (p = 0.42 and p = 0.10). While in PT, MMP2-H (Δ: 11.3m, HR: 0.46, p = 0.16), TGFB1-H (Δ: 11.3 m, HR: 0.33, p = 0.09), HLA-DRB4-H (Δ: 12.9 m, HR: 0.44, p = 0.11) and VEGFB-H (Δ: 10.7, HR: 0.34, p = 0.09) trended towards longer post-GCN survival compared to GN (MMP2-H, Δ: 3.4 m, p = 0.03, TGFB1-H, p = 0.661, HLA-DRB4-H, p = 0.67, VEGFB-H, Δ: 1.3 m, p = 0.03). Conclusions: GCN is associated with improved mOS compared to GN, especially in LM.Stromal gene expression in the liver differs from that in N-LM and the pancreas. While high stromal gene expression trends towards worse post-GCN survival in LM, it is associated with improved survival in N-LM and PT. Further validation is needed to understand the impact of stromal gene expression in different tumor sites on survival outcomes and signature development