St. Charles Medical Center

Dupuytren contracture (DC) is a fibroproliferative disorder characterized by collagen deposition in the palmar fascia. Treatment options include collagenase clostridium histolyticum (CCH) injection and surgery; however, DC frequently recurs after primary therapy. We hypothesized that CCH treatment could be effective and well tolerated for the treatment of contracture recurrence for patients unwilling to undergo reoperation or at high risk for complications. This Phase 4, multicenter, noninterventional, retrospective study analyzed medical records from 10 clinical centers in the US. Patients were treated with CCH for DC recurrence ≥6 months after previously successful surgical correction performed between January 1, 2010, and August 15, 2020. Primary end points were the measured joint contracture change from baseline, at first and last clinical evaluation within 12 months of CCH treatment of metacarpophalangeal (MP) and proximal interphalangeal (PIP) joint contractures. Secondary end points were "clinical success" (percentage of joints with reduction in contracture to 0° to 5°) and adverse events. Of 113 patients screened, 101 were analyzed (mean age, 64.1 years; 75% men). Median time to DC recurrence was 36.0 months. A total of 144 treated joints were analyzed (MP, n = 64; PIP, n = 75; unspecified, n = 5). Overall mean (SD) baseline contracture was 52° (21°) (MP, 43° [19°]; PIP, 61° [20°]). Mean (SD) improvement of contracture from baseline at last evaluation was 38° (21°) for all joints (MP, 36° [17°]; PIP, 41° [24°]), with 58% of joints having clinical success (MP, 75%; PIP, 43%). All skin tears (20 events in 19% of patients) resolved spontaneously, with 50% resolving in ≤21 days; there was one flexor profundus rupture that did not require secondary reconstruction. This retrospective analysis indicates that CCH treatment is an effective and well tolerated nonsurgical option for recurrent postsurgical contracture, with results comparable to patients without prior surgery. Therapeutic III.

Treatment for brain tumors in children has been associated with difficulties in neurocognitive functioning. The present study examined the differences in academic outcomes for male and female medulloblastoma survivors who were treated with and without cranial radiation. Data from 39 medulloblastoma survivors were collected retrospectively. Patients included in the study were clinically referred for a neuropsychological evaluation. One-way ANOVAs were used to examine differences in academic outcomes for male and female patients as well as patients who received and did not receive radiation as part of their treatment. Analyses indicated significant differences across male and female medulloblastoma survivors for sight word reading, phonological decoding, and mathematical calculation. Significant differences were not observed for patients who did and did not receive cranial radiation. Similar to findings examining differences in intellectual outcomes for brain tumor survivors, males performed lower than females approximately 4 years post-treatment. This suggests that males may be particularly vulnerable to neurocognitive difficulties following treatment for medulloblastoma and earlier monitoring and assessment may be warranted. Sex differences in brain development may be related to academic outcomes for pediatric brain tumor patients. Additional research is needed in the area.

BackgroundSurgical treatment of invasive lobular carcinoma (ILC) is challenging due to its diffuse growth pattern, and the positive margin rate after mastectomy is poorly described. MethodsWe retrospectively determined the positive margin rate in those with stage I-III ILC undergoing mastectomy. We evaluated the relationship between management strategy and recurrence free survival (RFS). ResultsIn 357 patients, the positive margin rate was 10.6% overall and 18.7% in those with T3 tumors. Having a positive margin was associated with significantly shorter RFS on multivariate analysis (p = 0.01). Undergoing additional local treatment (radiation or re-excision) for a positive margin was significantly associated with improved RFS (p = 0.004). Older women with positive margins were significantly less likely to undergo additional local therapy. ConclusionsEven mastectomy fails to clear margins in a high proportion of patients with large ILC tumors, a finding which may warrant testing neoadjuvant strategies even prior to planned mastectomy.

Here, we present a rare case of a patient who developed multiple primary melanomas within the boundaries of two nevi depigmentosa. The melanomas were excised, and as a preventive measure, the remainder of the nevi depigmentosa were removed. We performed whole-exome sequencing on excised tissue from the nevus depigmentosus, adjacent normal skin, and saliva to explain this intriguing phenomenon. We also performed a GeneTrails Comprehensive Solid Tumor Panel analysis on one of the melanoma tissues. Genetic analysis revealed germline MC1R V92M and TYR R402Q polymorphisms and a MET E168D germline mutation that may have increased the risk of melanoma development. This genetic predisposition, combined with a patient-reported history of substantial sun exposure and sunburns, which were more severe within the boundaries of the nevi depigmentosa due to the lack of photoprotective melanin, produced numerous somatic mutations in the melanocytes of the nevi depigmentosa. Fitting with this paradigm for melanoma development in chronically sun-damaged skin, the patient's melanomas harbored somatic mutations in CDKN2A (splice site), NF1, and ATRX and had a tumor mutation burden in the 90-95th percentile for melanoma.

Based on the improved outcomes achieved with fresh whole blood in cases of military trauma as well as with 1:1:1 transfusion strategies for massive traumatic hemorrhage in civilian settings, there has been resurgent interest in using whole blood for civilian trauma patients. There have been reports of giving up to 4 units of low-titer cold-stored O-positive to these patients. This is the first modern report of a massive transfusion with unrestricted low-titer group O whole blood (LTOWB) use in a civilian trauma patient. This is a case report describing the resuscitation and massive transfusion of LTOWB of a 69-year-old man struck by an automobile. While working to achieve hemorrhage control, the patient received 38 units of LTOWB, 13 units of RBCs, 12 units of fresh frozen plasma, 2 packs of platelets, and 2 units of cryoprecipitate. No evidence of hemolytic reaction was observed. The patient was O positive. Monitoring by thrombelastography revealed adequate clot initiation and propagation, but decreased clot strength (49.6 and 50.2) and a drop in fibrinogen (from 207 to 141) during the resuscitation. This is the first report of a massive transfusion for civilian trauma based on cold-stored whole blood in the recent era. While this patient suffered a tremendous burden of traumatic injury and his recovery is not yet complete, his LTOWB resuscitation was successful. Frequent monitoring of coagulation status with thrombelastography during utilization of LTOWB is indicated because the efficacy of its components (particularly platelets) is not yet fully understood.

A baby is rushed to the ED, seizing, heart beat slow and stuttering. Above the right eyebrow appears a big, violent, purple lump — the physician’s gaze stumbles over it: such an ugly wound on the surface, yet no match for the devastation hidden underneath.

Chest tubes are utilized to evacuate shed blood after left ventricular assist device (LVAD) implantation, however, they can become clogged, leading to retained blood. We implemented a protocol for active tube clearance (ATC) of chest tubes to determine if this might reduce interventions for retained blood. A total of 252 patients underwent LVAD implantation. Seventy-seven patients had conventional chest tube drainage (group 1), whereas 175 patients had ATC (group 2). A univariate and multivariate analysis adjusting for the use of conventional sternotomy (CS) and minimally invasive left thoracotomy (MILT) was performed. Univariate analysis revealed a 65% reduction in re-exploration (43–15%, p < 0.001), and an 82% reduction in delayed sternal closure (DSC; 34–6%, p <0.001). In a sub-analysis of CS only, there continued to be statistically significant 53% reduction in re-exploration (45% vs. 21%, p = 0.0011), and a 77% reduction in DSC (35% vs. 8%, p < 0.001) in group 2. Using a logistic regression model adjusting for CS versus MILT, there was a significant reduction in re-exploration (odds ratio [OR] = 0.44 [confidence interval {CI} = 0.23–0.85], p = 0.014) and DSC (OR = 0.20 [CI = 0.08–0.46], p <0.001) in group 2. Actively maintaining chest tube patency after LVAD implantation significantly reduces re-exploration and DSC.