Early-goal-directed therapy (EGDT) consists of early, aggressive fluid resuscitation and is known to improve survival in sepsis. It is unknown how often EGDT leads to subsequent fluid overload and whether post-EGDT fluid overload affects patients’ outcomes. Our hypothesis was that septic patients treated with EGDT were at risk for fluid overload and that fluid overload would be associated with adverse outcomes. We conducted a retrospective cohort of 405 consecutive patients admitted with severe sepsis and septic shock to the medical intensive care unit of a tertiary care academic hospital from January 2008 to December 2009. Baseline demographics, daily weights, fluid status, clinical or radiographic evidence of fluid overload, and medical interventions (thoracentesis, paracentesis, diuretic use, and ultrafiltration) were abstracted and associations explored using univariate and multivariate logistic and linear regression analyses. At day 1, 67% of patients developed evidence of fluid overload and in 48% fluid overload persisted to day three. Inter-rater agreement for presence of fluid overload was substantial (kappa=0.7). An increased trend in weight was noted in those with persistent clinical and radiologic evidence of fluid overload, but not with recorded positive fluid balance. When adjusted for baseline severity of illness, fluid overload was associated with increased use of fluid-related medical interventions (thoracentesis and diuretics) and hospital mortality (OR 1.92 [1.16-3.22]). In patients with severe sepsis and septic shock treated with EGDT, clinical evidence of persistent fluid overload is common and is associated with increased use of medical interventions and hospital mortality.

Excision and unroofing procedures were effective treatments with infrequent complications and low recurrence rates. Well-planned surgical treatment aiming to remove or unroof the area of intractable hidradenitis suppurativa was highly effective in the management of this challenging disease.

Objective To calculate the incidence of burning mouth syndrome (BMS) in Olmsted County, Minnesota, from 2000 to 2010. Patients and Methods Using the medical record linkage system of the Rochester Epidemiology Project, we identified newly diagnosed cases of BMS from January 1, 2000, through December 31, 2010. Diagnoses were confirmed through the presence of burning pain symptoms of the oral mucosa with normal oral examination findings and no associated clinical signs. Incidence was estimated using decennial census data for Olmsted County. Results In total, 169 incident cases were identified, representing an annual age- and sex-adjusted incidence of BMS of 11.4 per 100,000 person-years. Age-adjusted incidence was significantly higher in women than men (18.8 [95% CI, 16.4–22.9] vs 3.7 [95% CI, 2.6–5.7] per 100,000 person-years [P<.001]). Postmenopausal women aged 50 to 89 years had the highest disease incidence, with the maximal rate in women aged 70 to 79 years (70.3 per 100,000 person-years). After age 50 years, BMS incidence in men and women significantly increased across age-groups (P=.02). Olmsted County study participants were predominantly white, which is a study limitation. In addition, diagnostic criteria for identifying BMS in the present study may not apply for all situations because no diagnostic criteria are universally recognized for identifying BMS. Conclusion To our knowledge, this is the first population-based incidence study of BMS reported to date. The data show that BMS is an uncommon disease highly associated with female sex and advancing age.

A B S T R A C T PurposeLess than 20% of patients with melanoma who undergo sentinel lymph node (SLN) biopsy based on American Society of Clinical Oncology/Society of Surgical Oncology recommendations are SLN positive. We present a multi-institutional study to discover new molecular risk factors associated with SLN positivity in thin and intermediate-thickness melanoma. Patients and MethodsGene clusters with functional roles in melanoma metastasis were discovered by next-generation sequencing and validated by quantitative polymerase chain reaction using a discovery set of 73 benign nevi, 76 primary cutaneous melanoma, and 11 in-transit melanoma metastases. We then used polymerase chain reaction to quantify gene expression in a model development cohort of 360 consecutive thin and intermediate-thickness melanomas and a validation cohort of 146 melanomas. Outcome of interest was SLN biopsy metastasis within 90 days of melanoma diagnosis. Logic and logistic regression analyses were used to develop a model for the likelihood of SLN metastasis from molecular, clinical, and histologic variables. Results ITGB3, LAMB1, PLAT, and TP53 expression were associated with SLN metastasis. The predictive ability of a model that included these molecular variables in combination with clinicopathologic variables (patient age, Breslow depth, and tumor ulceration) was significantly greater than a model that only considered clinicopathologic variables and also performed well in the validation cohort (area under the curve, 0.93; 95% CI, 0.87 to 0.97; false-positive and false-negative rates of 22% and 0%, respectively, using a 10% cutoff for predicted SLN metastasis risk). ConclusionThe addition of cell adhesion-linked gene expression variables to clinicopathologic variables improves the identification of patients with SLN metastases within 90 days of melanoma diagnosis. J Clin Oncol 33:2509-2515. © 2015 by American Society of Clinical Oncology INTRODUCTIONThe identification of metastatic disease to regional lymph nodes in patients who present with cutaneous melanoma remains a challenge despite advances in imaging, molecular genetics, and cancer cell biology. Sentinel lymph node (SLN) biopsy is an established technique for nodal staging with therapeutic implications 1,2 Recommendations on when to use an SLN biopsy are based on clinicopathologic variables, including Breslow depth, mitotic rate, and tumor ulceration. [3][4][5] Morton et al 1,2 reported that 122 (16.0%) of 770 patients with intermediatethickness (Breslow depth of 1.2 to 3.5 mm) melanoma who underwent SLN biopsy had nodal metastasis. Moreover, the Sentinel Lymph Node Working Group reported that among 1,250 patients with thin melanoma (Յ 1 mm Breslow depth) who had an SLN biopsy, 65 (5.2%) had nodal metastasis. 6 Attempts to improve identification of patients at risk for SLN positivity using additional histopathologyderived variables have been largely unsuccessful. [3][4][5][6][7][8][9] Changes in cell adhesion, specifically the remodeling of integrin-linked cell adhesion ...