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Sebaceous carcinoma is a rare cancer, and little is known about its current epidemiology and treatment. This is particularly true for sebaceous carcinomas of the trunk and extremities.

Broken time-reversal symmetry in the absence of spin order indicates the presence of unusual phases such as orbital magnetism and loop currents1–4. The recently discovered kagome superconductors AV3Sb5(where A is K, Rb or Cs)5,6display an exotic charge-density-wave (CDW) state and have emerged as a strong candidate for materials hosting a loop current phase. The idea that the CDW breaks time-reversal symmetry7–14is, however, being intensely debated due to conflicting experimental data15–17. Here we use laser-coupled scanning tunnelling microscopy to study RbV3Sb5. By applying linearly polarized light along high-symmetry directions, we show that the relative intensities of the CDW peaks can be reversibly switched, implying a substantial electro-striction response, indicative of strong nonlinear electron–phonon coupling. A similar CDW intensity switching is observed with perpendicular magnetic fields, which implies an unusual piezo-magnetic response that, in turn, requires time-reversal symmetry breaking. We show that the simplest CDW that satisfies these constraints is an out-of-phase combination of bond charge order and loop currents that we dub a congruent CDW flux phase. Our laser scanning tunnelling microscopy data open the door to the possibility of dynamic optical control of complex quantum phenomenon in correlated materials.

Background To compare opioid prescribing practices of resident physicians across a variety of surgical and nonsurgical specialties; to identify factors which influence prescribing practices; and to examine resident utilization of best practice supplemental resources.Methods An anonymous survey which assessed prescribing practices was completed by residents from one of several different subspecialties, including internal medicine, obstetrics and gynecology, general surgery, neurosurgery, orthopedic surgery, and urology. Fisher’s exact test assessed differences in prescribing practices between specialties.Results Only 35% of residents reported receiving formal training in safe opioid prescribing. Overall, the most frequently reported influences on prescribing practices were the use of standardized order sets for specific procedures, attending preference, and patient’s history of prescribed opioids. Resident physicians significantly underutilize best practice supplemental resources, such as counseling patients on pain expectations prior to prescribing opioid medication; contacting established pain specialists; screening patients for opioid abuse; referring to the Prescription Monitoring Program; and counseling patients on safe disposal of unused pills (P< .001).Discussion The incorporation of comprehensive prescribing education into resident training and the utilization of standardized order sets can promote safe opioid prescribing.

•Selecting candidates for plastic and reconstructive surgery residency is complex, involving academic metrics and intrinsic personal qualities.•We hypothesized that higher grit correlates with greater matching success.•After adjusting for multiple confounders, higher grit score was found to be associated with significantly lower odds of matching into plastic surgery residency.•Higher step 1 and 2CK scores, number of publications, and female gender were associated with greater odds of matching.

There is limited data examining potential disparities in the receipt of immunotherapy among patients with stage III melanoma.

Background: Diverticular fistula, a pathologic connection from the colon to the skin or another organ, is an uncommon sequela of diverticular disease. It is generally considered an indication for surgery. The current literature is limited in terms of defining the epidemiology of this disease process. This analysis defines the demographics of fistulous diverticular disease on a national level. Methods: A retrospective review of the 2018 National Inpatient Sample (NIS) was conducted, using ICD-10 codes for diverticular disease, diverticular-associated fistulas, and associated surgeries. Demographic factors were compared between groups, and several sub-group analyses were performed. Results: A total of 7,105,498 discharges were recorded: 119,115 (1.68%) with non-fistulizing diverticular disease and 3,843 (0.05%) with diverticular fistula. Patients with diverticular fistula were more likely to be younger (64.7 v 68.2 years, p &lt; .0001) and female (57.3% v 55.4%, p = 0.028) than patients with non-fistulizing disease. They were also more likely to undergo surgery (64.9% v 25.7%, p &lt; .0001), to be admitted electively (44.7% v 12.0%, p &lt; .0001), and to have a longer length of stay (LOS) (mean 8.07 v 5.20 days, p &lt; .0001). Diverticular fistula patients that underwent surgery were more likely to be male (44.8% v 39.0%, p = 0.003), to be admitted electively (65.3% v 6.7%, p &lt; .0001), and to have longer LOS (mean 8.74 v 6.81 days, p &lt; .0001) than those who received medical treatment alone. Conclusion: Diverticular fistula is a rare diagnosis, accounting for 0.05% of total admissions and 3.12% of admissions for diverticular disease. However, this is more common than the previously reported rate of &lt; 0.1% of diverticular disease admissions. While surgery is generally indicated for diverticular fistula, only 64.9% of patients underwent surgical treatment. Although this study is limited by its retrospective nature and use of administrative data, our findings elucidate the prevalence and patterns of inpatient admissions for diverticular fistula in the United States. Graphical abstract:

This study aimed to characterize a large cohort of Latinx patients with autoimmune hepatitis (AIH) and analyze clinical outcomes, including biochemical remission, duration of steroid treatment, fibrosis regression, and incidence of clinical endpoints (hepatic decompensation, need for liver transplant, and death).

Introduction:Cardiogenic shock (CS) is associated with high mortality and morbidity. Severe mitral regurgitation (MR) in the setting of CS is associated with poor outcomes. Transcatheter Edge-to-Edge Repair (TEER) with the Mitraclip system is commonly used to treat MR, though its use in CS is less defined.Hypothesis:TEER with Mitraclip in patients with moderate to severe MR and CS improves cardiovascular outcomes compared to medical management alone.Methods:A single-center, retrospective study included adult patients with moderate to severe MR and CS between 2012 and 2021. Moderate to severe MR was defined by grades 3+ and 4+ MR. CS was defined as a sustained systolic blood pressure <90mmHg for at least 1 hour, use of inotropes, vasopressors, or mechanical circulatory support, and clinical and laboratory findings of end-organ damage. The primary outcome was major adverse cardiovascular events (MACE) defined as cardiovascular death, heart failure admission, stroke, and myocardial infarction at 30 days and 6 months. The secondary outcome was change in New York Heart Association (NYHA) classification.Results:There were 28 patients included in the medical management and 33 in the Mitraclip groups. Table 1 includes this study’s outcomes. There were no significant differences in patients with a MACE at 30 days (13 vs. 8, p=0.069), though there were significant differences at 6 months (12 vs. 7, p=0.002). There were no differences in cardiovascular death. Patients in the Mitraclip group had fewer heart failure admissions at 6 months (p=<0.001), though not at 30 days. At 30 days, more patients in the Mitraclip group improved to NYHA classes I/II compared to medical management alone (10 [35.7%] vs. 16 [50%], p=0.043). There were no differences in NYHA classes I/II at 6 months (7 [43.7%] vs. 13 [54.2%], p=0.63).Conclusions:TEER using the Mitraclip system improves mid-term cardiovascular outcomes in patients with CS compared to medical management alone.

Introduction:Transcatheter Edge to Edge Repair (TEER) of the mitral valve is a viable option for patients with moderate to severe mitral regurgitation (MR) who are at high surgical risk. TEER has been shown to improve quality of life (QOL) in patients with MR. Data is limited regarding QOL in patients with MR and cardiogenic shock (CS) who undergo TEER.Methods:A single-center, retrospective cohort study including adult patients with moderate to severe MR and CS who underwent TEER between January 2012 and December 2021. CS was defined as a sustained systolic blood pressure <90mmHg for at least 1 hour, use of inotropes, vasopressors, or mechanical circulatory support, and clinical and lab findings of end-organ damage. The primary outcome was change in disease-specific health status (Kansas City Cardiomyopathy Questionnaire-Overall Summary score [KCCQ-OS] at 30 days. Statistical analysis was done using Wilcoxon signed-rank test and t-test.Results:Thirty-three patients with mod-severe MR and CS had undergone TEER (See table 1 for baseline characteristics) . KCCQ data were available on 30% survivors at 30 days. KCCQ increased from 17.19 (11.88) before TEER to 53.85 (30.89) in 30 days (mean change 36.67; 95% CI 14.24-59.09; P<0.05, see table2). There was an improvement in 2 out of 4 KCCQ domains; symptoms frequency (mean change 49.17; 95% CI 18.17-80.16; P<0.05) and social limitation (mean change 49.54; 95% CI 22.25-76.83); P<0.05).Conclusion:TEER of the mitral valve improves QOL at 30 days in patients with moderate to severe MR and CS.

ObjectiveTo determine the impact of lifestyle factors on life expectancy lived with and without Alzheimer’s dementia.DesignProspective cohort study.SettingThe Chicago Health and Aging Project, a population based cohort study in the United States.Participants2449 men and women aged 65 years and older.Main exposureA healthy lifestyle score was developed based on five modifiable lifestyle factors: a diet for brain health (Mediterranean-DASH Diet Intervention for Neurodegenerative Delay—MIND diet score in upper 40% of cohort distribution), late life cognitive activities (composite score in upper 40%), moderate or vigorous physical activity (≥150 min/week), no smoking, and light to moderate alcohol consumption (women 1-15 g/day; men 1-30 g/day).Main outcomeLife expectancy with and without Alzheimer’s dementia in women and men.ResultsWomen aged 65 with four or five healthy factors had a life expectancy of 24.2 years (95% confidence interval 22.8 to 25.5) and lived 3.1 years longer than women aged 65 with zero or one healthy factor (life expectancy 21.1 years, 19.5 to 22.4). Of the total life expectancy at age 65, women with four or five healthy factors spent 10.8% (2.6 years, 2.0 to 3.3) of their remaining years with Alzheimer’s dementia, whereas women with zero or one healthy factor spent 19.3% (4.1 years, 3.2 to 5.1) with the disease. Life expectancy for women aged 65 without Alzheimer’s dementia and four or five healthy factors was 21.5 years (20.0 to 22.7), and for those with zero or one healthy factor it was 17.0 years (15.5 to 18.3). Men aged 65 with four or five healthy factors had a total life expectancy of 23.1 years (21.4 to 25.6), which is 5.7 years longer than men aged 65 with zero or one healthy factor (life expectancy 17.4 years, 15.8 to 20.1). Of the total life expectancy at age 65, men with four or five healthy factors spent 6.1% (1.4 years, 0.3 to 2.0) of their remaining years with Alzheimer’s dementia, and those with zero or one healthy factor spent 12.0% (2.1 years, 0.2 to 3.0) with the disease. Life expectancy for men aged 65 without Alzheimer’s dementia and four or five healthy factors was 21.7 years (19.7 to 24.9), and for those with zero or one healthy factor life expectancy was 15.3 years (13.4 to 19.1).ConclusionA healthy lifestyle was associated with a longer life expectancy among men and women, and they lived a larger proportion of their remaining years without Alzheimer’s dementia. The life expectancy estimates might help health professionals, policy makers, and stakeholders to plan future healthcare services, costs, and needs.