The Evolving Dilemma of Factor XI in Pregnancy: Suggestions for Management

A case of a patient with severe factor XI (FXI) deficiency who presented for her seventh labor and delivery is presented. The nature of FXI deficiency, its prevalence, and issues related to genetic screening are discussed. Published literature on the topic is reviewed, including criteria that were developed to assess bleeding, laboratory tools used to estimate bleeding risk, and available treatments. Within the context of this challenging clinical dilemma, specific recommendations are provided for the antepartum, intrapartum, and postpartum stages of pregnancy. These include recommendations that take into account both FXI levels and history of any abnormal bleeding. While there are effective treatments available, it is important to consider that institutional multidisciplinary protocols are needed to manage this complex disorder. More work is needed to define the best management protocols. Accepted for publication December 19, 2017. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Aryeh Shander, MD, Department of Anesthesiology, Englewood Hospital and Medical Center, 350 Engle St, Englewood, NJ 07631. Address e-mail to aryeh.shander@ehmchealth.org. © 2018 International Anesthesia Research Society

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Sex Difference of Angiotensin IV–, LVV-Hemorphin 7–, and Oxytocin-Induced Antiallodynia at the Spinal Level in Mice With Neuropathic Pain

Background: We demonstrated previously that angiotensin IV (Ang IV) and LVV-hemorphin 7 (LVV-H7) act through the blockade of insulin-regulated aminopeptidase to decrease oxytocin degradation, thereby causing antihyperalgesia at the spinal level in rats. We determined that intrathecal oxytocin can induce significant antihyperalgesia in male rats with inflammation but not in female rats. Thus, we speculate that Ang IV, LVV-H7, and oxytocin can induce antiallodynia, which could be of great therapeutic potential. Because the antihyperalgesia by using these peptides was with sex difference, their possible antiallodynia was examined in male and female mice for comparison. We investigated whether Ang IV, LVV-H7, and oxytocin produce antiallodynia at the spinal level in mice and whether this antiallodynia differs between the sexes. METHODS: Partial sciatic nerve ligation surgery was performed on adult male and female C57BL/6 mice from the same litter (25–30 g). The effects of intrathecal injections of Ang IV (25.8 nmol), LVV-H7 (27.2 nmol), and oxytocin (0.125 or 1.25 nmol) were assessed through the von Frey test 3 days after partial sciatic nerve ligation. RESULTS: Intrathecal injection of Ang IV, LVV-H7, and oxytocin all produced a potent antiallodynia in male mice. However, these antiallodynia effects were either extremely weak or absent in female mice at the same dose. CONCLUSIONS: Intrathecal Ang IV, LVV-H7, and oxytocin can all cause significant antiallodynia in male mice. The Ang IV-, LVV-H7-, and oxytocin-induced antiallodynia effects differed between the sexes at the spinal level in mice. Accepted for publication November 28, 2017. Funding: The study was supported by National Defense Medical Center, Taipei, Taiwan, and was funded by the Tri-Service General Hospital Songshan Branch, Taipei, Taiwan (TSGH-SSB-10407), and the Ministry of Science and Technology, Taiwan (103-2320-B-016-016-MY3). This manuscript was edited by Wallace Academic Editing The authors E. Y.-K. Huang and J.-H. Kao have contributed equal to this study. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Eagle Yi-Kung Huang, PhD and Jen-Hsin Kao, PhD, Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan. Address e-mail to eyh58@mail.ndmctsgh.edu.tw and cindykao1128@gmail.com. © 2018 International Anesthesia Research Society

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A Systematic Review of Outcomes Associated With Withholding or Continuing Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Before Noncardiac Surgery

BACKGROUND: The global rate of major noncardiac surgical procedures is increasing annually, and of those patients presenting for surgery, increasing numbers are taking either an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin receptor blocker (ARB). The current recommendations of whether to continue or withhold ACE-I and ARB in the perioperative period are conflicting. Previous meta-analyses have linked preoperative ACE-I/ARB therapy to the increased incidence of postinduction hypotension; however, they have failed to correlate this with adverse patient outcomes. The aim of this meta-analysis was to determine whether continuation or withholding ACE-I or ARB therapy in the perioperative period is associated with mortality and major morbidity. METHODS: This meta-analysis was prospectively registered on PROSPERO (CRD42017055291). A comprehensive search of MEDLINE (PubMed), CINAHL (EBSCO host), ProQuest, Cochrane database, Scopus, and Web of Science was conducted on December 6, 2016. We included adult patients >18 years of age on chronic ACE-I or ARB therapy who underwent noncardiac surgery in which ACE-I or ARB was either withheld or continued on the morning of surgery. Primary outcomes included all-cause mortality and major cardiac events (MACE). Secondary outcomes included the risk of congestive heart failure, acute kidney injury, stroke, intraoperative/postoperative hypotension, and the length of hospital stay. RESULTS: After abstract review, the full text of 25 studies was retrieved, of which 9 fulfilled the inclusion criteria: 5 were randomized control trials, and 4 were cohort studies. These studies included a total of 6022 patients on chronic ACE-I/ARB therapy before noncardiac surgery. A total of 1816 patients withheld treatment the morning of surgery and 4206 continued their ACE-I/ARB. Preoperative demographics were similar between the 2 groups. Withholding ACE-I/ARB therapy was not associated with a difference in mortality (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.62–1.52; I2 = 0%) or MACE (OR, 1.12; 95% CI, 0.82–1.52; I2 = 0%). However, withholding therapy was associated with significantly less intraoperative hypotension (OR, 0.63; 95% CI, 0.47–0.85; I2 = 71%). No effect estimate could be pooled concerning length of hospital stay and congestive heart failure. CONCLUSIONS: This meta-analysis did not demonstrate an association between perioperative administration of ACE-I/ARB and mortality or MACE. It did, however, confirm the current observation that perioperative continuation of ACE-I/ARBs is associated with an increased incidence of intraoperative hypotension. A large randomized control trial is necessary to determine the appropriate perioperative management of ACE-I and ARBs. Accepted for publication December 19, 2017. Funding: No outside funding was utilized in the search and retrieval of all articles. All funding was from departmental resources. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). PROSPERO registry: CRD42017055291. Reprints will not be available from the authors. Address correspondence to Caryl Hollmann, MBChB, DA (SA), Department of Anaesthesia and Perioperative Medicine, D23, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town 7925, South Africa. Address e-mail to carylhollmann@gmail.com. © 2018 International Anesthesia Research Society

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Activation of Melatonin Receptors by Ramelteon Induces Cardioprotection by Postconditioning in the Rat Heart

Activation of melatonin receptors protects the heart against ischemia-reperfusion injury. Ramelteon, a clinically used drug for insomnia, acts via activation of melatonin receptors. We investigated whether ramelteon induces acute infarct size reduction by postconditioning. Male Wistar rats were randomized to 6 groups. Hearts were treated with melatonin and ramelteon at the beginning of reperfusion. The melatonin receptor inhibitor luzindole was administered with and without melatonin and ramelteon, respectively. Ramelteon reduced infarct size to the same extent as melatonin. Both effects were completely abolished by luzindole. The results show for the first time that ramelteon induces cardioprotection by postconditioning. Accepted for publication September 27, 2017. Funding: This work was supported by departmental funding only. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Ragnar Huhn, MD, PhD, Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany. Address e-mail to Ragnar.Huhn@med.uni-duesseldorf.de. © 2018 International Anesthesia Research Society

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In Response

No abstract available

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Flupirtine: A Less-Explored, Neglected Nonopioid Analgesic

No abstract available

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Misguided by INR in Liver Disease Patients? Implications for Clinicians Including Pain Proceduralists

No abstract available

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ABC of Clinical Leadership, 2nd ed

No abstract available

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Summative Objective Structured Clinical Examination Assessment at the End of Anesthesia Residency for Perioperative Ultrasound

While standardized examinations and data from simulators and phantom models can assess knowledge and manual skills for ultrasound, an Objective Structured Clinical Examination (OSCE) could assess workflow understanding. We recruited 8 experts to develop an OSCE to assess workflow understanding in perioperative ultrasound. The experts used a binary grading system to score 19 graduating anesthesia residents at 6 stations. Overall average performance was 86.2%, and 3 stations had an acceptable internal reliability (Kuder–Richardson formula 20 coefficient >0.5). After refinement, this OSCE can be combined with standardized examinations and data from simulators and phantom models to assess proficiency in ultrasound. Accepted for publication December 11, 2017. Funding: This study was funded by the Foundation for Anesthesia Research and Education (FAER) as part of a grant awarded to Robina Matyal. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). J. D. Mitchell and R. Amir contributed equally to this work. Reprints will not be available from the authors. Address correspondence to John D. Mitchell, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1 Deaconess Rd, RB-470, Boston, MA 02215. Address e-mail to jdmitche@bidmc.harvard.edu. © 2018 International Anesthesia Research Society

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Novel TOF-MS means of quantifying apoAI amyloid protein load following combined liver kidney transplantation

No abstract available

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Gender, Race and Disease Etiology Predict De Novo Malignancy Risk following Liver Transplantation: Insights for Future Individualized Cancer Screening Guidance

AbstractBackgroundMalignancy after liver transplant (LT) is a leading cause of mortality, but data is limited. The aim of this study was to identify patients at higher risk for de novo malignancies after LT in a large multicenter database.MethodsThe Scientific Registry of Transplant Recipients database comprising all 108,412 liver transplant recipients across the U.S. between 1987 and March 2015 was analyzed with a median follow-up of 6.95 years. Potential risk factors for malignancies after LT were assessed using Cox regression analysis for the outcome of time to first malignancy.ResultsMean age 51.9 ± 10.8 years, 64.6% male, 74.5% Caucasian, and 15.8% with previous malignancy. Malignancies during follow-up were 4,483 (41.3%) skin, 1,519 (14.0%) hematologic, and 4,842 (44.7%) solid organ. The 10-year probability of de novo malignancy was 11.5% (11.3-11.8%). On multivariable analysis, age by decade (HR 1.52; p

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Incidence of Cytomegalovirus DNAemia in Pediatric Kidney Transplant Recipients after Cessation of Antiviral Prophylaxis

AbstractBackgroundLate cytomegalovirus (CMV) infection can occur after cessation of viral prophylaxis in kidney transplant recipients, yet, timing of infection is unclear and longer duration of prophylaxis may be warranted.MethodsWe conducted a retrospective cohort study of 86 children (35 CMV donor seropositive, recipient seronegative [D+R-] and 51 CMV recipient seropositive [R+])

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Successful sequential liver and haematopoietic stem cell transplantation in a child with CD40 ligand deficiency and Cryptosporidium-induced liver cirrhosis

ABSTRACTBACKGROUNDHematopoietic stem cell transplantation (HSCT) is curative in patients with primary immunodeficiencies. However, pre-HSCT conditioning entails unacceptably high risks if the liver is compromised. The presence of a recurrent opportunistic infection affecting the biliary tree and determining liver cirrhosis with portal hypertension posed particular decisional difficulties in a seven-year-old child with X-linked CD40-ligand deficiency. We aim at adding to the scanty experience available on such rare cases, as successful management with sequential liver transplantation (LT) and HSCT has been reported in detail only in one young adult to date.METHODSa closely sequential strategy, with a surgical complication-free LT, followed by reduced-intensity conditioning, allowed HSCT to be performed only one month after LT, preventing Cryptosporidium parvum recolonization of the liver graft.RESULTScombined sequential LT and HSCT resolved the cirrhotic evolution and corrected the immunodeficiency so that the infection responsible for the progressive sclerosing cholangitis did not recur.CONCLUSIONShopefully this report of the successful resolution of a potentially fatal combination of immunodeficiency and chronic opportunistic infection with end-stage organ damage in a child, will encourage others to adopt a sequential transplant approach to this highly complex pathology. However, caution is to be exercised to carefully balance the risks intrinsic to transplant surgery and immunosuppression in primary immunodeficiencies. BACKGROUND Hematopoietic stem cell transplantation (HSCT) is curative in patients with primary immunodeficiencies. However, pre-HSCT conditioning entails unacceptably high risks if the liver is compromised. The presence of a recurrent opportunistic infection affecting the biliary tree and determining liver cirrhosis with portal hypertension posed particular decisional difficulties in a seven-year-old child with X-linked CD40-ligand deficiency. We aim at adding to the scanty experience available on such rare cases, as successful management with sequential liver transplantation (LT) and HSCT has been reported in detail only in one young adult to date. METHODS a closely sequential strategy, with a surgical complication-free LT, followed by reduced-intensity conditioning, allowed HSCT to be performed only one month after LT, preventing Cryptosporidium parvum recolonization of the liver graft. RESULTS combined sequential LT and HSCT resolved the cirrhotic evolution and corrected the immunodeficiency so that the infection responsible for the progressive sclerosing cholangitis did not recur. CONCLUSIONS hopefully this report of the successful resolution of a potentially fatal combination of immunodeficiency and chronic opportunistic infection with end-stage organ damage in a child, will encourage others to adopt a sequential transplant approach to this highly complex pathology. However, caution is to be exercised to carefully balance the risks intrinsic to transplant surgery and immunosuppression in primary immunodeficiencies. Corresponding Author: Pier Luigi Calvo, MD, Paediatrician, Gastroenterologist & Hepatologist, Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza, Piazza Polonia, 94, 10126 Turin, ITALY. pcalvo@cittadellasalute.to.it AUTHORSHIP PAGE QP, DOD and CPL had the patient under their care and conceived, designed and wrote the article. TF, RR, SM planned and performed liver transplant and critically reviewed the paper. DE performed liver histological analysis. CF, VE, FF performed haematopoietic stem cell transplantation and critically reviewed the paper. PM followed the patient after liver transplant and critically reviewed the paper. All authors listed contributed to writing the manuscript and are responsible for the content of the paper. The authors declare no conflicts of interest. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Simultaneous detection of barrier- and immune-related gene variations in patients with atopic dermatitis by reverse blot hybridization assay

Summary

Background

Hereditary factors are involved in the pathogenesis of atopic dermatitis (AD). However, AD-related gene variations are significantly different across ethnicities.

Aim

To identify mutations and single-nucleotide polymorphisms (SNPs) in barrier- or immune-related genes from Korean patients with AD and compare the variations with those observed in nonatopic healthy controls (HCs), and to use novel reverse blot hybridization assay (REBA) for AD-related gene variants.

Methods

We carried out REBA to simultaneously detect variations in genes related to barrier or immune function, namely, FLG, SPINK5, KLK7, DEFB1, TNFα, KDR, FCER1A, IL4, IL5,IL5RA, IL9, IL10, IL12, IL12R, IL13 and IL18, from Korean patients with AD, and compared the variation to that in nonatopic healthy controls.

Results

The homozygous mutants of KLK7 and SPINK5-2475, and the heterozygous mutants of FLG 3321delA, SPINK5-1156, DEFB1, KDR, IL5RA, IL9 and IL12RB1 were significantly more frequent in AD. It has been predicted that the larger the number of gene variants, the higher the odds ratio of AD prevalence; however, we did not find any significant correlation between the number of gene variants and AD severity.

Conclusion

Using REBA, we identified more genetic variants that can predict AD occurrence. We also verified that REBA can be used to easily and accurately detect multiple AD-related gene variants simultaneously. In addition, we identified a correlation between KLK7 mutation and AD in Koreans, which is the first such report, to our knowledge.

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The Lateral Femoral Cutaneous Nerve: Description of the Sensory Territory and a Novel Ultrasound-Guided Nerve Block Technique

Background and Objectives Nerve blockade of the lateral femoral cutaneous (LFC) nerve provides some analgesia after hip surgery. However, knowledge is lacking about the extent of the cutaneous area anesthetized by established LFC nerve block techniques, as well as the success rate of anesthetic coverage of various surgical incisions. Nerve block techniques that rely on ultrasonographic identification of the LFC nerve distal to the inguinal ligament can be technically challenging. Furthermore, the branching of the LFC nerve is variable, and it is unknown if proximal LFC nerve branches are anesthetized using the current techniques. The primary aim of this study was to investigate a novel ultrasound-guided LFC nerve block technique based on injection into the fat-filled flat tunnel (FFFT), which is a duplicature of the fascia lata between the sartorius and the tensor fasciae latae muscle, in order to assess the success rate of anesthetizing the proximal LFC nerve branches and covering of the different surgical incisions used for hip surgery. Methods First, a cadaveric study was conducted in order to identify an FFFT injection technique that would provide adequate injectate spread to the proximal LFC nerve branches. Second, a clinical study was conducted in a group of 20 healthy volunteers over 2 consecutive days. On trial day 1, successful complete anesthesia of the LFC nerve was defined by performing a suprainguinal fascia iliaca block bilaterally in each subject. On trial day 2, a triple-blind randomized controlled trial compared the effect of the novel ultrasound-guided LFC nerve block technique for bupivacaine versus placebo. The primary end point was the success rate of anesthesia of the proximal cutaneous area innervated by the LFC nerve for the FFFT injection with bupivacaine versus placebo. Results Adequate spread of injectate to the proximal LFC nerve branches in cadavers was obtained by injecting 10 mL with dynamic needle-tip tracking in the FFFT. Application of this technique in the randomized controlled trial provided anesthesia of the lateral thigh with a success rate of 95% (95% confidence interval, 73.9%–99.8%) for the active side and 0% for placebo (P

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Efficacy and Safety of Lidocaine Infusion Treatment for Neuropathic Pain: A Randomized, Double-Blind, and Placebo-Controlled Study

Background and Objectives Lidocaine infusion therapy (LIT) is an effective treatment for relieving neuropathic pain (NeP). However, it remains unclear whether pain relief can be sustained through repeated lidocaine infusions. This study aimed to determine whether repeated intravenous administration of low-dose lidocaine could provide prolonged pain relief in patients with specific NeP conditions. Methods This is a prospective, randomized, double-blind, placebo-controlled, parallel study. We compared the efficacy and safety of lidocaine infusions (3 mg/kg) in the LIT group and normal saline infusions in the control group once a week for 4 consecutive weeks in patients with postherpetic neuralgia or complex regional pain syndrome type II. The primary outcome was the difference in the percentage change in the 11-point numerical rating scale (NRS) pain score from baseline to after the final infusion. Secondary outcomes included pain scores during 4 weeks of follow-up and any complications. Results Forty-two patients completed this study protocol. The percentage reduction in NRS pain scores after the final infusion was significantly greater in the LIT group compared with the control group (P = 0.011). However, this pain reduction was not detectable at the 4-week follow-up. The difference in the percentage change in NRS pain scores was especially prominent in the LIT group after the third and fourth infusions. None of the study participants experienced serious complications from the treatment. Conclusions Lidocaine infusion therapy (3 mg/kg of lidocaine administered over 1 hour) provided effective short-term pain relief, which was substantially prominent after repeated infusions were administered to patients with refractory NeP. Clinical Trial Registration This study was registered at ClinicalTrials.gov, identifier NCT02597257. Accepted for publication September 2, 2017. Address correspondence to: Jee Youn Moon, MD, PhD, FIPP, CIPS, Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, 110 Daehang-ro, Jongno-gu, Seoul 110-744, Korea (e-mail: jymoon0901@gmail.com). This research was supported by a grant (14172MFDS178) from Korean Ministry of Food and Drug Safety in 2014. The agency was not involved in conduct of this study or its submission. The authors declare no conflict of interest. Y.-C.K., A.M.C., and C.-S.L. contributed equally to this study. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Dexamethasone as an Adjuvant to Femoral Nerve Block in Children and Adolescents Undergoing Knee Arthroscopy: A Prospective, Randomized, Double-Blind, Placebo-Controlled Trial

Background and Objectives Perineural dexamethasone has been demonstrated to extend postsurgical analgesia after peripheral nerve blockade in adults. The mechanism of action of dexamethasone as a regional anesthetic adjuvant is unclear as intravenous dexamethasone has been shown to have similar analgesic efficacy as perineural dexamethasone. The efficacy of perineural dexamethasone has not been previously explored in the pediatric population. Methods After obtaining informed consent, children (aged 10–18 years) presenting for arthroscopic knee surgery with a femoral nerve block were randomized to 1 of 3 groups: ropivacaine 0.5% and intramuscular saline (group R), ropivacaine 0.5% plus perineural dexamethasone 0.1 mg/kg (maximum 4 mg) and intramuscular saline (group D), and ropivacaine 0.5% and intramuscular dexamethasone 0.1 mg/kg (maximum 4 mg) (group M). The primary outcome was the number of doses of analgesic agents in the first 48 hours after hospital discharge. The number of doses was compared across study groups using Wilcoxon rank sum tests. Results Seventy-seven patients were enrolled in the study, of whom 4 were withdrawn because of additional surgical repair being performed, emergence delirium requiring unblinding, or loss to follow-up. The remaining 36 boys and 37 girls (aged 15 ± 2 years) included 23 patients randomized to group D, 23 patients randomized to group M, and 27 patients randomized to group R. The median number of pain medication doses within 48 hours of discharge was 2, 3, and 2 in groups D, M, and R, respectively. There were no significant differences in this outcome between groups D and M (difference in medians, 1; 95% confidence interval [CI] of difference in medians, −1 to 2; P = 0.475), groups D and R (difference in medians, 0; 95% CI of difference, −2 to 1; P = 0.821), or groups M and R (difference in medians, −1; 95% CI of difference, −2 to 1; P = 0.594). Other secondary outcomes, including time to first analgesic consumption after discharge, visual analog scale pain score, and subjective intensity of motor block, did not evince statistically significant differences among the study groups. Conclusions In the pediatric population, perineural or intramuscular dexamethasone did not improve analgesia after femoral nerve blockade for knee arthroscopy. Whether the observed lack of benefit reflects a true adult-pediatric difference or a limitation of the study could not be determined. Future pediatric studies are needed to evaluate dexamethasone for other block types and other types of surgery. Clinical Trial Registration This study was registered at ClinicalTrials.gov, identifier NCT01971645. Accepted for publication October 4, 2017. Address correspondence to: Giorgio Veneziano, MD, Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205 (e-mail: Giorgio.Veneziano@Nationwidechildrens.org). This project was supported by The Clinical and Translational Intramural Funding Program (award grant number UL1TR001070), through the Research Institute at Nationwide Children's Hospital (Columbus, OH). The content is solely the responsibility of the authors and does not necessarily represent the official views of Nationwide Children's Hospital. This work was presented in part at moderated abstract presentations at the Society of Pediatric Pain Medicine's CCAS 2017 Annual Meeting on March 2 and the SPA-AAP Pediatric Anesthesiology 2017, on March 3, 2017, both in Austin, TX. The authors declare no conflict of interest. This study was registered with the Food and Drug Administration as an investigational new drug (IND 120188). Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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A topical treatment containing heat-treated Lactobacillus johnsonii NCC 533 reduces Staphylococcus aureus adhesion and induces antimicrobial peptide expression in an in vitro reconstructed human epidermis model

Abstract

Staphylococcus aureus colonization is thought to contribute to the pathophysiology of atopic dermatitis (AD). AD patients exhibit reduced levels of cutaneous antimicrobial peptides (AMPs), which may explain their increased susceptibility to infections. Using an in vitro reconstructed human epidermis (RHE) model, we sought to determine whether topical application of a non-replicating probiotic, heat-treated Lactobacillus johnsonii NCC 533 (HT La1), could inhibit S. aureus adhesion to skin and boost cutaneous innate immunity. We found that application of HT La1 suspension to RHE samples reduced the binding of radiolabeled S. aureus by up to 74%. To investigate a potential effect of HT La1 on innate immunity, we analyzed the expression of nine AMP genes, including those encoding beta defensins and S100 proteins, following topical application of HT La1 in suspension or in a daily moisturizer lotion. Analyzed genes were induced by up to four-fold in a dose-dependent manner by HT La1 in suspension, and by up to 2.4-fold by HT La1 in the moisturizer lotion. Finally, using ELISA and immunohistochemical detection, we evaluated the expression and secretion of the AMPs hBD-2 and psoriasin, and determined that both proteins were induced by topical HT La1, particularly in the stratum corneum of the RHE. These findings demonstrate that a topically applied, non-replicating probiotic can modulate endogenous AMP expression and inhibit binding of S. aureus to an RHE model in vitro. Moreover, they suggest that a topical formulation containing HT La1 could benefit atopic skin by enhancing cutaneous innate immunity and reducing S. aureus colonization.

This article is protected by copyright. All rights reserved.

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Staphylococcal scalded skin syndrome in a 4-year-old child: a case report

Staphylococcal scalded skin syndrome is an exfoliating skin disease which primarily affects children. Differential diagnosis includes toxic epidermal necrolysis, staphylococcal scalded skin syndrome, epidermol...

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Post-transplant lymphoproliferative disease with features of cutaneous natural killer/T-cell lymphoma

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Homeobox transcription factor DLX4 is not necessary for skin development and homeostasis

Abstract

Dlx4 is a member of a family of homeobox genes with homology to Drosophila distal-less (dll) gene. We show that Dlx4 expression pattern partially overlaps with its cis-linked gene Dlx3 during mouse development as well as in neonatal and adult skin. In mice, Dlx4 is expressed in the branchial arches, embryonic limbs, digits, nose, hair follicle and in the basal and suprabasal layers of mouse interfollicular epidermis in neonatal and adult skin. We show that inactivation of Dlx4 in mice did not result in any overtly gross pathology. Skin development, homeostasis and response to TPA treatment was similar in mice with loss of Dlx4 compared to wild type counterparts.

This article is protected by copyright. All rights reserved.

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The prevalence of human papillomavirus in pediatric tonsils: a systematic review of the literature

Abstract

Background

HPV-related head and neck cancer rates have been increasing in recent years, with the tonsils being the most commonly affected site. However, the current rate of HPV infection in the pediatric population remains poorly defined. The objective of this study was to systematically review and evaluate the prevalence and distribution of HPV in the tonsils of pediatric patients undergoing routine tonsillectomy.

Methods and Results

The literature was searched using PubMed, EMBASE, Scopus, CINAHL, Cochrane Library, and ProQuest Dissertations & Theses Global databases (inception to December 2017) by two independent review authors. Inclusion criteria included articles which evaluated the prevalence of HPV in a pediatric cohort without known warts or recurrent respiratory papillomatosis, those which used tonsil biopsy specimens for analysis, and those with six or more subjects and clear outcomes reported. Eleven studies met the inclusion criteria. Using the Oxford Clinical Evidence-based Medicine (OCEBM) guidelines, two reviewers appraised the level of evidence of each study, extracted data, and resolved discrepancies by consensus. The systematic review identified 11 articles (n = 2520). Seven studies detected HPV in the subject population, with prevalence values ranging from 0 to 21%. The level of evidence for all included studies was OCEBM Level 3.

Conclusions

HPV may be present in pediatric tonsillectomy specimens; however, the largest included study demonstrated a prevalence of 0%. Future testing should be performed using methods with high sensitivities and specificities, such as reverse transcript real-time PCR or digital droplet PCR.

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Nickel hypersensitivity following closure of atrial septal defect: A case report and review of the literature

Abstract

We present an unusual case where symptoms of headache and chest pain persisted for 3 years following the implantation of a septal occluder device for an atrial septal defect despite endothelialisation of the device. The patient was found to have nickel hypersensitivity on patch testing. Following the removal of the device the patient had complete resolution of headaches and chest pain up to 10 months post-explantation.

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Rapid exacerbation of malignant melanoma during short-term discontinuation of vemurafenib

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Intra-Arterial Thrombolytic Therapy Is Not a Therapeutic Option for Filler-Related Central Retinal Artery Occlusion

Facial plast Surg
DOI: 10.1055/s-0037-1621730

Cosmetic facial filler-related central retinal artery occlusion (CRAO) is a devastating complication of facial hyaluronic acid (HA) injection and can be managed by intra-arterial thrombolytic therapy (IATT). The authors report on a 20-year-old woman who developed unilateral CRAO due to facial HA injection and who, despite prompt IATT, lost vision. A review of the related literature found 14 other female patients who developed cosmetic facial filler-related CRAO and accepted IATT management. In no case was vision loss clinically improved. IATT is not an effective preventive treatment of dermal filler-associated CRAO. The authors suggest careful preprocedural patient selection to prevent this complication.
[...]

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Article in Thieme eJournals:
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Unerwartete Folgen einer HNO-Standardtherapie

Laryngo-Rhino-Otol
DOI: 10.1055/s-0044-100257

© Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
Table of contents  |  Full text

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Biological response to self-etch adhesive after partial caries removal in rats

Abstract

Objectives

The purposes of this study were to evaluate a model of slow caries progression and to investigate the performance of a self-etch adhesive system for partial caries removal.

Materials and methods

Rat molars were infected with Streptococcus sobrinus 6715 culture. Different time points were analyzed: days 78, 85, and 95 (± 2). After this, the samples were processed for morphological analysis. Additionally, the first molars were restored with zinc oxide and eugenol (IRM™; Dentsply; Brazil) or adhesive system (Clearfil SE Bond™; Kuraray Medical; Japan) 78 days after caries induction. After, 3 or 15 days post-treatment, the animals were euthanized, and their mandibles were processed for morphological analysis, classified by means of scores, and submitted to statistical analysis. Subsequently, immunohistochemical analysis was performed for osteonectin (OSN) and transforming growth factor-ß1 (TGF-ß1) expression.

Results

According to the caries induction model used, on day 95 greater inflammatory infiltration (p < 0.001), and more extensive degradation of secondary/primary dentin were demonstrated than on day 78 (p < 0.05). Furthermore, the restorative materials presented similar performance (p > 0.05) and proved to be fundamental to control the carious lesion. The TGF-ß1 and OSN were shown to be active during the caries process.

Conclusions

The slow caries lesion model was feasible for morphological analysis of the dentin-pulp complex. The self-etch adhesive system triggered no acute inflammatory infiltration or pulp necrosis, instead it seemed to stimulate early pulp repair.

Clinical relevance

Clearfil SE Bond™ applied directly on caries-affected dentin did not predispose to pulp inflammation; instead, it appeared to provide early biological benefits.

http://ift.tt/2DZQZDm

Immunohistochemical Analysis of Inflammatory Rheumatoid Synovial Tissues Using Anti-Human Podoplanin Monoclonal Antibody Panel

Monoclonal Antibodies in Immunodiagnosis and Immunotherapy , Vol. 0, No. 0.


http://ift.tt/2Furvel

Polypoidal Choroidal Vasculopathy Associated with Optic Disc Coloboma

Purpose: To report a case of polypoidal choroidal vasculopathy associated with optic disc coloboma. Methods: Case report. Results: A 50-year-old woman presented with optic disc coloboma and retinochoroidal coloboma associated with subretinal hemorrhage and serous retinal detachment (SRD) in her left eye. Optical coherence tomography (OCT) confirmed SRD at the macula and showed a sharply elevated retinal epithelial detachment at the choroidal excavation. OCT also revealed choroidal cavitation along the temporal side of the optic coloboma. Fluorescein angiography showed hyperfluorescent dye leakage and indocyanine green angiography revealed polypoidal lesions. We diagnosed polypoidal choroidal vasculopathy (PCV). PCV was located at the end of the choroidal cavitation. Her left eye was treated with an intraocular injection of the anti-vascular endothelial growth factor aflibercept (2 mg). Photodynamic therapy was performed using the standard protocol 1 week after the intravitreal application of aflibercept. One month after the combined treatment, OCT showed completely resolved SRD and her symptoms disappeared. Her best-corrected visual acuity remained stable and no recurrence was found during a 12-month follow-up period. Conclusion: PCV associated with optic disc coloboma has not been previously reported. The morphological abnormality of choroidal cavitation and choroidal excavation connecting with optic disc coloboma may contribute to the development of PCV in this case.
Case Rep Ophthalmol 2018;9:92–95

http://ift.tt/2BBQ4U4

Optical Coherence Tomography Angiography of Foveal Neovascularization in Diabetic Retinopathy

Purpose: To report a case of foveal neovascularization in a patient with proliferative diabetic retinopathy as seen on optical coherence tomography angiography (OCT-A). Methods: Multimodal imaging was used for diagnostic investigation. Patient: A 61-year-old male with a 16-year history of insulin-dependent diabetes mellitus was referred to our medical retina department for examination and management. Meticulous fundus examination and multimodal imaging revealed proliferative diabetic retinopathy lesions, including neovascularization located in the foveal area. Results: OCT-A allowed us to detect the neovascular lesion, confirm that it originated from perifoveal capillaries, estimate its retinal depth, and evaluate the vessel blood flow in multiple layers. Conclusion: To the best of our knowledge this is the first report of OCT-A imaging of foveal neovascularization in diabetic retinopathy. OCT-A is a very useful examination for the diagnostic investigation of patients with diabetic retinopathy.
Case Rep Ophthalmol 2018;9:87–91

http://ift.tt/2nluWgz

A Case of Anterior Spinal Artery Syndrome Caused by Streptococcus mitis Endocarditis

Background. Infectious endocarditis (IE) typically occurs in the setting of intravenous drug use, prosthetic heart valves, or rheumatic heart disease. However, there are a few reports of IE occurring in the setting of immunosuppression secondary to cancer and/or chemotherapy. Here, we present a case of a cancer patient who developed anterior spinal artery (ASA) syndrome secondary to a septic embolus from IE. Case Presentation. A 78-year-old male with a history of gastroesophageal cancer treated with chemotherapy and radiation presented to the hospital after a fall at home. He reported experiencing dyspnea and orthopnea for two weeks prior to presentation. In the ED, his vital signs were stable, and his examination was significant for a flaccid paralysis of the right lower extremity. Diagnosis of septic emboli secondary to IE was made after the echocardiogram showed the presence of vegetations on the aortic valve, blood cultures were positive for Streptococcus mitis, and thoracic spine MRI was indicative of an infarction at T10. Discussion. This case highlights the presence of IE in the setting of cancer and chemotherapy. Although cancer is a rare cause of IE, clinicians must maintain a high index of suspicion in order to minimize the sequelae of IE.

http://ift.tt/2BBlcTQ

Dosage adjustments in patients with psoriasis on adalimumab: a retrospective chart review

Abstract

Adalimumab is a well-established treatment for chronic plaque psoriasis. While many clinical trials have shown its efficacy, few studies have looked at deviations from labeled dosing in the real-world setting.¹ The aim of this study was to determine the frequency of off-label dosing in patients with psoriasis on adalimumab and the reasons for these deviations.

This article is protected by copyright. All rights reserved.

http://ift.tt/2DHvkw1

Patch testing in facial dermatitis using Chinese Baseline Series (60 allergens) and Cosmetic Series (58 allergens)

Abstract

Facial dermatitis (FD) is a common problem encountered in clinical practice. It effects patients' self-esteem and quality of life. Mild reactions such as itching, pricking, dryness can occur in more than 10% of patients[1]. Recurrence is common in FD. The cause of FD is often difficult to determine. Metals, cosmetics, air pollution and physical factors such as wind or changes in temperature and humidity in the environment may all contribute to the development of FD[2]. Patch test is useful in establishing the identification of FD[1,2]. The present study was carried out to determine the incidence and role of contact allergy in FD, using the Chinese Baseline Series and Cosmetic Series.

This article is protected by copyright. All rights reserved.

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The influence of exposome on acne

Abstract

Background

Acne vulgaris is one of the main reasons for dermatological consultations. Severity and response to treatment may be impacted by various external factors or exposome.

Aim

to assess the impact of environmental factors on acne and to provide a comprehensive overview of the acne exposome.

Methods

two consensus meetings of five European dermatologists and a comprehensive literature search on exposome factors triggering acne served as a basis for this review.

Results

acne exposome was defined as the sum of all environmental factors influencing the occurrence, duration and severity of acne. Exposome factors impact on the response and the frequency of relapse to treatments by interacting with the skin barrier, sebaceous gland, innate immunity and cutaneous microbiota. They may be classified in the following six main categories: nutrition, psychological and lifestyle factors, occupational factors including cosmetics, as well as pollutants, medication and climatic factors. Moreover, practical considerations for the dermatologist's clinical practice are proposed.

Conclusion

Exposome factors including nutrition, medication, occupational factors, pollutants, climatic factors, and psychosocial and lifestyle factors may impact on the course and severity of acne and on treatment efficacy. Identifying and reducing the impact of exposome is important for an adequate acne disease management.

This article is protected by copyright. All rights reserved.

http://ift.tt/2DMAs29

Retrospective study on the correlation between 18-fluorodeoxyglucose uptake in positron emission tomography-computer tomography and tumor volume, cytological activity as assessed with Ki-67 and GLUT-1 staining in 10 cases of Merkel cell carcinoma

Abstract

Merkel cell carcinoma (MCC) is a rare malignant neuro-endocrine tumor of the skin that shows aggressive behavior and has a high tendency for local recurrence and lymph node or distant metastasis.¹ Recently, some reports have stated that 18-fluorodeoxyglucose positron emission tomography-computer tomography (FDG PET-CT) is more useful than conventional CT.^{2, 3} However, the utility of FDG PET-CT for determining the proliferative or metabolic activity of MCC is unclear. In this study, we investigated the correlation between FDG uptake and proliferative of metabolic activity as revealed by PET-CT imaging with Ki-67 immunological staining or GLUT-1 immunological staining in 10 cases of MCC. In addition, we tested the correlation between FDG uptake and tumor volume.

This article is protected by copyright. All rights reserved.

http://ift.tt/2EkFS5j

Frailty in Thoracic Surgery

Conditions:   Thoracic;   Thoracic Neoplasm;   Lung Cancer;   Esophageal Cancer;   Surgery--Complications;   Surgery;   Sarcopenia;   Malnutrition;   Frail Elderly Syndrome
Intervention:   Diagnostic Test: Frailty model
Sponsor:   The Cleveland Clinic
Recruiting

http://ift.tt/2EjqOFa

Lenvatinib Mesylate and Pembrolizumab in Treating Patients With Metastatic or Recurrent Gastric or Gastroesophageal Cancer

Conditions:   Gastric Adenocarcinoma;   Gastroesophageal Junction Adenocarcinoma;   Recurrent Gastric Carcinoma;   Stage IV Gastric Cancer AJCC v7
Interventions:   Other: Laboratory Biomarker Analysis;   Drug: Lenvatinib Mesylate;   Biological: Pembrolizumab
Sponsors:   New York University School of Medicine;   National Cancer Institute (NCI)
Recruiting

http://ift.tt/2DIClgm

Investigation of Neurocognitive Measures of Sport-Related Injury

Condition:   Concussion, Brain
Intervention:   Other: Cervical spine musculature
Sponsor:   Mayo Clinic
Not yet recruiting

http://ift.tt/2EjRQMJ

Lobaplation or Cisplatin in Adjuvant Chemotherapy for Esophageal Carcinoma

Condition:   Esophageal Cancer
Interventions:   Drug: Lobaplatin;   Drug: Cisplatin
Sponsor:   Henan Cancer Hospital
Not yet recruiting

http://ift.tt/2DMremx

Evaluation of Plaque Removal Efficacy & Patient Acceptability of Knotted Floss Technique in Type II Gingival Embrasures

Conditions:   Oral Hygiene;   Dental Devices, Home Care
Interventions:   Device: Knotted floss technique;   Device: Conventional flossing technique;   Device: Conventional Interdental Brushing
Sponsor:   Uttaranchal Dental & Medical Research Institute
Not yet recruiting

http://ift.tt/2EjRKER

Frontal fibrosing alopecia after antiandrogen hormonal therapy in a male patient

Abstract

An 82-year-old man with a prostate adenocarcinoma, started eight years before a treatment with oral bicalutamide 50 mg daily and subcutaneous goserelin 10,8 mg each three months, an antiandrogen and a LHRH analogue, respectively. The rest of his past medical history was unremarkable. A few months after starting with the treatment, he began with recession of the frontotemporal hairline also with hypopigmentation and atrophy of the areas of alopecia and loss of axillary and pubic hair (Figure 1). He did not present any clinical signs or patterns of male androgenetic alopecia. He denied having any siblings or kindreds with a scarring alopecia and therefore a familial FFA was excluded. Laboratory test showed low levels of prostate specific antigen (0,024ɥg/L) and undetectable free serum testosterone levels (<0,1 nmol/L). A biopsy on the scalp revealed a lichenoid lymphocitic inflammatory infiltrate, important fibrosis with loss of elastic fibers and hair follicle destruction (Figure 2,3). The clinical and histopathological features were consistent with frontal fibrosing alopecia. He is still having this treatment in order to prevent the progression of the prostate adenocarcinoma.

This article is protected by copyright. All rights reserved.

http://ift.tt/2BBBdcr

A study of androgenic signs and disorders in Greek female patients with acne

Abstract

Acne represents an established cutaneous manifestation of hyperandrogenism (1). There are scarce studies of androgenic signs or disorders including polycystic ovary syndrome (PCOS), hirsutism, menstrual irregularities or androgenic alopecia, in patients with acne.

This article is protected by copyright. All rights reserved.

http://ift.tt/2ngN23y

Oncologic outcomes of extended neck dissections in human papillomavirus-related oropharyngeal squamous cell carcinoma

Abstract

Background

Oncologic outcomes of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (SCC) requiring resection of major muscular or neurovascular tissue during neck dissection for invasive nodal disease remain uncertain.

Methods

Patients with HPV-related oropharyngeal SCC requiring resection of major muscular or neurovascular tissue during their neck dissections were retrospectively identified.

Results

Seventy-two patients were included. Regional and distant recurrences occurred in 6% and 17% of patients. Advanced T classification, pathological node number of 5 or more, and omission of adjuvant therapy were associated with decreased disease-free survival (DFS). The addition of adjuvant chemotherapy was not associated with improved survival.

Conclusion

Patients with invasive nodal disease from HPV-related oropharyngeal SCC can be managed with up-front surgery and adjuvant therapy, as indicated with good regional control. Although distant recurrence was the primary site of failure, adjuvant chemotherapy was not associated with improved outcomes. The T classification, node number, and adjuvant radiotherapy are independent prognostic factors in this patient population.

http://ift.tt/2EjjE3K

Risk analysis of malignant potential of oral verrucous hyperplasia: A follow-up study of 269 patients and copy number variation analysis

Abstract

Background

Oral verrucous hyperplasia is commonly observed in the oral cavity of betel quid chewers and is a potential malignant disorder. However, the prognostic factors and genetic alterations of oral verrucous hyperplasia are unclear.

Methods

We calculate the survival rate and prognostic factors using a Kaplan-Meier analysis and Cox proportional hazards regression model. Copy number variations were analyzed using a single-nucleotide polymorphism (SNP) array.

Results

The 5-year disease-free and cancer-free survival rates of patients with oral verrucous hyperplasia were approximately 40% and 70%, respectively. Heavy betel quid chewing, advanced oral submucous fibrosis, and nonbuccal and nontongue lesions were risk factors for malignant transformation, whereas dysplasia did not affect outcomes. The gene amplification of CTTN, FOLR3, ORAOV1, PPFIA1, and RNF121 were associated with the poor prognosis of oral verrucous hyperplasia.

Conclusion

Heavy betel quid chewing, advanced oral submucous fibrosis, and nonbuccal and nontongue lesions are high-risk factors of patients with oral verrucous hyperplasia. The 5-copy number variation-associated genes could be used for early diagnosis and predicting the prognosis.

http://ift.tt/2DHLHJe

Potts disease associated with large and multiple abscesses in a 30-year-old migrant from Chad

Description 

After a 1-year history of increasing mechanical back pain, a 30-year-old Chadian man with no medical record progressively developed a voluminous paravertebral mass (figure 1A). He described night sweats without fever for several months associated with a 20 kg weight loss (admission weight at 68 kg). Physical examination revealed no neurological defect. Laboratory tests showed a biological inflammatory syndrome with C reactive protein (CRP) plasmatic level at 80 mg/L and fibrinogen at 5.1 g/L. A vertebral MRI showed a T11–T12 vertebral osteomyelitis with a discal and corporeal abscess surrounded by important adjacent bone oedema, epiduritis causing mild spinal cord compression, as well as voluminous, prevertebral (12x8x5 cm), left psoas (9x8x8 cm) and retrovertebral (16x5x4 cm) liquid collections with peripheral contrast enhancement, suggestive of abscesses (figure 1B–D). Culture of the punctured collection of the retrovertebral abscess yielded multisusceptible Mycobacterium tuberculosis. Body scan revealed no other disease localisation. HIV serological test was negative and...

http://ift.tt/2nkmvCu

Intravascular lymphoma presenting with postural hypotension

An 84-year-old woman presented with severe postural hypotension. Further assessment revealed weight loss, fatigue and fever at night. On examination, she had bilateral skin lesions on the inner thighs and skin biopsy revealed intravascular high grade B cell lymphoma. This was successfully treated with curative chemotherapy. The cause of the postural hypotension in this case was felt likely to be autonomic neuropathy caused by neurovascular infiltration by intravascular lymphoma. Treatment of the lymphoma has resolved the postural hypotension, although some symptoms of postural instability persist.

http://ift.tt/2BBIatU

Fuchs syndrome: a case of fever, mucositis and conjunctivitis

Description

A 5-year-old boy presented with fever and cough of 2 weeks' duration, conjunctivitis and lip swelling with blistering for 6 days, and 1 day of skin rash. His past medical history was significant for incomplete Kawasaki disease (KD) at 3 years of age with no cardiac sequelae. Significant findings on physical examination included bilateral conjunctival injection with perilimbic sparing, red and cracked lips with crusting, oral mucositis and ulcerations of the buccal mucosae and tongue (figure 1), and a mild generalised maculopapular rash. He was systemically well otherwise, and there were no target lesions evident on his skin.

Figure 1

Oral mucositis with blistering of lips in a patient with Fuchs syndrome.

Differential diagnoses at that point included recurrent incomplete KD, Stevens-Johnson syndrome (SJS) and gingivostomatitis. However, oral mucositis was not consistent with KD. Furthermore, the absence of any skin...

http://ift.tt/2nkmjTM

Cryptosporidium diagnosed on endoscopic biopsy in a paediatric patient with inflammatory bowel disease

Cryptosporidium, a parasitic infection commonly associated with diarrhoea, may be difficult to differentiate from a flare in patients with inflammatory bowel disease and can lead to unnecessary therapy and increase in morbidity and mortality. We report the case of a paediatric patient who had substantial stool output requiring significant fluid resuscitation and who was later diagnosed with cryptosporidium on endoscopic biopsy. Diagnostic work up for cryptosporidium should be strongly considered when a patient presents with a flare involving massive stool output.

http://ift.tt/2BBI9WS

Segmental dilatation of small bowel presenting with severe anaemia: a diagnostic puzzle

A 7-year-old boy presented to Paediatric outpatient with worsening lethargy and tiredness. On examination he had extreme pallor. Blood investigations confirmed severe iron deficiency anaemia. He was started on iron supplements and received blood transfusion. However, the response to iron treatment was suboptimal, he therefore underwent extensive workup for the cause of iron deficiency anaemia. The barium meal showed dilated segments of ileum with two distal stenoses. The surgical resection of the involved segment was performed with end to end anastamosis. Histology of the resected segment was inconclusive of inflammatory bowel disease, malignancy or vascular malformation. The child has remained well since surgery with no further blood transfusion or iron therapy.

http://ift.tt/2njw7NL

Chronic incomplete non-puerperal uterine inversion due to huge submucous fibroid: diagnosis and management

Description

Incomplete non-puerperal uterine inversion is a rare complication that can arise secondary to the presence of submucous fibroid.1 In the majority of cases reported in the literature, the definitive diagnosis is usually made at the time of hysterectomy.2 In reported cases where hysterectomy was not done, Haultain procedure was done to correct the inversion.3 In the following case, the diagnosis was made preoperatively and the fibroid was resected vaginally by LigaSure.

A 31-year-old nulliparous woman presented to the emergency room with history of excessive bleeding for a few months. She also had urine retention for 1 day. On examination, she was pale. Vaginal examination showed a large mass distending the vagina with foul smell and moderate bleeding. Her haemoglobin was 6.2 g/L. Pelvic ultrasound scan was not conclusive in ascertaining the origin of the mass. MRI revealed the presence of a pedunculated,...

http://ift.tt/2BCWPVU

New onset diabetes after nivolumab treatment

The authors describe a case of a life-threatening diabetic emergency 25 days after initiation of nivolumab (3 mg/kg) for stage 4 lung adenocarcinoma. She was admitted to the emergency department, with hyperglycaemia-related signs and symptoms, such as polyuria, polydipsia, weight loss, confusion, asthenia, dehydration, hypotension and Kussmaul respiratory pattern. Her body mass index was 21.9 kg/m² and she did not show acanthosis nigricans. Arterial blood gas determination revealed high anion gap metabolic acidaemia and blood tests showed hyperglycaemia (1060 mg/dL), hyperketonaemia (beta-hydroxybutyrate: 6.6 mmol/dL), elevated total serum osmolality (389 mOsm/kg), low serum and urinary C-peptide and positive antiglutamic acid decarboxylase antibodies. Since nivolumab was initiated a few days before, and due to its known immune-mediated endocrine adverse events, we assumed the diagnosis of new onset immune-mediated type 1 diabetes mellitus. After prompt and adequate treatment of diabetic ketoacidosis/hyperosmolar hyperglycaemic state, she was discharged improved on multiple daily injections of insulin.

http://ift.tt/2nljJwy

Single vs multiallergen sublingual immunotherapy in the polysensitized patient: a pilot study

Background

Sublingual immunotherapy (SLIT) has emerged as an effective and exceptionally safe method of treatment of the atopic patient. However, the optimal number of allergens that should be included in the SLIT treatment regimen for the polysensitized patient is not known and practices vary widely. This study aims to compare the efficacy of single-allergen SLIT with pauci-allergen vs multiallergen aqueous SLIT in polysensitized patients.

Methods

Sixteen subjects sensitized to 6+ allergens were enrolled in the study. Subjects were blinded and randomized to SLIT treatment groups that included 1 (single), 3 (pauci), or all sensitized allergens (multi). Allergens selected were those to which the patient was most sensitized and correlated with history. Primary outcomes included daily allergy medication use, weekly Rhinoconjunctivitis Symptom Score (RCSS), and the mini–Rhinoconjuncitivitis Quality of Life Questionnaire (m-RQLQ). All metrics were measured at baseline, 6 weeks, 3 months, 6 months, and 9 months.

Results

There were significant decreases from baseline in RCSS and m-RQLQ scores in all study groups at each interval after beginning SLIT (p < 0.05). There was no significant decrease in number of daily allergy medications used regardless of number of allergens in patient's treatment vial (p = 0.50). No significant differences emerged based on number of allergens used.

Conclusion

Single-antigen, pauci-antigen, and multiantigen aqueous SLIT significantly improved allergy symptoms. There was no significant difference observed in efficacy of single-allergen SLIT vs pauci-allergen or multi-allergen SLIT in polysensitized patients.

http://ift.tt/2EkPSvE

Assessment of the general quality of sunscreen products available in Palestine and method verification of the sun protection factor using Food and Drug Administration guidelines

Summary

Background

Sunlight exposure affects all skin types causing skin tanning, burns or even skin cancer. Sunscreens were invented to prevent these outcomes by scattering or absorbing the UV light.

Aims

This study aimed to verify the effectiveness of Mansur method in SPF measurement and to find out how much reliable the labeled sun protection factor (SPF) value for the products that are imported to Palestine knowing that they are considered as cosmetics and they don't undergo tests by the Ministry Of Health (MOH).

Materials

In this research, sun protection factor (SPF) was determined for 16 commercially available sunscreen products using Mansur equation which was also validated; moreover sunscreen classification, product phase determination and pH measurement were also done.

Results

Sun protection factor values were mostly 50, 43.75% of the analyzed samples were close to the labeled SPF, 31.25% were under the labeled value, and 25% SPF value above the labeled value. All samples exhibited a pH close to skin pH. 62% of them were found to be O/W. Cosmetic companies and importers should focus on pediatric sunscreens, since only 12.5% are pediatric sunscreens.

Conclusions

Ministry Of Health should ask prove about the quality of an SPF value of sunscreens for final registration of these products. More instructions should be available on the label regarding the proper use especially, if they are not water proof.

http://ift.tt/2noejQK

Case series about ex vivo identification of squamous cell carcinomas by laser-induced autofluorescence and Fourier transform infrared spectroscopy

Abstract

An ex vivo case series aimed at identification of normal laryngeal tissue from laryngeal epidermoid squamous keratinized carcinoma by measuring laser-induced autofluorescence (LIAF) and Fourier transform infrared–attenuated total reflectance (FTIR-ATR) spectra is presented. The case series results were obtained for paired samples extracted from three patients (exclusion: macroscopic changes of normal vocal cord observed during surgery; surgical intervention on vocal cord, treated only with chemotherapy or radiotherapy for carcinoma; inclusion: men, aged 57–68, non-smokers). For LIAF analysis, a 375-nm picosecond pulsed laser diode with 31 MHz pulse repetition rate, 100 ps full-time width at half-maximum, and average power 0.49 μW was used. LIAF and FTIR-ATR spectra show noticeable differences between normal and malignant tissues. LIAF spectra differed in shape of emitted band, peak position, and band relative intensity of the two kinds of samples, evidencing hypsochromic shift and mean fluorescence intensity decrease of (75.42 ± 3)% in malignant tissue with respect to the normal one. The lack of 1745 cm⁻¹ band in FTIR-ATR spectra for malignant tissues could be considered an important indicative of the presence of this kind of tissue; moreover, it resulted a greater contribution of lipids and proteins in normal tissue and of collagen in malignant tissue. Penetration depth of the evanescent wave was about 2 μm at an angle of 42°. The two spectroscopic methods are complementary, are applicable for real-time measurements, and may enhance cancer detection and diagnostics. Results presented in this study evidence the potential of the two methods for future in vivo studies.

http://ift.tt/2rJPX9C

Post-transplantation Development of Food Allergies

Abstract

Purpose of Review

The development of food allergies is increasingly being recognized as a post-solid organ transplant complication. In this article, we review the spectrum of post-transplant food allergy development and the proposed mechanisms for de novo food allergies and the clinical significance they pose.

Recent Findings

The development of new food allergies is disproportionately associated with pediatric liver transplants, where it occurs in up to 38% of select populations. The mechanism of food allergy development is not completely understood; however, it is likely promoted by unbalanced immune suppression.

Summary

De novo food allergy development is a common complication of solid organ transplants with the highest risk occurring in pediatric liver transplant recipients. There are likely multiple mechanisms for food allergy development including passive transfer of membrane-bound IgE and lymphocytes from donor to recipient, as well as loss of food tolerance and active development of new food allergies. The optimal management of food allergies following organ transplants has not been well researched but may include changing the immune suppression regimen if the food allergy does not resolve without intervention.

http://ift.tt/2njcjKp

Chronology of regional lymph node metastases in cutaneous melanoma: a model based on mitotic rate

Abstract

Recently, the MSLT-II¹ and DeCOG² clinical trials have failed to demonstrate a benefit for the lymphadenectomy vs. observation in the setting of a patient with positive sentinel lymph node biopsy. Therefore, it is expected in the short term an increase in the patients with a more conservative management and obviously, more regional recurrences.

This article is protected by copyright. All rights reserved.

http://ift.tt/2DM1TNu

False-Positive Blood Cultures in Acute Leukemia: An Underrecognized Finding

The occurrence of false-positive blood cultures in patients with acute myeloid leukemia has been rarely described in the literature. Awareness of this finding is important to avoid unnecessary delays in initiating appropriate cytoreductive therapy. Here, we present the case of a 70-year-old male with acute leukemia and persistently positive blood cultures despite broad-spectrum antibiotic therapy. No source of infection could be found clinically, and no pathogen could be isolated from blood cultures. Inspection of the CO2 plots of the positive blood cultures showed a steady linear increase in CO2 levels, suggesting false-positive detection by the automated microbial detection system. Cytoreductive therapy was then initiated, and several subsequent blood cultures were negative.

http://ift.tt/2ElNR20

Topical Paromomycin for treating solitary mucosal leishmaniasis

http://ift.tt/2ni0NPk

Clinical features and management of schwannoma affecting the upper and lower lips

Abstract

Head and neck schwannomas comprise 25–40% of all schwannomas, with presentation on the lips as the rarest and most surgically complicated site for perioral tumors. A systematic literature review was conducted to include 21 cases of patients with schwannoma of the upper or lower lips. The majority of patients presented with a single, painless, well-encapsulated nodule on the upper or lower lips. The nodules were consistently slow-growing, with an average 29.3 months from symptom onset to clinical presentation. Most cases were complicated by profound cosmetic disfigurement as well as dysphagia, dysarthria, snoring, and/or sleep apnea. Overall, histological analysis was consistent with classic schwannoma, and all cases were treated via complete surgical excision, and for malignant tumors, additional therapy was utilized. All but four cases achieved full remission by final follow-up. Recurrence rate for benign lip schwannomas was 5.3%, which is remarkably different from the standard recurrence rate of 8–24% for benign peripheral schwannomas. Additionally, the proportion of malignant tumors was greater for lip schwannomas than other schwannomas. Lip schwannomas demonstrate different characteristics than schwannomas from other locations on the body, and these remarkable differences highlight significant implications for clinical practice. Complete excision is the primary mode of treatment with overall excellent postoperative prognosis and rare instances of recurrence. Given the rarity of this tumor, this review of available cases serves to comprehensively describe clinical presentation and surgical treatment approaches to upper and lower lip schwannomas.

http://ift.tt/2BBucbo

Impact of climate change on dermatological conditions related to flooding: update from the International Society of Dermatology Climate Change Committee

Abstract

Climate change contributes to the increase in severity and frequency of flooding, which is the most frequent and deadly disaster worldwide. Flood-related damage can be very severe and include health effects. Among those health impacts, dermatological diseases are one of the most frequently encountered. Both infectious and noninfectious dermatological conditions are increasing after flooding. We searched PubMed using the search term climate change OR global warming OR rainfall OR flooding OR skin. Articles published in the English-language literature were included. We also searched the International Society of Dermatology website library on climate change for additional articles. There is an increased risk of trauma during the course of a natural disaster. The majority of post-tsunami wound infections were polymicrobial, but gram-negative bacteria were the leading causes. Infectious diseases with dermatological manifestations, such as impetigo, leptospirosis, measles, dengue fever, tinea corporis, malaria, and leishmaniasis, are important causes of morbidity among flood-afflicted individuals. Insect bites and stings, and parasite infestations such as scabies and cutaneous larva migrans are also frequently observed. Inflammatory conditions including irritant contact dermatitis are among the leading dermatological conditions. Dermatological conditions such as alopecia areata, vitiligo, psoriasis, and urticaria can be induced or exacerbated by psychological conditions post disaster. Prevention is essential in the management of skin diseases because of flooding. Avoiding exposure to contaminated environments, wearing protective devices, rapid provision of clean water and sanitation facilities, prompt vector controls, and education about disease risk and prevention are important.

http://ift.tt/2ni0Jiy

Pathogenesis and treatment options for chemotherapy-induced alopecia: a systematic review

Abstract

Chemotherapy-induced alopecia (CIA) is one of the most troubling long-lasting side effects of cancer treatment. An estimated 65% of patients undergoing classic chemotherapy will experience hair loss, which is an extremely upsetting adverse event for many. CIA has been traditionally considered to be a diffuse, nonscarring alopecia; however, there are increasing reports of permanent hair loss post chemotherapy. Despite its large impact on patients, there are few proven treatments for CIA. Recent advancements in understanding the pathogenesis of hair loss are promising novel preventative and therapeutic strategies. Currently, scalp cooling during chemotherapy is the most effective preventive intervention with response rates ranging from 50 to 80%. To avoid patient morbidity, clinicians should be aware of the pathogenesis of CIA, characteristic patterns of hair loss associated with specific drug regimens, preventive measures that may be taken, and therapeutic options post chemotherapy. The following represents an updated systematic review of CIA, including characteristic clinical patterns, pathophysiology of the disease, therapeutic approaches, as well as a cost-effective analysis to assess the significance of this toxicity.

http://ift.tt/2BAAQPj

Incidence of diseases primarily affecting the skin by age group: population-based epidemiologic study in Olmsted County, Minnesota, and comparison with age-specific incidence rates worldwide

Abstract

Understanding the effects of age on the epidemiology of diseases primarily affecting the skin is important to the practice of dermatology, both for proper allocation of resources and for optimal patient-centered care. To fully appreciate the effect that age may have on the population-based calculations of incidence of diseases primarily affecting the skin in Olmsted County, Minnesota, and worldwide, we performed a review of all relevant Rochester Epidemiology Project–published data and compared them to similar reports in the worldwide English literature. Using the Rochester Epidemiology Project, population-based epidemiologic studies have been performed to estimate the incidence of specific skin diseases over the past 50 years. In older persons (>65 years), nonmelanoma skin cancer, lentigo maligna, herpes zoster, delusional infestation, venous stasis syndrome, venous ulcer, and burning mouth syndrome were more commonly diagnosed. In those younger than 65 years, atypical nevi, psoriatic arthritis, pityriasis rosea, herpes progenitalis, genital warts, alopecia areata, hidradenitis suppurativa, infantile hemangioma, Behçet's disease, and sarcoidosis (isolated cutaneous, with sarcoidosis-specific cutaneous lesions and with erythema nodosum) had a higher incidence. Many of the incidence rates by age group of diseases primarily affecting the skin derived from the Rochester Epidemiology Project were similar to those reported elsewhere.

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Harlequin ichthyosis due to novel splice site mutation in the ABCA12 gene: postnatal to prenatal diagnosis

Abstract

Background

Harlequin ichthyosis (HI) is a severe genetic disorder caused by the mutation in the ABCA12 gene. Infants born with this condition have markedly thickened, hard stratum corneum skin all over the body.

Methods

A female child born with a thick white plate of skin with deep cracks all over the body was investigated for genes associated with congenital Ichthyosis by Next Generation sequencing. The variant relevant to the clinical indications was identified using Picard and GATK version 3.6. Variant's pathogenicity was predicted by "in silico" tools like Mutation Taster 2, Mutation Assessor and LRT. Bidirectional Sanger sequencing further validated the same variant detected in the proband and confirmed in the parental blood and CVS.

Results

A homozygous 5′ splice site variation that affects the position at 4 nucleotides downstream to the donor proximal splice site of intron 40 (c.5939+4A>G; ENST00000272895) of the ABCA12 gene was detected in the proband, and the parents were heterozygous for the same variant. This led to the confirmation of diagnosis of Harlequin ichthyosis in the proband. "In silico" prediction of the variant was found to be damaging by MutationTaster2. The CVS sample during subsequent pregnancy was confirmed to be heterozygous for the same variant.

Conclusions

The novel intronic mutation found in the proband confirmed the clinical diagnosis as a severe type of HI and has helped the family in providing precise genetic counseling for further prevention of the disease and carrier screening of other family members.

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GAPO syndrome: a rare genodermatosis presenting with unique features

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Absence of serum IgE antibodies indicates non-type 2 disease in young asthmatics

Abstract

Background

Atopic asthma is associated with elevated type-2 biomarkers such as fraction of exhaled nitric oxide (FeNO) and blood eosinophil (B-Eos) count. However, increased type-2 markers have also been reported in traditionally-defined non-atopic asthma.

Objective

To determine a clinically useful level of IgE sensitisation for ruling out type-2 asthma.

Methods

Asthmatics (N = 408; age 10-35 years) were analysed using the multi-allergen tests Phadiatop and fx5 (ImmunoCAP). Subjects were grouped based on IgE-antibody concentrations: ≥ 0.35 kU_A/L for at least one test (n=326) or < 0.35 kU_A/L for both tests (n=82). Τhe latter group was subsequently divided into two groups: IgE 0.10-0.34 kU_A/L (n=34) and IgE < 0.10 kU_A/L (n=48). The relationships between type-2 biomarkers, and inadequate asthma control (ACT < 20), reduced lung function (FEV₁ < 80%), recent asthma attacks, and airway hyperresponsiveness (AHR) to methacholine were determined.

Results

In univariate analyses, at least one type-2 marker related to each asthma outcome in subjects with IgE ≥ 0.35 kU_A/L. In subjects with IgE 0.10-0.34 kU_A/L, elevated FeNO related to reduced lung function (p=0.008) and B-Eos to AHR (p = 0.03). No associations were found in subjects with IgE < 0.10 kU_A/L. In multivariate analysis, a relationship between FeNO and reduced lung function remained in subjects with IgE < 0.35 kU_A/L (p = 0.03).

Conclusion and clinical relevance

Clinically relevant elevation of type-2 biomarkers was seen in young asthmatics with IgE antibodies < 0.35 kU_A/L, but not those with IgE < 0.10 kU_A/L. It seems possible to define non-type 2 asthma through sensitive IgE-antibody measurement.

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Component resolved diagnostics demonstrates that most peanut allergic individuals could potentially introduce tree nuts to their diet

Abstract

Background

Nut allergy varies from pollen cross-allergy, to primary severe allergy with life-threatening symptoms. The screening of IgE antibodies to a wide spectrum of allergens, including species-specific and cross-reactive allergens, is made possible via microarray analysis.

Objective

We sought to study the association of variable IgE sensitization profiles to clinical response in peanut-challenged children and adolescents in a birch-endemic region. In addition, we studied the avoidance of tree nuts and species-specific sensitizations.

Methods

We studied 102 peanut-sensitized patients who underwent a double-blind placebo-controlled challenge to peanut. We analyzed ISAC ImmunoCAP microarray to 112 allergens, singleplex ImmunoCAPs for hazelnut Cor a 14 and cashew Ana o 3, and performed skin prick tests to peanut, tree nuts and sesame seed. We surveyed avoidance diets with a questionnaire.

Results

Sensitization to PR-10 proteins was frequent (Bet v 1 90%), but equally high in the challenge negatives and positives. IgE to Ara h 2 and Ara h 6 discriminated peanut allergic (n=69) and tolerant (n=33) the best. Avoidance of tree nuts was common (52 to 96%), but only

6 to 44% presented species-specific sensitizations to tree nuts, so a great number could potentially introduce these species into their diet.

Conclusions and clinical relevance

PR-10-sensitizations were frequent and strong regardless of peanut allergy status. Component resolved diagnostics can be employed to demonstrate to patients that sensitization to seed storage proteins of tree nuts is uncommon. Several tree nuts could potentially be reintroduced to the diet.

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Impedance Oscillometry: Emerging Role in the Management of Chronic Respiratory Disease

Abstract

Purpose of Review

Chronic respiratory diseases affecting adults and children are widely prevalent, so lung function testing is imperative for diagnosis and management. Spirometry is the traditional standard measure of lung function; however, certain groups of patients are unable to provide accurate and reproducible exhalation maneuvers. Consequently, the impedance oscillometry system (IOS) has been developed as an effort, independent technique to assess airway function in children and the elderly. To better understand this emerging modality, the following review will compare IOS with spirometry, examine the function of the device, provide interpretation strategies, and discuss the evidence supporting its use in adults and children with chronic lung disease.

Recent Findings

In a population of symptomatic adults with suspected COPD, impedance oscillometry resistance measurements correlate with FEV₁ and lung resistance increases with the severity of airflow limitation. In patients with asthma, IOS is a sensitive measure of airway hyperresponsiveness and bronchodilator response.

Summary

Impedance oscillometry is evolving as an alternative measure to assess lung function pediatric and adult populations.

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No difference in UVB-induced changes in antigen-presenting cells and in cytokines between subjects with and without loss-of-function mutations in FLG

Abstract

Ultraviolet B (UVB) irradiation-induced skin inflammation leads to epidermal depletion of Langerhans cells (LCs), which is followed by a rapid influx of monocytes.(1) Approximately 10% of Northern Europeans carry loss-of-function mutations in the filaggrin gene (FLG) which cause partial or complete lack of epidermal filaggrin and filaggrin metabolites.(2) Deficit of the filaggrin metabolite trans-urocanic acid has been shown to cause an increased keratinocyte photosensitivity to UVB irradiation in human skin models.(3)

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