JNA Journal Club

No abstract available

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Correction to: Effect of 1064-nm Q-switched Nd:YAG laser on invasiveness and innate immune response in keratinocytes infected with Candida albicans

Abstract

In the published online version of the article, the authors' given and family names were incorrectly captured. The corrected names are shown in the author group section above.

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Effect of preoperative immunonutrition on postoperative short-term outcomes of patients with head and neck squamous cell carcinoma

Abstract

Background

Patients with head and neck squamous cell carcinoma (HNSCC) often acquire an impaired nutritional status resulting in compromised outcomes. Perioperative immunonutrition may have a positive effect on outcomes after elective surgery.

Methods

Short-term outcomes before and after implementation of preoperative immunonutrition were retrospectively assessed. Regression models adjusted for outcome predictors were used to compare the length of stay (LOS) in the hospital, local infections, and general complications.

Results

Four hundred eleven patients were included (control group = 209 and the intervention group = 202). With immunonutrition, hospital LOS was significantly lower (median 6 vs 8 days; adjusted mean difference of −5.65 days; P < .001) and local infections were significantly reduced (7.4% vs 15.3%; adjusted odds ratio [OR] 0.30; P = .006). Subgroup analysis showed more pronounced effects in patients with previous radiotherapy and extensive surgery.

Conclusion

Patients receiving preoperative immunonutrition had a shorter hospital LOS and a lower rate for wound infections and local complications. These effects remained robust after a multivariate adjustment.

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A profile of Propionibacterium acnes resistance and sensitivity at a tertiary dermatological centre in Singapore

Propionibacterium acnes (P. acnes) is a key component in the pathogenesis of acne. Both topical and oral antibiotics are key therapeutic options. Unfortunately, antibiotic resistance is rapidly increasing globally. Many countries have reported greater than 50% of P.acnes strains acquiring resistance to topical macrolides^1-3. In Singapore, antibiotic resistance rates of 8% in 1999⁴ rising to 14.9%⁵ in 2007 were reported. We aimed to update the local prevalence of antibiotic resistance and identify features which may distinguish patients demonstrating antibiotic resistance from those who are pan-sensitive.

This article is protected by copyright. All rights reserved.

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Pulsed-dye laser therapy for carcinoma in situ of the penis

Carcinoma in situ (CIS) of the penis is a precancerous condition with a 5 to 10% risk for progression into an invasive penile squamous cell carcinoma (SCC)¹. Clinical variants of genital CIS encompass bowenoid papulosis, erythroplasia of Queyrat and Bowen's disease. Treatment options of penile CIS include topical application of 5-fluorouracil (5-FU) or imiquimod, photodynamic therapy (PDT), ablative laser therapy, cryotherapy and surgery² .

This article is protected by copyright. All rights reserved.

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Omalizumab updosing allows disease activity control in refractory patients with chronic spontaneous urticaria

Omalizumab has been shown to be a very effective drug in chronic spontaneous urticaria (CSU) improving patients' quality of life.¹ Phase III clinical trials ASTERIA I/II and GLACIAL showed respectively 58.8-52.4% of patients achieving a twice daily average Urticaria Activity Score 7 (UAS7td)≤6 at week 12.² Outside of clinical trials, the response varies between 77-83%.³ However, some patients do not achieve well-controlled activity of the disease with the licensed dose of omalizumab (300mg/4 weeks).

This article is protected by copyright. All rights reserved.

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Dermoscopic features of pilar leiomyomas

Cutaneous pilar leiomyomas are benign smooth muscle neoplasms that usually present as painful firm erythematous to brown coloured papules and nodules.¹ Dermoscopy has been used as an auxiliary tool in the diagnosis of various cutaneous tumors. Herein we report the various dermoscopic features of 48 cutaneous pilar leiomyomas in five patients.

This article is protected by copyright. All rights reserved.

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Adaptation and micro-structure of Co-Cr alloy maxillary complete denture base plates fabricated by selective laser melting technique

Abstract

The purpose of the study was to evaluate the adaptation and micro-structure of Co-Cr alloy maxillary complete denture base plates fabricated by the selective laser melting (SLM) technique. Twenty pairs of edentulous casts were randomly and evenly divided into two groups, and manufacturing of the Co-Cr alloy maxillary complete denture base was conducted either by the SLM technique or by the conventional method. The base-cast sets were transversally sectioned into three sections at the distal canines, mesial of the first molars and the posterior palatal zone. The gap between the metal base and cast was measured in these three sections with a stereoscopic microscope, and the data were analysed using t tests. A total of five specimens of 5 mm diameter were fabricated with the Co-Cr alloy by SLM and the traditional casting technology. A scanning electron microscope (SEM) was used to evaluate the differences in microstructure between these specimens. There was no statistical difference between the three sections in all four groups (P > 0.05). At the region of the canines, the clearance value for the SLM Co-Cr alloy group was larger than that of the conventional method group (P < 0.05). At the mesial of the first molar region and the posterior palatal zone, there was no statistical difference between the gaps observed in the two groups (P > 0.05). The SLM Co-Cr alloy has a denser microstructure behaviour and less casting defect than the cast Co-Cr alloy. The SLM technique showed initial feasibility for the manufacture of dental bases of complete dentures, but large sample studies are needed to prove its reliability in clinical applications. The mechanical properties and microstructure of the denture frameworks prepared by selective laser melting indicate that these dentures are appropriate for clinical use.

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Reduced immunohistochemical PTEN staining is associated with higher progression rate and recurrence episodes in non-invasive low-grade papillary urothelial carcinoma of the bladder

Abstract

Non-invasive low-grade papillary urothelial carcinoma (NILGPUC) of the bladder is regarded as a relatively indolent disease. However, its propensity for frequent recurrences constitutes a major clinical problem. Additionally, there is a progression risk of 10–15% to either a higher grade and/or a higher stage disease in these tumors. The molecular factors that will predict recurrence and progression in low-grade pTa bladder carcinoma have not yet been elucidated. Herein, we investigated the association of phosphatase and tensin homolog deleted on chromosome 10 (PTEN) alterations with recurrence and progression in NILGPUC using immunohistochemistry. Eighty-one cases of bladder cancer initially diagnosed as NILGPUC in a single institution with follow-up were encountered after searching medical records. Tissue microarrays (TMA) that contained both tumor and non-neoplastic mucosa from each case were constructed using paraffin blocks of transurethral resections. Sections from TMA blocks were stained immunohistochemically for PTEN protein and were evaluable in 76 cases. Any absence of staining was recorded and correlated with clinical findings. Ten patients (13.2%) showed progression and 41 (53.9%) showed recurrence. Reduced PTEN expression was observed in 29 cases (38.1%). Cases with reduced PTEN had higher progression rate compared to cases with intact PTEN (p = 0.026). Tumor relapse was more frequent in cases with reduced PTEN (65.5 vs 46.8%), but this difference was not statistically significant (p = 0.112). On the other hand, decreased PTEN expression was associated with higher number of recurrence episodes (p = 0.002). PTEN seems to have a link with the disease course in NILGPUC of the bladder.

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Chondroid nodule in the female peritoneum arises from normal tissue and not from teratoma or conception product

Abstract

The pathogenesis of benign-looking cartilaginous tissue within the peritoneum is unknown. Chondroid metaplasia of subcoelomic mesenchyme has been suggested, as has been the case for other gynecological diseases such as endometriosis, peritoneal leiomyomatosis, or gliomatosis peritonei, but has never been proven. Chondroid nodules in the peritoneum may represent either teratomatous tissue, fetal rests from a conception product, or metaplasia of pluripotent mesenchymal cells. Herein, the unique genetic characteristics of ovarian teratomas (homozygous at many polymorphic microsatellite loci) versus normal tissues (heterozygous at the same loci) were used to investigate the origin of chondroid nodules in the peritoneum. DNA samples extracted from paraffin-embedded normal peritoneal tissue and chondroid peritoneal nodules from two patients were studied. In both cases, chondroid and normal tissue showed heterozygosity at each informative microsatellite locus on different chromosomes, with a profile similar to the mother. These results indicate that peritoneal chondroid nodules arise within the peritoneum, presumably from pluripotent mesodermal stem cells, and are not related to teratomatous proliferation, or previous pregnancy. This finding shows once again the plasticity and metaplastic potential of stem cells within the peritoneal cavity.

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Selected Literature Watch

Violence and Gender , Vol. 0, No. 0.


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Anhydramnios in Patients With Pemphigoid Gestationis

This case report describes the occurrence of anhydramnios in 2 patients with pemphigoid gestationis.

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The US Food and Drug Administration’s Approach for Safe Innovation of Medical Devices in Dermatology

With the increased awareness of skin conditions and demand for aesthetic treatments requiring the expertise of dermatologists, there has been a growth in the associated medical device industry. Dermatology medical devices include point-of-care diagnostics, ablative technologies, skin imaging devices, dermal fillers, lasers, and wound dressings. Many new devices in dermatology offer practitioners and patients additional options for a variety of conditions including diabetic wound care, skin lesion screening, and alopecia treatment.

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Dermatologic Device Approval by the US Food and Drug Administration

This cross-sectional database study characterizes the postapproval changes to Class III dermatologic devices and evaluates inconsistencies in the use of the premarket approval pathway.

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Sun Protection Behaviors in Early Childhood Education Programs

This survey study assesses the current policies, practices, and attitudes among staff of Head Start/Early Head Start and day care centers regarding sun protection in children aged 2 to 6 years.

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What you should know about third nipples

A look a third (sometimes called supernumary) nipples, a rare condition where a person has an extra one. Included is detail on causes and diagnosis.

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Hodgkin-Lymphom – neue Horizonte

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Stellenwert der isolierten Extremitätenperfusion bei Sarkomen

Zusammenfassung

Hintergrund und Ziel

Die isolierte Extremitätenperfusion mit Tumornekrosefaktor-α (TNF-α) und Melphalan (TM-ILP [ILP: „isolated limb perfusion"]) ist eines der wirksamsten Therapieverfahren zur neoadjuvanten Therapie von nicht resektablen Weichgewebesarkomen der Extremitäten. Diese Übersichtsarbeit beschreibt die Zusammenhänge und Wirkungsweise der TM-ILP, v. a. im Hinblick auf die Einhaltung der Sicherheitsabstände und die Möglichkeiten der TM-ILP, diese durch Devitalisierung der Tumorzellen in den Randbereichen bzw. den zukünftigen Resektionsrändern zu verbessern.

Methoden

Es wurden eine Recherche und Auswertung aktueller Literatur durchgeführt.

Ergebnisse

Durch die Vorbehandlung mittels TM-ILP kann eine sonst notwendige Amputation in 80 % der Fälle vermieden werden. Im Rahmen eines kurativen, multimodalen Therapieansatzes kann der Tumor nach der initialen TM-ILP 6–8 Wochen später mit knappen Sicherheitsabständen unter Erhalt der Extremität entfernt werden. Auch in palliativer Therapieintention kann die TM-ILP Anwendung finden. Hierdurch kann, insbesondere in Kombination mit einer anschließenden systemischen Chemotherapie, ein längerfristiger Wachstumsarrest des Tumors erreicht werden. In Kombination mit einer anschließenden Strahlentherapie kann dieser Effekt noch verstärkt werden.

Schlussfolgerung

Trotz der bestehenden Amputationsindikation zeigen Patienten nach ILP hervorragende Lebensqualität, die auch im längerfristigen Verlauf konstant bleibt.

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Genome-wide single nucleotide polymorphism-based autozygosity mapping facilitates identification of mutations in consanguineous families with epidermolysis bullosa

Abstract

Autozygosity mapping (AM) is a technique utilized for mapping homozygous autosomal recessive (AR) traits and facilitation of genetic diagnosis. We investigated the utility of AM for the molecular diagnosis of heterogeneous AR disorders, using epidermolysis bullosa (EB) as a paradigm. We applied this technique to a cohort of 46 distinct EB families using both short tandem repeat (STR) and genome-wide single nucleotide polymorphism (SNP) array-based AM to guide targeted Sanger sequencing of EB candidate genes. Initially, 39 of the 46 cases were diagnosed with homozygous mutations using this method. Independently, 26 cases, including the seven initially unresolved cases, were analyzed with an EB-targeted next-generation sequencing (NGS) panel. NGS identified mutations in five additional cases, initially undiagnosed due to presence of compound heterozygosity, deep intronic mutations, or runs of homozygosity below the set threshold of 2 Mb, for a total yield of 44 out of 46 cases (95.7%) diagnosed genetically.

This article is protected by copyright. All rights reserved.

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Optic nerve grey crescent: an assessment using swept-source OCT

Description

Optic nerve head is an area of opening within the scleral canal; pigmentary changes at the margins and around the disc encompass a few important differential diagnoses. Optic nerve head grey crescent is one such clinical entity where it is characterised by bilateral greyish pigmentation of the temporal neuroretinal rims. The appearance is due to an internal extension of Bruch's layer into the peripapillary scleral canal. It was first noted by Shields in 1980 in African-American patients. The pigmentation mainly lies within the optic nerve head; in contrast, the alpha and beta zone lies outside the optic nerve head. The beta zone of peripapillary region is mainly an atrophy of the choroid and retinal layers for a varying degree with underlying visible sclera, whereas the crescent area is an area of encroachment of the peripapillary layers onto the disc. The clinical implication of this clinical entity is...

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A mesh masquerading as malignancy: a cancer misdiagnosed

After a positive faecal occult blood test, a 60-year-old woman underwent a screening colonoscopy which identified a malignant-looking ulcer in the ascending colon. Biopsies from the lesion were inconclusive. A subsequent CT scan of the abdomen and pelvis commented on a polypoid lesion in the ascending colon. A colorectal cancer multidisciplinary team discussion concluded that a right hemicolectomy was indicated as the lesion was suspicious for malignancy. Intraoperatively, there was a firm ascending colon mass adherent to the abdominal wall, which was resected with clear margins. There were no other complications, and the patient was discharged without further issues. Histopathology from the retrieved specimen revealed a complete absence of malignancy, but rather, inflamed granulation tissue with 'reaction to foreign birefringent material'—likely to represent a mesh from an incisional hernia repair 9 years previously. The patient is currently recovering well without complication.

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The effect of a therapeutic lithium level on a stroke-related cerebellar tremor

Lithium is a mood stabiliser used in the treatment of acute mania, bipolar disorder and as augmentation for unipolar major depression. Tremor is a common adverse effect associated with lithium at both therapeutic and toxic serum levels. We present a case of dose-dependent changes in the quality and intensity of a stroke-related, chronic cerebellar tremor with lithium treatment at serum levels within the therapeutic range. On admission, the patient in this case had a baseline fine, postural tremor, which increased in frequency and evolved to include myoclonic jerks once lithium therapy was initiated. Although the patient's serum lithium level was never in the toxic range, his tremor returned to baseline on reduction of his serum lithium level. This case highlights that a pre-existing, baseline tremor may lower the threshold for developing myoclonus. It also suggests that caution may be warranted with lithium therapy in the setting of known cerebellar disease.

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Severe systemic inflammatory response syndrome immediately after spinal surgery in a patient with axial gout

We report a 55-year-old man with gouty arthritis who developed a 3-month history of low back pain, gradual lower extremities weakness and urinary incontinence. Lumbar MRI showed an exophytic lesion at L3–L4. Immediately after spinal decompression surgery, he developed fever, disorientation, polyarthritis, acute kidney injury and leucocytosis. He was treated with multiple antimicrobial agents for presumed spinal abscess but did not improve. Multiple body site cultures were negative. Aspiration of the sacroiliac joint revealed the presence of monosodium uric acid crystals. A diagnosis of acute gout was done, and he was treated with high-dose intravenous methylprednisolone and colchicine. Within 48 hours, he had a remarkable clinical improvement. At discharge, neurological and laboratory abnormalities had resolved. Awareness of risk factors for axial gout and a high degree of suspicion are important to establish a prompt diagnosis and treatment to prevent severe complications as seen in this case.

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Parapedicular vertebral augmentation with polymethylmetacrylate for pedicle screw loosening

A 71-year-old man who had a L1/S1 posterior fusion revision surgery complained of increasing back pain 5 weeks after the open surgical procedure. The pain was initially estimated at 9/10 on the visual analog scale (VAS) and thought to be related to a right-sided L2 screw loosening. A right parapedicular vertebroplasty was performed and polymethylmethacrylate cement was instilled around the right pedicle screw, filling the anterior two-thirds of the vertebral body. On postvertebroplasty day 1, the patient had significant improvement in his low back pain. The pain further decreased at 1 and 3 months after the intervention (2/10 on the VAS). Vertebroplasty is a minimally invasive, accessible, effective, and long lasting treatment for compression fractures. We believe that this technique could also be indicated to treat pain related to low grade screw loosening in properly selected patients.

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Left ventricular free-wall rupture that occurred during a cardiopulmonary exercise test

Although exercise testing has become a standard procedure before discharge for patients with acute coronary syndrome, a fatal accident during the test is extremely rare. A 60-year-old man was admitted for a non-ST-segment elevation myocardial infarction. A coronary angiogram showed stenosis at the distal lesion of the circumflex, and a balloon angioplasty was performed. His recovery was smooth, and a cardiopulmonary exercise test was performed 5 days after admission. At 2.5 metabolic equivalents, he suddenly went into cardiac arrest, and percutaneous cardiopulmonary support was initiated. Echocardiography revealed the presence of a large amount of pericardial effusion, and emergency cardiac surgery was performed to repair the free-wall rupture. This highlights the importance of careful monitoring of patients with percutaneous coronary intervention during cardiopulmonary exercise testing.

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Super obesity is not necessarily a contraindication to deep inferior epigastric perforator flap breast reconstruction

The deep inferior epigastric perforator (DIEP) flap is widely recognised as a safe and reliable flap for use as a first-choice option in autologous tissue breast reconstruction. Patients with obesity represent a challenging group for autologous breast reconstruction, as they are at increased risk of developing major and minor complications in comparison with patients with normal weight. We report a 59-year-old woman with super obesity, who presented to our department with right breast skin necrosis after implant reconstruction following mastectomy for right breast cancer. After implant removal and local treatment with both surgical debridement and negative pressure wound therapy, the patient successfully underwent a DIEP flap breast reconstruction. We conclude that super obesity should not be a contraindication to DIEP flap breast reconstruction.

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The curse of relieving pain

A 39-year-old woman with a history of chronic back pain due to spinal haemangiomas, multiple malignancies and depression was brought by Emergency medical servicesS to the emergency centre (EC) after being found unresponsive on the bathroom floor. The patient had an exacerbation of her back pain the previous day for which she admitted to taking double her usual dose of oxycodone, in addition to alprazolam, lorazepam, diphenhydramine and a glass of wine. She reported that she lost consciousness and was down for over 8 hours. In the EC, she complained of right forearm pain which was accompanied by mild diffuse soft-tissue swelling and decreased sensation in the right hand. Radial pulse was intact. Creatine kinase was found to be at 4663 U/L. The patient was found to have acute compartment syndrome and underwent emergent forearm fasciotomy. She eventually regained full function of the right arm.

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Closed gastroschisis with left defect: a rare variant

Description

Gastroschisis is a congenital abdominal wall defect where the intestine, stomach and rarely the other abdominal organs like the ovary, urinary bladder and the liver eviscerate through the defect. It occurs in 4–5 per 10 000 live births and is more common in preterm, low birth weight and female babies. Very rarely, the abdominal wall defect completely closes around the eviscerated bowel resulting in closed gastroschisis (CG). This constitutes 6% of all gastroschisis.1

A 2.2 kg term baby boy delivered at home at 36 weeks of gestation presented on day 1 of life with an eviscerated loop of herniated bowel segment seen to the left of the umbilicus (figure 1). The bowel loop was uncovered, erythematous and congested, butlooked viable; the underlying umbilicus was closed. The child had bilious vomiting and had not passed meconium. The X-ray of the abdomen was suggestive of intestinal obstruction. The child was...

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Fulminant myocarditis

Description

A previously healthy 36-year-old man presented to the emergency department with dyspnoea after 3 days of fatigue and coughing. He experienced shortness of breath and had 8 hours of fever before admission. His body temperature was 38°C. His ECG showed a wide QRS complex with no signs of acute myocardial infarction (figure 1). Echocardiography demonstrated oedematous left ventricular myocardium and severe, diffusely hypokinetic left ventricular wall motion with estimated ejection fraction of 30%. Intra-aortic balloon pump (IABP) insertion was immediately performed for cardiogenic shock. Meanwhile, he experienced cardiac arrest with ventricular tachycardia. As cardioversion was unsuccessful, peripheral venous-arterial extracorporeal membrane oxygenation (va-ECMO) was initiated, with temporary pacemaker placement and dobutamine administration. Coronary angiography revealed normal coronary arteries. Shortly thereafter, he developed complete ventricular standstill, with no ventricular activity on the ECG and echocardiogram (figure 2 and video 1). Endomyocardial biopsy revealed massive...

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Rare presentation of AICA syndrome

We report a rare presentation of an anterior inferior cerebellar artery (AICA) infarct in a 74-year-old woman with acute-onset nausea, vomiting, vertigo and gait instability long before the full onset of symptoms and a negative MRI on admission. Over the next several days the patient developed left facial weakness, numbness, hypoacusis, and limb and gait ataxia, and was found to have acute infarcts of the left pons and cerebellar peduncle consistent with an AICA syndrome. We discuss this rare stepwise presentation in AICA syndrome and possible underlying pathophysiology. Such patients at risk for cerebrovascular disease should undergo a careful history, exam and follow-up, even with negative MRI findings, as their symptoms may precede a serious vascular event.

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Combination drug chemotherapy and massive skeletal allograft in the management of hydatid disease of femur

Hydatid disease of long bone is a rare presentation. Chemotherapy and surgery constitute the standard treatment of choice. Non-union of a pathological fracture of femur particularly due to hydatid disease has been known to be resistant to treatment. These resistant cases require combination drug chemotherapy and excision of the lesion. Reconstruction of a large skeletal defect following resection of the lesion poses a challenge to the orthopaedic surgeons. We discuss the staged treatment of hydatid disease of shaft of femur with resection and cement spacer application followed by reconstruction using massive skeletal allograft under cover of combination drug chemotherapy.

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Cranial neuropathy and severe pain due to early disseminated Borrelia burgdorferi infection

A 61-year-old man presented to the emergency department in the summer with a right seventh cranial nerve lower motor neuron palsy and worsening paraesthesias for 6 weeks. He had debilitating pain at the scalp and spine. Prior work up was unrevealing. The patient resided in the upper Midwest region of the USA and worked outdoors, optimising the landscape for white tailed deer. Repeat cerebrospinal fluid testing revealed a lymphocytic pleocytosis and positive IgM Lyme serology. Brain MRI demonstrated enhancement of multiple cranial nerves bilaterally. He was diagnosed with early Lyme neuroborreliosis and treated with 28 days of intravenous ceftriaxone. While the painful meningoradiculitis, also known as Bannwarth syndrome, is more commonly seen in Europe, facial palsy is more frequently encountered in the USA. Clinical manifestations of neuroborreliosis are important to recognise as the classic presentation varies by geography and on occasion repeat serological testing may be necessary.

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New drugs and new toxicities: pembrolizumab-induced myocarditis

Pembrolizumab is an immune checkpoint inhibitor that significantly improves clinical outcomes in numerous solid organ malignancies. Despite successful therapeutic responses, this new drug comes with a constellation of adverse reactions. Herein, we chronicle the case of a patient with metastatic non-small-cell lung cancer treated with pembrolizumab. After two cycles, he developed new-onset dyspnoea on exertion. Electrocardiogram showed idioventricular rhythm with diffuse ST-segment elevations. Echocardiography revealed severe biventricular cardiac dysfunction. Based on diagnostic workup and exclusion of probable aetiologies, the patient was diagnosed with pembrolizumab-induced myocarditis. The treatment was initiated with corticosteroids and guideline-conform heart failure therapy. He demonstrated a marked clinical response with resolution of congestive heart failure symptoms. This article summarises the clinical evidence regarding the epidemiology, pathophysiology, clinical features, diagnostic modalities and management of patients with pembrolizumab-associated myocarditis. In addition, it highlights that programmed death receptor-1 inhibition can cause a spectrum of autoimmune adverse events requiring clinical monitoring and periodic screenings.

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Delayed presentation of a virilising, pure testosterone-secreting adrenocortical carcinoma with coexistent composite myelolipoma and a venous thrombus extending to the heart

A 40-year-old normotensive woman presented with abnormal facial hair for 4 years and amenorrhoea for 13 years. Hormonal, biochemical and haematological evaluation showed isolated elevation of serum testosterone and free testosterone. Her follicle-stimulating hormone and luteinising hormone were in the premenopausal range. Until recently she had reconciled to early 'menopause' and visited beauty clinics but never sought medical evaluation. Imaging revealed an enhancing left adrenal mass with fat densities and venous thrombus extending through the inferior vena cava to a 7 cm mass in the right atrium. She underwent left kidney-preserving surgery utilising hypothermic cardiopulmonary bypass with early clamping of the pulmonary artery without circulatory arrest. Histology showed adrenocortical carcinoma with composite incidental myelolipoma and neoplastic thrombus. At 2 months, testosterone has normalised and she is doing well. Isolated testosterone-secreting adrenocortical carcinoma with massive venous thrombus is rare as is coincidental composite macroscopic myelolipoma.

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Post-cholecystectomy partial biliary stricture leading to primary intrahepatic calculi

Description

A 40-year-old woman presented with complaints of pain in the right hypochondrium and intermittent high-grade fever with chills for 3 months. She had a history of waxing and waning jaundice for the last 2 months. She had undergone open cholecystectomy 15 years back. Abdominal examination revealed a non-tender hepatomegaly. Blood investigations showed a deranged liver function suggestive of obstructive biliary pathology. Total bilirubin level was raised (4.6 mg/dL) with predominant direct component (3.5 mg/dL). Her serum alkaline phosphatase was elevated (1683 U/L) but transaminase levels were within normal range.

An abdominal ultrasound showed mild hepatomegaly with bilateral intrahepatic biliary radicle dilation. Multiple calculi were present in the intrahepatic bile ducts and a hypoechoic shadow was seen near hilum. In view of suspected mass lesion at hilum, an abdominal CT scan was obtained that showed thickening of the common hepatic duct. Intrahepatic ducts were grossly dilated and were filled with multiple...

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Intracranial myopericytoma: a tumour in a rare location

A 49-year-old female with history of headache, nausea and vomiting with some weeks of evolution, without neurological symptoms. Radiology revealed an expansive lesion near the inferior vermix and cerebellar tonsils, with heterogeneous gadolinium uptake and mass effect on the fourth ventricle, representing a probable extraventricular origin for the lesion. Pathological examination showed a proliferation of oval/spindle cell proliferation with eosinophil cytoplasm and small and monotonous nuclei, without mitoses. The cells had a concentric growth, surrounding thin-walled blood vessels with foci of stromal myxoid degeneration and whorled pattern. The vessels had a haemangiopericytoma pattern and were lined by non-atypical endothelial cells. The tumorous cells expressed vimentin, alpha-smooth actin and heavy-chain caldesmon and were negative for epithelial membrane antigen, protein S100, HMB45, CD34, calponin and desmin, thus providing the final diagnosis of intracranial myopericytoma.

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Doxycycline sclerotherapy for post-traumatic inguinal lymphocele in a child

Lymphoceles are abnormal collections of lymphatic fluid caused by a disruption in the lymphatic channels and leakage of lymph. This most commonly occurs after surgical procedures, but occasionally lymphoceles may be the result of trauma, more commonly penetrating trauma. Lymphoceles resulting from blunt trauma are rare in both adults and children. In the adult population, there are few published case reports, and management principles vary. To date, there are no reports of traumatic lymphoceles in the paediatric population, and therefore there is no precedent for treatment. Here, we report the case of a young boy who developed an inguinal lymphocele from a bicycle handle bar injury which was successfully treated with doxycycline sclerotherapy.

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Extensive skin ulcers in a child with juvenile dermatomyositis

Juvenile dermatomyositis (JDM) is a multisystemic disorder. Vasculitic ulcers in JDM have been reported to involve axilla, elbow or extensor surfaces of other joints. We report a young boy with JDM who presented with extensive cutaneous ulcers involving scrotum, prepuce, gluteal region, neck, bilateral axilla, periumbilical area and bilateral elbows and popliteal fossa. His disease course was marked by several relapses and he required immunosuppression with prednisolone, subcutaneous methotrexate and intravenous cyclophosphamide. His muscle weakness improved and skin ulcers healed after 6 months of intensive immunosuppressive therapy. Children with JDM and ulcers often show increased resistance to immunosuppressive therapy. Extensive cutaneous ulcers in JDM, especially those involving the scrotum, have never been described. Awareness regarding the uncommon manifestations is important to guide appropriate therapy.

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Multiple anomalies in the origin and course of vertebral arteries and aberrant right subclavian artery in a child with moyamoya syndrome

Here we report, for the first time, a combination of five-vessel aortic arch, anomalous origin of the right vertebral artery (VA) from the common carotid artery (CCA), an aberrant right subclavian artery (SCA), and bilateral symmetrical segmental agenesis of VAs.In this case report, we present a patient with moyamoya syndrome (MMS) and Down syndrome (DS) who has bilateral symmetrical segmental agenesis of VAs, left VA originating from aortic arch and anomalous origin of right VA arising from CCA in combination with an aberrant right SCA. Therefore, five vessels are originating from aortic arch. Here, we report, for the first time, a combination of five-vessel aortic arch with an aberrant right SCA and symmetrical segmental agenesis of both VAs. The possible embryological mechanisms of the anomalies as well as an relation with MMS and DS are discussed.

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Ipilimumab or FOLFOX in Combination With Nivolumab and Trastuzumab in HER2 Positive EsophagoGastric Adenocarcinoma

Conditions:   Gastric Cancer;   Esophageal Cancer;   Adenocarcinoma Gastric;   HER2 Positive Gastric Cancer;   Metastatic Gastric Cancer;   GastroEsophageal Cancer
Interventions:   Drug: Nivolumab;   Drug: Ipilimumab
Sponsors:   AIO-Studien-gGmbH;   Bristol-Myers Squibb
Not yet recruiting

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Effect of the Neck Extension on Blind Intubation Via Ambu® AuraGain™

Conditions:   Intubation; Difficult or Failed;   Intubation Complication
Interventions:   Device: Ambu® AuraGain™;   Procedure: neck extension
Sponsor:   Seoul National University Hospital
Not yet recruiting

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A Dose Escalation and Confirmation Study of PT-112 in Advanced Solid Tumors in Combination With Avelumab

Conditions:   Non Small Cell Lung Cancer (NSCLC);   Urothelial Carcinoma (UC);   Squamous Cell Carcinoma of the Head and Neck (SCCHN);   Metastatic Breast Cancer (mBC);   Castration-resistant Prostate Cancer (CRPC)
Interventions:   Drug: PT-112;   Biological: avelumab
Sponsors:   Phosplatin Therapeutics;   Pfizer;   EMD Serono
Not yet recruiting

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Effect of low-level laser therapy on the healing process of donor site in patients with grade 3 burn ulcer after skin graft surgery (a randomized clinical trial)

Abstract

Skin graft is a standard therapeutic technique in patients with deep ulcers, but managing donor site after grafting is very important. Although several modern dressings are available to enhance the comfort of donor site, using techniques that accelerate wound healing may enhance patient satisfaction. Low-level laser therapy (LLLT) has been used in several medical fields, including healing of diabetic, surgical, and pressure ulcers, but there is not any report of using this method for healing of donor site in burn patients. The protocols and informed consent were reviewed according to Medical Ethics Board of Shahid Beheshti University of Medical Sciences (IR.SBMU.REC.1394.363) and Iranian Registry of Clinical Trials (IRCT2016020226069N2). Eighteen donor sites in 11 patients with grade 3 burn ulcer were selected. Donor areas were divided into 2 parts, for laser irradiation and control randomly. Laser area was irradiated by a red, 655-nm laser light, 150 mW, 2 J/cm², on days 0 (immediately after surgery), 3, 5, and 7. Dressing and other therapeutic care for both sites were the same. The patients and the person who analyzed the results were blinded. The size of donor site reduced in both groups during the 7-day study period (P < 0.01) and this reduction was significantly greater in the laser group (P = 0.01). In the present study, for the first time, we evaluate the effects of LLLT on the healing process of donor site in burn patients. The results showed that local irradiation of red laser accelerates wound healing process significantly.

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Free flaps for head and neck cancer in paediatric and neonatal patients

Purpose of review To review recent literature on the subject of free tissue transfer options in paediatric head and neck surgery, with a particular emphasis on highlighting the advantages and disadvantages of different reconstructions in the paediatric patient. Recent findings Free tissue transfer in paediatric patients is predictable and applicable for a wide range of congenital and acquired defects in the head and neck. The free fibula flap is a mainstay of mandibular reconstruction and allows excellent implant-supported prosthodontic rehabilitation and growth potential at the recipient site with little or no donor site morbidity. Other less commonly explored options include the deep circumflex iliac artery flap, scapula flap and medial femoral condyle flap. The gracilis mucle remains the mainstay for facial reanimation with other options including pectoralis minor, rectus abdominis, extensor digitorum brevis and latissimus dorsi. There are compelling arguments for centralization of services and creative strategies in postoperative rehabilitation (e.g. play therapy). Summary Free flaps in paediatric patients are a viable option and may even have advantages relative to adults because of the absence of atherosclerosis, purported lower risk of vasospasm and proportionally larger vessel size. Transfer earlier in life maximizes functional potential and 'normalizes' treatment. Correspondence to Ross Elledge, Specialty Registrar (ST6) in Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, Queen Elizabeth Hospital, Birmingham B15 2TH, West Midlands, UK. Tel: +44(0)78 758 28359;. E-mail: rosselledge@doctors.net.uk Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Successful Treatment of a Keratoacanthoma with Electrochemotherapy: A Case Report

Abstract

Introduction

Few studies have evaluated the efficacy of intralesional bleomycin injection combined with electroporation for the treatment of cutaneous tumors. However, the phenomenon that electroporation can enhance the cytotoxicity of bleomycin in vivo by 300–700 fold has been intensely investigated.

Case Presentation

Keratoacanthoma in an 86-year-old patient was treated with intralesional bleomycin combined with electroporation. Treatment consisted of local application of shorty and intense electric pulses followed by local injection of bleomycin. Electroporation was always well tolerated by the patient, with no significant complaints, and the tumor had completely regressed by day 71 of the follow-up.

Conclusion

The results suggest that intralesional bleomycin injection combined with electroporation could represent a valid alternative therapeutic approach for the treatment of keratoacanthomas.

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Atrial septal defect in a patient with congenital disorder of glycosylation type 1a: a case report

Atrial septal defect often become more severe when encountered in genetic syndromes. Congenital disorder of glycosylation type 1a is an inherited metabolic disorder associated with mutations in PMM2 gene and can ...

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Author’s response to Letter-to-the-editor regarding “Are the Epworth Sleepiness Scale and Stop-Bang Model effective at predicting the severity of obstructive Sleep Apnoea (OSA); in particular OSA requiring treatment?”

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Reply to the letter concerning “Revision adenoidectomy in children: a population-based cohort study in Taiwan”

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A prospective 52-week randomised controlled trial of patient-initiated care consultations for patients with psoriasis

Abstract

Background

Treatment and care of moderate to severe psoriasis requires lifelong consultations with a dermatologist with close monitoring of systemic treatment.

Objectives

To investigate the effect of patient-initiated care consultations (PICC) for patients with psoriasis in a dermatology outpatient clinic.

Methods

A prospective randomised controlled trial with patients in well-controlled systemic treatment randomised to either 1) the PICC group, where they participated in one annual consultation with a dermatologist but were able to initiate consultations when needed; or 2) routine care, where they participated in a consultation every 12-16 weeks. The primary outcome was the Dermatology Life Quality Index (DLQI). Other outcomes were safety, patient adherence and satisfaction with healthcare assessed at baseline and after 52 weeks.

Results

150 patients were included, with 58.0% treated with biologicals, 37.3% with methotrexate and 4.7% with acitretin. At week 52 no statistically significant mean difference between groups was detected in DLQI 0.28 (95% CI, -0.35–0.9) or Psoriasis Area Severity Index -0.24 (95% CI, -0.84–0.36). Patients in the PICC group requested 63.1% fewer consultations with a dermatologist, mean ±SD 2.5 ±0.1 vs. 5.1 ±0.6, (p=0.001). Patient adherence and safety with treatment monitoring was equal between groups, but the PICC group was significantly better at attending consultations than the control group (p=0.003).

Conclusion

PICC offers additional clinical benefits compared to routine care, making patients less dependent on clinical visits. The intervention adds no harm to monitoring systemic treatment and patients report high quality of life and satisfaction with healthcare.

This article is protected by copyright. All rights reserved.

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Does goal-directed haemodynamic and fluid therapy improve peri-operative outcomes?: A systematic review and meta-analysis

BACKGROUND Much uncertainty exists as to whether peri-operative goal-directed therapy is of benefit. OBJECTIVES To discover if peri-operative goal-directed therapy decreases mortality and morbidity in adult surgical patients. DESIGN An updated systematic review and random effects meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase and the Cochrane Library were searched up to 31 December 2016. ELIGIBILITY CRITERIA Randomised controlled trials enrolling adult surgical patients allocated to receive goal-directed therapy or standard care were eligible for inclusion. Trauma patients and parturients were excluded. Goal-directed therapy was defined as fluid and/or vasopressor therapy titrated to haemodynamic goals [e.g. cardiac output (CO)]. Outcomes included mortality, morbidity and hospital length of stay. Risk of bias was assessed using Cochrane methodology. RESULTS Ninety-five randomised trials (11 659 patients) were included. Only four studies were at low risk of bias. Modern goal-directed therapy reduced mortality compared with standard care [odds ratio (OR) 0.66; 95% confidence interval (CI) 0.50 to 0.87; number needed to treat = 59; N = 52; I2 = 0.0%]. In subgroup analysis, there was no mortality benefit for fluid-only goal-directed therapy, cardiac surgery patients or nonelective surgery. Contemporary goal-directed therapy also reduced pneumonia (OR 0.69; 95% CI, 0.51 to 0. 92; number needed to treat = 38), acute kidney injury (OR 0. 73; 95% CI, 0.58 to 0.92; number needed to treat = 29), wound infection (OR 0.48; 95% CI, 0.37 to 0.63; number needed to treat = 19) and hospital length of stay (days) (−0.90; 95% CI, −1.32 to −0.48; I2 = 81. 2%). No important differences in outcomes were found for the pulmonary artery catheter studies, after accounting for advances in the standard of care. CONCLUSION Peri-operative modern goal-directed therapy reduces morbidity and mortality. Importantly, the quality of evidence was low to very low (e.g. Grading of Recommendations, Assessment, Development and Evaluation scoring), and there was much clinical heterogeneity among the goal-directed therapy devices and protocols. Additional well designed and adequately powered trials on peri-operative goal-directed therapy are necessary. Correspondence to Dr Matthew A. Chong, MD, Department of Anesthesia and Perioperative Medicine, University Hospital – London Health Sciences Centre, 339 Windermere Road, C3-108, London, ON, Canada N6A 5A5 E-mail: matthew.a.chong@gmail.com 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/2ylyqmW). © 2018 European Society of Anaesthesiology

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Comparative efficacy of two anti-aging products containing retinyl palmitate in healthy human volunteers

Summary

Background

No study yet described the comparative efficacy of two over-the-counter (OTC) anti-aging products in Asian subjects using the techniques involving analysis of living skin.

Aim

We sought to evaluate the anti-aging efficacy of two commercial formulations containing retinyl palmitate using a high-resolution UVA video camera.

Method

Total 11 healthy male volunteers, agreed to participate in this single-blind split-face design study with the mean age of 25.5 years. Every night, volunteers applied one type of cream on the left side and other type of cream on the right side of the face, as directed according to the study design for 60 days. Measurements of the parameters were taken at 0, 1st, 7th, 15th, 30th, and 60th day of study period using noninvasive UVA video camera Visioscan^® VC98. Cream applied on right side of the face labeled as "R" and on the left side as "L."

Results

Sixty-day use of the creams showed significant improvement in SELS parameters of the skin. Percent change in skin wrinkling (SEw) parameter calculated after 60 days was −6.68% after applying cream R and −8.27% after applying cream L.

Conclusion

We concluded that constituents in both creams have potentially influenced skin surface parameters, thus indicating that, these creams as a better option to lessen the effects of aging on facial skin on long-term application.

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The use of natural ingredients in innovative Korean cosmeceuticals

Summary

Background

The cosmeceutical industry is an ever-growing and in demand market, especially in Asia. Korea has been on the forefront of creating the newest generation and most innovative cosmeceuticals products including ingredients such as snail secretions, starfish powder, botanical extracts, green tea, and red ginseng. Given their increasing prevalence in the cosmeceutical industry, scientists have been conducting investigations into these extracts and their properties.

Objective

To summarize the current literature surrounding multiple natural ingredients found in Korean cosmeceutical products.

Methods

A review of the literature surrounding natural ingredients found in Korean cosmeceuticals was conducted using PubMed (U.S. National Library of Medicine).

Results

Multiple natural extracts have been found to have antiaging, antitumor, and antimelanogenic effects making them useful additives in current cosmeceutical products.

Conclusion

With the public's increasing awareness of cosmeceutical products, it is important for physicians to understand the properties of these extracts in order to inform patients correctly and ensure patient safety.

http://ift.tt/2n7iFLZ