Δευτέρα 28 Ιανουαρίου 2019
Diagnosis and treatment choices of suspected benign paroxysmal positional vertigo: current approach of general practitioners, neurologists, and ENT physicians
Abstract
Purpose
Benign paroxysmal positional vertigo (BPPV) is a frequently underdiagnosed cause of vertigo, potentially due to the underuse of diagnostic and therapeutic canalith repositioning procedures (CRPs). We aimed to investigate self-reported use of the diagnostic and therapeutic approach to BPPV patients by Lithuanian neurologists, ear, nose, and throat (ENT) physicians, and general practitioners (GPs), and to explore potential reasons for the underuse of the maneuvers.
Methods
Neurologists, ENT physicians, and GPs were invited to complete a written questionnaire focused on diagnostic and therapeutic practices related to BPPV. Between-group differences and associations between responses were analyzed statistically.
Results
In total, 97 neurologists, 85 ENT physicians and 142 GPs (21.1%, 26.8%, and 5.7%, respectively, of all corresponding licensed Lithuanian physicians) completed the questionnaire. 24% of neurologists, 33% ENT physicians and 50% GPs do not perform diagnostic maneuvers for patients with suspected BPPV, and 28%, 61%, and 84%, respectively, do not perform CRPs. Years of clinical experience was a negative predictor of CRP performance [OR 0.97 (95% CI 0.95–0.99), p = 0.001]. Frequent reasons for not performing CRPs were time taken for the procedure, fear of provoking symptoms, and lack of knowledge. All physicians frequently ordered additional imaging or consultations for suspected BPPV and reported prescribing a range of medications.
Conclusions
A significant proportion of Lithuanian neurologists, ENT physicians, and GPs do not employ diagnostic maneuvers and CRPs for BPPV patients, contrary to established guidelines. Lack of expertise and time available is a common culprit that leads to unnecessary drug prescribing and investigation.
http://bit.ly/2G93cpY
Transarterial radioembolization in patients with hepatocellular carcinoma of intermediate B2 substage
Abstract
Purpose
Patients with hepatocellular carcinoma (HCC) of intermediate stage (BCLC-B according to the Barcelona Clinic Liver Cancer classification) are a heterogeneous group with different degrees of liver function impairment and tumour burden. The recommended treatment is transarterial chemoembolization (TACE). However, patients in this group may be judged as poor candidates for TACE because the risk-benefit ratio is low. Such patients may receive transarterial radioembolization (TARE) only by entering a clinical trial. Experts have proposed that the stage could be further divided into four substages based on available evidence of treatment benefit. We report here, for the first time, the outcome in patients with BCLC-B2 substage HCC treated with TARE.
Methods
A retrospective analysis of the survival of 126 patients with BCLC-B2 substage HCC treated with TARE in three European hospitals was performed.
Results
Overall median survival in patients with BCLC-B2 substage was not significantly different in relation to tumour characteristics; 19.35 months (95% CI 8.27–30.42 months) in patients with a single large (>7 cm) HCC, and 18.43 months (95% CI 15.08–21.77 months) in patients with multinodular HCC (p = 0.27). However, there was a higher proportion of long-term survivors at 36 months among those with a single large tumour (29%) than among those with multiple tumours (16.8%).
Conclusion
Given the poor efficacy of TACE in treating patients with BCLC-B2 substage HCC, TARE treatment could be a better choice, especially in those with a large tumour.
http://bit.ly/2MCfx6X
Comparison of 18 F-GE-180 and dynamic 18 F-FET PET in high grade glioma: a double-tracer pilot study
Abstract
Background
PET represents a valuable tool for glioma imaging. In addition to amino acid tracers such as 18F-FET, PET targeting the 18-kDa mitochondrial translocator-protein (TSPO) is of high interest for high-grade glioma (HGG) imaging due to its upregulation in HGG cells. 18F-GE-180, a novel TSPO ligand, has shown a high target-to-background contrast in HGG. Therefore, we intra-individually compared its uptake characteristics to dynamic 18F-FET PET and contrast-enhanced MRI in patients with HGG.
Methods
Twenty HGG patients (nine IDH-wildtype, 11 IDH-mutant) at initial diagnosis (n = 8) or recurrence (n = 12) were consecutively included and underwent 18F-GE-180 PET, dynamic 18F-FET PET, and MRI. The maximal tumour-to-background ratios (TBRmax) and biological tumour volumes (BTV) were evaluated in 18F-GE-180 and 18F-FET PET. Dynamic 18F-FET PET analysis included the evaluation of minimal time-to-peak (TTPmin). In MRI, the volume of contrast-enhancement was delineated (VOLCE). Volumes were spatially correlated using the Sørensen–Dice coefficient.
Results
The median TBRmax tended to be higher in 18F-GE-180 PET compared to 18F-FET PET [4.58 (2.33–8.95) vs 3.89 (1.56–7.15); p = 0.062] in the overall group. In subgroup analyses, IDH-wildtype gliomas showed a significantly higher median TBRmax in 18F-GE-180 PET compared to 18F-FET PET [5.45 (2.56–8.95) vs 4.06 (1.56–4.48); p = 0.008]; by contrast, no significant difference was observed in IDH-mutant gliomas [3.97 (2.33–6.81) vs 3.79 (2.01–7.15) p = 1.000]. Only 5/20 cases showed higher TBRmax in 18F-FET PET compared to 18F-GE-180 PET, all of them being IDH-mutant gliomas. No parameter in 18F-GE-180 PET correlated with TTPmin (p > 0.05 each). There was a tendency towards higher median BTVGE-180 [32.1 (0.4–236.0) ml] compared to BTVFET [19.3 (0.7–150.2) ml; p = 0.062] with a moderate spatial overlap [median Sørensen–Dice coefficient 0.55 (0.07–0.85)]. In MRI, median VOLCE [9.7 (0.1–72.5) ml] was significantly smaller than both BTVFET and BTVGE180 (p < 0.001 each), leading to a poor spatial correlation with BTVGE-180 [0.29 (0.01–0.48)] and BTVFET [0.38 (0.01–0.68)].
Conclusion
PET with 18F-GE-180 and 18F-FET provides differing imaging information in HGG dependent on the IDH-mutational status, with diverging spatial overlap and vast exceedance of contrast-enhancement in MRI. Combined PET imaging might reveal new insights regarding non-invasive characterization of tumour heterogeneity and might influence patients' management.
http://bit.ly/2sVhWR6
Diagnostic performance of choline PET for detection of hyperfunctioning parathyroid glands in hyperparathyroidism: a systematic review and meta-analysis
Abstract
Purpose
Hyperparathyroidism (HPT) is a common endocrine disorder caused by hyperfunctioning parathyroid glands (HP). The correct detection and localization of HP is challenging but crucial, as it may guide surgical treatment, particularly in patients with primary HPT. There is a growing body of data regarding the role of radiolabelled choline positron emission tomography (PET) in this setting. Therefore, we performed a systematic review and meta-analysis of the diagnostic performance of this method in detecting HP in patients with HPT.
Methods
This systematic review and meta-analysis was carried out according to PRISMA guidelines. A comprehensive computer literature search of PubMed/MEDLINE, EMBASE and Cochrane Library databases for studies published through May 2018 was performed using the following search algorithm: (a) "choline" or "fluorocholine" or "F-choline" or "C-choline" or "FCH" or "CH" or "FECH" or "FMCH" and (b) "PET" or "positron emission tomography" and (c) "parathyroid" or "hyperparathyroidism". The diagnostic performance of radiolabelled choline PET was expressed as sensitivity and positive predictive value (PPV) on a per-patient and per-lesion basis and as detection rate (DR) on a per-patient basis, with pooled proportion and 95% confidence interval (95% CI) obtained using a random-effects model.
Results
Eighteen studies were included in the systematic review. Fourteen articles (517 patients) were selected for the meta-analysis. The meta-analysis provided the following results on a per-patient analysis analysis: sensitivity 95% (95% CI: 92–97%), PPV 97% (95% CI: 95–98%) and DR 91% (95% CI: 87–94%). On a per-lesion analysis, pooled sensitivity and PPV were 92% (95% CI: 88–96) and 92% (95% CI: 89–95%), respectively. No significant heterogeneity was found among the selected studies.
Conclusions
Radiolabelled choline PET demonstrated excellent diagnostic performance in detecting HP in patients with HPT. Large multicentre studies and cost-effectiveness analyses are needed to better define the role of this imaging method in this setting.
http://bit.ly/2sRLgIl
Regulation of human brown adipose tissue by adenosine and A 2A receptors – studies with [ 15 O]H 2 O and [ 11 C]TMSX PET/CT
Abstract
Purpose
Brown adipose tissue (BAT) has emerged as a potential target to combat obesity and diabetes, but novel strategies to activate BAT are needed. Adenosine and A2A receptor (A2AR) agonism activate BAT in rodents, and endogenous adenosine is released locally in BAT as a by-product of noradrenaline, but physiological data from humans is lacking. The purpose of this pilot study was to investigate the effects of exogenous adenosine on human BAT perfusion, and to determine the density of A2ARs in human BAT in vivo for the first time, using PET/CT imaging.
Methods
Healthy, lean men (n = 10) participated in PET/CT imaging with two radioligands. Perfusion of BAT, white adipose tissue (WAT) and muscle was quantified with [15O]H2O at baseline, during cold exposure and during intravenous administration of adenosine. A2AR density of the tissues was quantified with [11C]TMSX at baseline and during cold exposure.
Results
Adenosine increased the perfusion of BAT even more than cold exposure (baseline 8.3 ± 4.5, cold 19.6 ± 9.3, adenosine 28.6 ± 7.9 ml/100 g/min, p < 0.01). Distribution volume of [11C]TMSX in BAT was significantly lower during cold exposure compared to baseline. In cold, low [11C]TMSX binding coincided with high concentrations of noradrenaline.
Conclusions
Adenosine administration caused a maximal perfusion effect in human supraclavicular BAT, indicating increased oxidative metabolism. Cold exposure increased noradrenaline concentrations and decreased the density of A2AR available for radioligand binding in BAT, suggesting augmented release of endogenous adenosine. Our results show that adenosine and A2AR are relevant for activation of human BAT, and A2AR provides a future target for enhancing BAT metabolism.
http://bit.ly/2MIabaA
Highly favourable outcomes with peptide receptor radionuclide therapy (PRRT) for metastatic rectal neuroendocrine neoplasia (NEN)
Abstract
Purpose
Rectal neuroendocrine neoplasia (NEN) is more common than other NEN origins, but is less commonly metastatic. However, when present, distant disease carries a particularly poor prognosis. Evidence guiding optimal treatment of such patients is lacking. We assessed PRRT outcomes in patients with somatostatin receptor (SSTR) positive metastatic rectal NEN from two referral centres.
Methods
Patients treated with PRRT were retrospectively reviewed. Morphologic (RECIST 1.1), SSTR imaging responses and toxicity were assessed 3 months post-PRRT. Kaplan-Meier estimate was used to determine progression-free survival (PFS) and overall survival (OS) from start of PRRT.
Results
Twenty-seven consecutive patients (M = 20, age 31-81 years) were reviewed. The majority (70%) had ENETs grade 2 disease (19 patients), three had Grade 3, one Grade 1, and four not documented. Overall, 63% (10/16 patients with available FDG PET/CT) had FDG avid disease. Twenty-six patients were treated for disease progression. Most had 177Lu-DOTA-octreotate with median cumulative activity of 30 GBq, median four cycles. 14 patients had radiosensitising chemotherapy (5FU or capecitabine). At 3 months post-PRRT, CT disease control rate (DCR) was 96%: partial response was observed in 70% (19/27) and stable disease in 26%. All but one had partial SSTR imaging response. The median PFS was 29 months. Ten patients died, with median overall survival 81 months with a median follow-up of 67 months. Seventeen patients had further treatments after initial PRRT (10 had further cycles of PRRT). Three patients had grade 3 lymphopenia, without significant renal toxicity, MDS or leukaemia.
Conclusion
Our results indicate high efficacy and morphologic responses with minimal toxicity and very encouraging survival from PRRT in patients with metastatic rectal NEN despite the adverse prognostic features of this cohort. Further prospective PRRT trials are warranted in this subgroup.
http://bit.ly/2MIa272
Influence of lanreotide on uptake of 68 Ga-DOTATATE in patients with neuroendocrine tumours: a prospective intra-patient evaluation
Abstract
Introduction
Somatostatin receptor imaging with PET is the standard of care for patients with a neuroendocrine tumour (NET). Since therapy and imaging with somatostatin analogues utilize the same receptor, current guidelines recommend withdrawing long-acting somatostatin analogues for 3-4 weeks prior to somatostatin receptor PET imaging. The aim of this study is to prospectively assess the effect of lanreotide use on the uptake of 68Ga-DOTATATE intra-individually 1 day prior to and 1 day post injection of lanreotide.
Methods
Thirty-four patients with metastatic and/or unresectable NET and currently on lanreotide therapy for at least 4 months were included in the study. A 68Ga-DOTATATE PET/CT scan was performed on the day before and the day after lanreotide injection. In each patient 68Ga-DOTATATE uptake (SUVmax, mean, peak) was assessed in both tumour lesions and normal tissue. All scans were assessed by two blinded nuclear medicine physicians for visual analysis. Paired T-tests were performed to determine the differences between the scans.
Results
Of the 34 patients included, 31 were available for analyses in which 190 tumour lesions were measured. Uptake of 68Ga-DOTATATE in tumour lesions was increased significantly after lanreotide, but decreased significantly in the liver, spleen, and thyroid gland resulting in a higher tumour-to-liver ratio.
Conclusion
Lanreotide injection prior to 68Ga-DOTATATE PET/CT does not result in decreased tumour uptake. In contrast, tumour uptake was increased, whereas the uptake in normal organs is decreased, leading to an increased tumour-to-liver ratio. However, these differences were small and not deemed clinically relevant. These results strongly suggest that discontinuation of lanreotide injections in the weeks prior to 68Ga-DOTATATE PET examinations is unnecessary and does not compromise nuclear medicine imaging results.
http://bit.ly/2MI9VIE
Safety and efficacy of targeted alpha therapy with 213 Bi-DOTA-substance P in recurrent glioblastoma
Abstract
Treatment options for recurrent glioblastoma multiforme (GBM) are very limited. GBM cells express high levels of the GPCR neurokinin type 1 receptor (NK-1R), and a modified substance P can be used as its ligand for the tumor cell targeting. Targeted alpha therapy with DOTA-Substance P labeled with the short range alpha emitter 213Bi allows for selective irradiation and killing of tumor cells.
Material and methods
Twenty patients with recurrent GBM were included into the study following a standard therapy. 1–2 intracavitary or intratumoral port-a-cath systems were stereotactically inserted. Patients were treated with 1–7 doses of 213Bi-DOTA-Substance P (213Bi-DOTA-SP) in 2-month intervals. 68Ga-DOTA-Substance P (68Ga-DOTA-SP) was co-injected with 213Bi-DOTA-SP to assess the biodistribution using PET/CT. Therapeutic response was monitored with performance status and MRI imaging.
Results
Treatment with activity up to 11.2 GBq 213Bi-DOTA-SP was well tolerated with only mild and transient adverse reactions. The median progression free survival was 2.7 months. The median overall survival from the first diagnosis was 23.6 months and median survival after recurrence was 10.9 months. The median survival time from the start of 213Bi-DOTA-SP was 7.5 months.
Conclusions
Treatment of recurrent GBM with 213Bi-DOTA-SP is safe and well tolerated. The median overall survival after recurrence of 10.9 months compares favorably to the available alternative treatment options. Once the supply of high activity 225Ac/213Bi radionuclide generators is secured, targeted alpha therapy with 213Bi-DOTA-SP may evolve as a promising novel option to treat recurrent GBM.
http://bit.ly/2sPRGrs
FET PET reveals considerable spatial differences in tumour burden compared to conventional MRI in newly diagnosed glioblastoma
Abstract
Purpose
Areas of contrast enhancement (CE) on MRI are usually the target for resection or radiotherapy target volume definition in glioblastomas. However, the solid tumour mass may extend beyond areas of CE. Amino acid PET can detect parts of the tumour that show no CE. We systematically investigated tumour volumes delineated by amino acid PET and MRI in patients with newly diagnosed, untreated glioblastoma.
Methods
Preoperatively, 50 patients with neuropathologically confirmed glioblastoma underwent O-(2-[18F]-fluoroethyl)-l-tyrosine (FET) PET, and fluid-attenuated inversion recovery (FLAIR) and contrast-enhanced MRI. Areas of CE were manually segmented. FET PET tumour volumes were segmented using a tumour-to-brain ratio of ≥1.6. The percentage overlap volumes, and Dice and Jaccard spatial similarity coefficients (DSC, JSC) were calculated. FLAIR images were evaluated visually.
Results
In 43 patients (86%), the FET tumour volume was significantly larger than the CE volume (21.5 ± 14.3 mL vs. 9.4 ± 11.3 mL; P < 0.001). Forty patients (80%) showed both increased uptake of FET and CE. In these 40 patients, the spatial similarity between FET uptake and CE was low (mean DSC 0.39 ± 0.21, mean JSC 0.26 ± 0.16). Ten patients (20%) showed no CE, and one of these patients showed no FET uptake. In five patients (10%), increased FET uptake was present outside areas of FLAIR hyperintensity.
Conclusion
Our results show that the metabolically active tumour volume delineated by FET PET is significantly larger than tumour volume delineated by CE. Furthermore, the results strongly suggest that the information derived from both imaging modalities should be integrated into the management of patients with newly diagnosed glioblastoma.
http://bit.ly/2MI9RIU
Personalized 177 Lu-octreotate peptide receptor radionuclide therapy of neuroendocrine tumours: initial results from the P-PRRT trial
Abstract
Purpose
Peptide receptor radionuclide therapy (PRRT) is mostly administered using a fixed injected activity (IA) per cycle. This empiric regime results in highly variable absorbed doses to the critical organs and undertreatment of the majority of patients. We conceived a personalized PRRT protocol in which the IA is adjusted to deliver a prescribed absorbed dose to the kidney, with the aim to safely increase tumour irradiation. We herein report on the initial results of our prospective study of personalized PRRT, the P-PRRT Trial (NCT02754297).
Methods
PRRT-naïve patients with progressive and/or symptomatic neuroendocrine tumour (NET) were scheduled to receive a four-cycle induction course of 177Lu-octreotate with quantitative SPECT/CT-based dosimetry. The IA was personalized according to the glomerular filtration rate and the body surface area for the first cycle, and according to the prior renal Gy/GBq for the subsequent cycles. The prescribed renal absorbed dose of 23 Gy was reduced by 25–50% in case of significant renal or haematological impairment. Responders were allowed to receive consolidation or maintenance cycles, for each of which 6 Gy to the kidney were prescribed. We simulated the empiric PRRT regime by fixing the IA at 7.4 GBq per cycle, with the same percentage reductions as above. Radiological, molecular imaging, biochemical, and quality of life responses, as well as safety, were assessed.
Results
Fifty-two patients underwent 171 cycles. In 34 patients who completed the induction course, a median cumulative IA of 36.1 (range, 6.3–78.6) GBq was administered, and the median cumulative kidney and maximum tumour absorbed doses were 22.1 (range, 8.3–24.3) Gy and 185.7 (range: 15.2–443.1) Gy respectively. Compared with the simulated fixed-IA induction regime, there was a median 1.26-fold increase (range, 0.47–2.12 fold) in the cumulative maximum tumour absorbed dose, which was higher in 85.3% of patients. In 39 assessable patients, the best objective response was partial response in nine (23.1%), minor response in 14 (35.9%), stable disease in 13 (33.3%) and progressive disease in three patients (7.7%). In particular, 11 of 13 patients (84.6%) with pancreatic NET had partial or minor response. The global health status/quality of life score significantly increased in 50% of patients. Acute and subacute side-effects were all of grade 1 or 2, and the most common were nausea (in 32.7% of patients) and fatigue (in 30.8% of patients) respectively. Subacute grade 3 or 4 toxicities occurred in less than 10% of patients, with the exception of lymphocytopenia in 51.9% of patients, without any clinical consequences however. No patient experienced severe renal toxicity.
Conclusions
Personalized PRRT makes it possible to safely increase tumour irradiation in the majority of patients. Our first results indicate a favourable tolerance profile, which appears similar to that of the empiric regime. The response rates are promising, in particular in patients with NET of pancreatic origin.
http://bit.ly/2sUMqD3
Comprehensive anatomical and functional imaging in patients with type I neurofibromatosis using simultaneous FDG-PET/MRI
Abstract
Purpose
To demonstrate the clinical use of FDG-PET/MRI for monitoring enlargement and metabolism of plexiform neurofibromas (PNF) in patients with neurofibromatosis type 1 (NF1), in whom the development of a malignant peripheral nerve sheath tumor (MPNST) is often a life limiting event.
Methods
NF1 patients who underwent a simultaneous FDG-PET/MRI examination in our institution from September 2012 to February 2018 were included. Indication was suspicion of malignant transformation of a PNF to MPNST. A maximum of six peripheral nerve lesions per patient were defined as targets. Standardized uptake values (SUV) and apparent diffusion coefficients (ADC) were measured. The presence of target sign and contrast-medium enhancement was visually recorded. Growth rates were estimated comparing prior or follow-up examinations and correlated with FDG uptake and ADC values. The presence of CNS lesions in cerebral T2 weighted images was recorded.
Results
In 28 NF1 patients a total number of 83 peripheral nerve tumors, 75 benign PNFs and eight MPNSTs, were selected as target lesions. The SUVs of MPNSTs were significantly higher than the SUVs of PNF (3.84 ± 3.98 [SUVmean MPNSTs] vs. 1.85 ± 1.03 [SUVmean PNF], P < .01). Similarly, lesion SUVmean-to-liver SUVmean ratios significantly differed between MPNSTs and PNF (3.20 ± 2.70 [MPNSTs] vs. 1.23 ± 0.61 [PNF]; P < .01). For differentiation between still benign PNF and MPNSTs, we defined SUVmax ≥ 2.78 as a significant cut-off value. Growth rate of PNF correlated significantly positively with SUVmean (rs = .41; P = .003). MRI parameters like ADCmean (1.87 ± 0.24 × 10−3 mm2/s [PNF] vs. 1.76 ± 0.11 × 10−3 mm2/s [MPNSTs]; P > .05], contrast medium enhancement (P = .50) and target sign (P = .86) did not differ between groups.
Conclusion
Simultaneous FDG-PET/MRI is a comprehensive imaging modality for monitoring PNF in NF1 patients. The combined acquisition of both morphologic information in MRI and metabolic information in PET enables the correlation of lesion growth rates with metabolic activity and to define SUV thresholds of significance to identify malignant transformation, which is of utmost clinical significance.
http://bit.ly/2MFfMhA
The EANM practical guidelines for sentinel lymph node localisation in oral cavity squamous cell carcinoma
Abstract
Purpose
Sentinel lymph node biopsy is an essential staging tool in patients with clinically localized oral cavity squamous cell carcinoma. The harvesting of a sentinel lymph node entails a sequence of procedures with participation of specialists in nuclear medicine, radiology, surgery, and pathology. The aim of this document is to provide guidelines for nuclear medicine physicians performing lymphoscintigraphy for sentinel lymph node detection in patients with early N0 oral cavity squamous cell carcinoma.
Methods
These practice guidelines were written and have been approved by the European Association of Nuclear Medicine (EANM) and the International Atomic Energy Agency (IAEA) to promote high-quality lymphoscintigraphy. The final result has been discussed by distinguished experts from the EANM Oncology Committee, and national nuclear medicine societies. The document has been endorsed by the Society of Nuclear Medicine and Molecular Imaging (SNMMI).
These guidelines, together with another two focused on Surgery and Pathology (and published in specialised journals), are part of the synergistic efforts developed in preparation for the "2018 Sentinel Node Biopsy in Head and Neck Consensus Conference".
Conclusion
The present practice guidelines will help nuclear medicine practitioners play their essential role in providing high-quality lymphatic mapping for the care of early N0 oral cavity squamous cell carcinoma patients.
http://bit.ly/2FTTLLz
Additional value of integrated 18 F-choline PET/4D contrast-enhanced CT in the localization of hyperfunctioning parathyroid glands and correlation with molecular profile
Abstract
Purpose
The localization of hyperfunctioning parathyroid gland(s) (HPTG) in patients with primary hyperparathyroidism (PHPT) with negative or inconclusive first-line imaging is a significant challenge. This study aimed to evaluate the role of integrated 18F-choline PET/4D contrast-enhanced computed tomography (4DCeCT) in these patients, compare its detection rate and sensitivity with those of 18F-choline PET/CT and (4DCeCT), and analyse the association between choline metabolism and morphological, biochemical and molecular parameters of HPTG.
Methods
We prospectively enrolled 44 PHPT patients with negative or inconclusive first-line imaging. 18F-Choline PET/CT and 4DCeCT were performed at the same time, and integrated 18F-choline PET/4DCeCT images were obtained after coregistration. Experienced physicians examined the images. The SUVratio and degree of contrast enhancement were recorded for each positive finding. Histopathology, laboratory and multidisciplinary follow-up were used as the standard of reference. Both the detection rates and sensitivities of the three imaging modalities were calculated retrospectively. Immunohistochemistry was performed to evaluate the molecular profile of HPTGs.
Results
18F-Choline PET/4DCeCT was positive in 32 of 44 patients with PHPT (detection rate 72.7%), and 31 of 31 surgically treated patients (sensitivity 100%). These results were significantly (p < 0.05) better than those of 18F-choline PET/CT (56.8% and 80%, respectively) and those of 4DCeCT (54.5 and 74%, respectively). A significant correlation between SUV and calcium level was found. In a multivariate analysis, only calcium level was significantly associated with 18F-choline PET/4DCeCT findings. SUVratio and Ki67 expression were significantly correlated.
Conclusion
Integrated 18F-choline PET/4DCeCT should be considered as an effective tool to detect PHPT in patients with negative or inconclusive first-line imaging. Choline metabolism is correlated with both calcium level and Ki67 expression in HPTG.
http://bit.ly/2sUMqmx
Yttrium-90 glass microspheres radioembolization (RE) for biliary tract cancer: a large single-center experience
Abstract
Purpose
Radioembolization (RE) is a promising treatment option for biliary tract cancers (BTC). We report here the largest series to date using this treatment modality.
Methods
We retrospectively studied data from 64 patients treated outside prospective clinical trial at our institution. We studied baseline characteristics as potential prognostic factors. We studied dose delivered to the tumor as predictive factors of outcomes in patients not receiving concomitant chemotherapy.
Results
The Progression-Free Survival and Overall Survival (OS) were 7.6 months [95% Confidence Interval (CI): 4.6–10.6] and 16.4 months [95% CI: 7.8–25.0] in the whole cohort. The factors independently associated with OS in multivariable analysis were the primary localization of ICC (HR = 0.27, 95% CI: 0.11–0.68, p = 0.005) and a PS > 0 (HR = 2.21, 95% CI: 1.11–4.38, p = 0.024). During follow-up, 12 patients (19%) underwent surgery following downstaging, with a median OS of 51.9 months. In patients not treated with concomitant chemotherapy (n = 31), OS was significantly higher in patients with a dose delivered to the tumor 260Gy or higher than in patients with a dose delivered to the tumor lower than 260Gy (median 28.2 vs 11.4 months, log-rank p = 0.019).
Conclusion
Our results confirm that RE is a promising treatment modality in BTC. A high proportion of patients could be downstaged to surgery, with promising long-term survival. Dose delivered to the tumor correlated with clinical outcomes when chemotherapy was not used concomitantly.
http://bit.ly/2FUloUL
Eosinophilic infiltration: an under‐reported histological finding in urticarial vasculitis
Abstract
Background
Urticarial vasculitis (UV) is a clinicopathologic entity in which skin lesions resemble urticaria clinically but last more than 24 hours and resolve with residual purpura. In this study, we evaluated distinguishing histological features of UV from common urticaria to differentiate between these two entities.
Methods
During 1 year, 55 urticaria and 245 UV samples were assessed. The selection criteria for UV included: (1) samples that the histological diagnosis was confirmed by two independent dermatopathologists, (2) the histological diagnosis of UV was inconsistent with the first clinical impression and lesion characteristics.
Results
Of our 245 UV patients, 96% had endothelial swelling, 18% had red blood cell (RBC) extravasation, neutrophilic infiltration was seen in 46.7%, and perivascular, interstitial, and perineural eosinophilic infiltration in 198 (81.8%), 181 (74.2%), and 118 (48.1%), respectively. Among different histological findings, endothelial cell swelling as well as neutrophil around vessels and eosinophilic infiltrations were statistically different between two groups (P‐value ˂ 0.001). Both urticaria and UV samples showed a predominantly lymphocytic infiltration more than 10 cells per high power field (HPF) (98.2% of urticaria, 98.8% of UV), and only two patients (0.8%) with UV had predominant neutrophilic infiltration (more than 10 cells/HPF).
Conclusion
We have found that both urticaria and UV showed a predominantly lymphocytic infiltration along with RBC extravasation, endothelial cell swelling, and fibrin deposition in UV. Moreover, significant perineural, perivascular, and interstitial infiltration of eosinophil in UV lesions compared to urticaria was another point that indicates special contribution of these cells in UV pathogenesis.
http://bit.ly/2G8M7wk
Platelet‐rich plasma and microneedling improves hair growth in patients ofandrogenetic alopecia when used as an adjuvant to minoxidil
Summary
Background
Platelet‐rich plasma (PRP) is a popular procedure for the treatment of androgenetic alopecia (AGA).
Aim
To ascertain the role of minoxidil 5% lotion alone versus minoxidil 5% lotion and PRP versus minoxidil 5% lotion, PRP with microneedling in AGA.
Material and methods
Ninety‐three AGA patients with Hamilton‐Norwood score 1‐5 were grouped into three groups A, B, and C. Patients in group A (control group) were treated with minoxidil 5% lotion twice daily (n = 31), whereas patients in group B underwent treatment with minoxidil 5% lotion twice daily and PRP (n = 31), and group C patients received minoxidil 5% lotion twice daily, PRP, and microneedling (n = 31). Baseline and post‐treatment photographs were taken along with dermoscopic evaluation. Selection of the dermoscopic variables included in the evaluation process was based on the published literature and dermoscopists' expertise and experience. Hair pull test was performed before and during follow‐up.
Results
Post‐treatment, hair pull test was negative in 27 patients (87.1%, P < 0.01) of group C, 20 patients (64.5%, P < 0.05) of group B, and 15 patients (48.4%) of group A. Hair growth was better appreciated in group C (26/31) compared to groups B (17/31)and A (10/31).The patients' self‐satisfaction score on a Likert scale was more than seven (high satisfaction) in 24/31 patients in group C. There was a statistically significant difference between three groups in terms of hair pull test, terminal‐to‐vellus hair ratio, and patient satisfaction score as determined by one‐way ANOVA.
Conclusion
PRP with microneedling is better in comparison with PRP alone or minoxidil monotherapy in patients with AGA.
http://bit.ly/2HDJ3KL
Platelet‐rich plasma and microneedling improves hair growth in patients ofandrogenetic alopecia when used as an adjuvant to minoxidil
Summary
Background
Platelet‐rich plasma (PRP) is a popular procedure for the treatment of androgenetic alopecia (AGA).
Aim
To ascertain the role of minoxidil 5% lotion alone versus minoxidil 5% lotion and PRP versus minoxidil 5% lotion, PRP with microneedling in AGA.
Material and methods
Ninety‐three AGA patients with Hamilton‐Norwood score 1‐5 were grouped into three groups A, B, and C. Patients in group A (control group) were treated with minoxidil 5% lotion twice daily (n = 31), whereas patients in group B underwent treatment with minoxidil 5% lotion twice daily and PRP (n = 31), and group C patients received minoxidil 5% lotion twice daily, PRP, and microneedling (n = 31). Baseline and post‐treatment photographs were taken along with dermoscopic evaluation. Selection of the dermoscopic variables included in the evaluation process was based on the published literature and dermoscopists' expertise and experience. Hair pull test was performed before and during follow‐up.
Results
Post‐treatment, hair pull test was negative in 27 patients (87.1%, P < 0.01) of group C, 20 patients (64.5%, P < 0.05) of group B, and 15 patients (48.4%) of group A. Hair growth was better appreciated in group C (26/31) compared to groups B (17/31)and A (10/31).The patients' self‐satisfaction score on a Likert scale was more than seven (high satisfaction) in 24/31 patients in group C. There was a statistically significant difference between three groups in terms of hair pull test, terminal‐to‐vellus hair ratio, and patient satisfaction score as determined by one‐way ANOVA.
Conclusion
PRP with microneedling is better in comparison with PRP alone or minoxidil monotherapy in patients with AGA.
http://bit.ly/2HDJ3KL
Acute blue finger syndrome: a rare benign cause of acute digit discolouration
Acute blue finger syndrome is a rare benign condition that mimics digital ischaemia. We discuss the case of a 32-year-old woman who presented with a 6hour history of blue discolouration of the middle finger of the right hand, associated with pain and swelling. There was no history of trauma and this was the first time that the patient had experienced these symptoms. Examination found blue discolouration of the digit primarily on the volar aspect with associated swelling. All investigations, including blood tests, X-rays and Doppler scanning, were normal. The symptoms resolved spontaneously within 48 hours. There were no recurrent episodes or long-term sequelae. Patients presenting with an acutely blue finger need rapid assessment to exclude digit ischaemia. Knowledge of this rare benign condition may prevent unnecessary distress, invasive investigations and potentially harmful treatment of a healthy patient.
http://bit.ly/2CS80N6
Rare case with plethora of upper urinary tract anomalies associated with pelviureteric junction obstruction: a surgical challenge managed with robot assistance
The genitourinary system for reasons unknown is more likely to have birth defects than any other system. The anomaly of collecting system draining the kidney represent mystifying subset of congenital anomalies. Pelviureteric junction obstruction (PUJO) is most common. Chronic obstruction can lead to stasis, urinary infection and stone formation in PUJO. Extrarenal calyces, which is characterised by presence of calyces and renal pelvis outside the renal parenchyma is one of the rare anomalies seen among the collecting system right gonadal vein drains into inferior vena cava. Its altered drainage into right renal vein is rarely seen and reported. Glut of these multiple anomalies in a single case is an extremely rare event. We hereby discuss a case of 40-year-old male patient with combination of all these anomalies and discuss the embryology, presentation and management.
http://bit.ly/2CTrJMt
Primary Ewing sarcoma of the kidney
Primary Ewing sarcoma (ES) or primitive neuroectodermal tumour (PNET) is a rare tumour in adults and primary renal involvement is extremely rare. Patients with renal ES or PNET respond to and would benefit from conventional ES treatment according to ES study protocols. Here, we report a case of a young woman, presenting with right flank pain and haematuria. After ultrasound and CT evaluation, a right middle pole renal mass was detected. The patient underwent radical right nephrectomy, and a grade 4 ES with peritoneal involvement was documented. Subsequently, the patient underwent adjuvant chemotherapy for 5 months. Follow-up 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT scan demonstrated bilateral cervical, hilar, mediastinal and retroperitoneal FDG-avid adenopathies associated with mild right-sided pleural effusion with no metabolic activity, signifying the role of PET/CT scan in tumour restaging.
http://bit.ly/2RU0Lyh
Ileal conduit volvulus: rare complication of urinary diversion
Ileal conduit volvulus is a rare complication of urinary diversion. It has been suggested that various factors including prolonged length of the ileal segment, lack of fixation of the conduit to the peritoneum and failure to close the incised mesentery predispose patients to this complication. We present the case of a 76-year-old man who presented to hospital with severe abdominal pain and oliguria secondary to a volvulus of his ileal conduit. Investigations revealed early acute kidney injury as a result of urinary obstruction which was evident on abdominal CT. The patient subsequently underwent operative repair of the volvulus. Symptoms resolved following the procedure, kidney function improved and the patient was discharged without complication.
http://bit.ly/2CRvLVj
Peroneal artery entrapment syndrome (PRAES): a rare cause of ischaemic toes
A 75-year-old man presenting with intermittent discolouration of his left toes was referred to vascular surgery with suspicion of embolic vascular disease. A contrast-enhanced MR angiogram was performed which revealed bilateral dominant peroneal arteries (PRAs). There was evidence of short atherosclerotic stenosis directly at the point where the left PRA passes through the tibiofibular interosseous membrane which we postulate to be the source of the emboli. We present what is believed to be the first reported case of PRA entrapment complicated by distal toe emboli.
http://bit.ly/2CQlMQc
Behavioural changes as the first manifestation of a silent frontal lobe stroke
A 67-year-old man was admitted to our hospital after his relatives found him to have severe personality and behavioural changes. His behaviour was inappropriate and uninhibited. The patient reported no symptoms and he showed poor insight into his own behaviour. Neuroimaging showed an orbitofrontal lesion, due to an infarction of the anterior cerebral artery. The patient was diagnosed with frontal lobe syndrome.
http://bit.ly/2RXWvy3
Double axillary vein variation diagnosed with ultrasound guidance during infraclavicular nerve block intervention
The use of ultrasound guidance increases the safety of peripheral block interventions by allowing anaesthesiologists to simultaneously see the position of block needle, the targeted nerves and surrounding vessels. In this report, we represented three patients diagnosed with double axillary vein variation with ultrasound guidance during infraclavicular nerve block intervention. The patients were scheduled for different types of upper limb surgeries. All patients received infraclavicular nerve block for anaesthetic management. A double axillary vein variation was diagnosed with ultrasound during block interventions. Hydro-location technique was used in all cases and the procedures were completed uneventfully. In the current literature, there is limited number of reports concerning double axillary vein variation. Detailed knowledge of the axillary anatomy is important to avoid complications such as intravascular injection during peripheral nerve block interventions. The use of ultrasound guidance and hydro-location technique should be considered for nerve blocks, especially in the axillary area.
http://bit.ly/2CPtA4D
Pseudomonas meningoencephalitis masquerading as a stroke in a patient on tocilizumab
A previously high-functioning woman presents with clinical and CT features of a subacute ischaemic stroke. Her medical history is relevant for refractory giant cell arteritis on long-term high-dose prednisolone and recent commencement of tocilizumab (interleukin-6 monoclonal antibody). The potential for stroke mimic is considered and a magnetic resonance brain scan is requested. She rapidly deteriorates within 24 hours of admission and unexpectantly dies. An autopsy reveals that she has bilateral pulmonary emboli with lower limb deep vein thrombosis and Pseudomonas meningoencephalitis with frank pus on the brain. We discuss the potential risks of immunosuppression and the role of imaging in the diagnosis of stroke.
http://bit.ly/2RRIeCZ
Intestinal obstruction caused by small bowel adenocarcinoma misdiagnosed as psychogenic disorder
We describe a case of intestinal obstruction caused by a small bowel adenocarcinoma misdiagnosed as psychogenic disorder. A woman in her 40s was admitted to Nagoya City University Hospital with fatigue, anorexia, nausea and vomiting. CT, oesophagogastroduodenoscopy and colonoscopy revealed no signs of organic abnormality in her gastrointestinal tract. As the patient had previously been diagnosed with and treated for depression, her symptoms were suspected to be due to psychogenic disorder. Therefore, she was diagnosed with severe depression and was administered antidepressant agents. Despite intense psychiatric treatment, her symptoms worsened and she was later diagnosed with ileus due to adenocarcinoma in the jejunum. After drainage by insertion of a transnasal decompression tube, a partial jejunum resection was performed. After the resection, the patient's symptoms including fatigue and depression resolved without the use of antidepressant agents.
http://bit.ly/2CPLoNi
Simultaneous presentation of thyroid storm and diabetic ketoacidosis in a previously healthy 21-year-old man
A 21-year-old young man with no history of diabetes or thyroid disease presented to the emergency department with simultaneous thyroid storm and diabetic ketoacidosis. Notable findings on admission were a ventricular rate of 235 beats/min, tachypnoea, tremors, polydipsia and a lack of fever. Due to the unusual constellation of symptoms, diagnosis was only possible after initial laboratory results came back. While the lack of fever is unusual in thyroid storm, diabetic ketoacidosis has previously been reported to suppress fever, and this case supports the occurrence of this phenomenon. This case was highly unusual because the patient had not previously been diagnosed with either type 1 diabetes or Graves' disease.
http://bit.ly/2RRMm5M
Rectal bleeding caused by a syphilitic inflammatory mass
A 47-year-old man presented with fatigue, decrease appetite, abdominal pain and rectal bleeding. His colonoscopy revealed a single, firm, raised, centrally ulcerated mass at the anorectal junction. During this same admission, he was diagnosed with HIV and syphilis, found to have multiple hepatic lesions and positive cerebrospinal fluidvenereal disease research laboratory test (VDRL). Biopsies from both the hepatic lesions and rectal ulcer showed spirochaetes by immunostaining. The initial presentation was felt to be secondary to a rectal inflammatory mass caused by syphilis.
http://bit.ly/2CP5qHJ
Hypocalcaemia and hyponatraemia masquerading the diagnosis of Gitelman syndrome
Gitelman syndrome is the most common renal tubulopathy, recently exhibiting a dramatic rise of incidence in Asia.
A 50-year-old woman presented with vomiting, fatigue and quadriparesis. Physical examination revealed a positive Trousseau sign , hypotonia and areflexia.
Suspecting hypocalcaemia, she was given intravenous 10% calcium gluconate (10 mL administered slowly over 10 min) but her manifestations persisted. An exhaustive laboratory work up revealed the diagnosis of Gitelman syndrome.
The peculiarity of this case however, is entailed in its coexistence with hypocalcaemia and hyponatraemia. In addition, the age of primary presentation being 50 years further culminates its atypicality.
Multiple electrolyte imbalances were corrected by oral and intravenous supplementation and a high sodium-potassium diet was advocated. Administration of spironolactone imposed a pitfall in the management of our patient due to exacerbation of pre-existing hyponatraemia.
On follow-up, her electrolyte profile was stable and corresponding symptoms were alleviated.
http://bit.ly/2RSmzdG
Aortitis and pachymeningitis: an unusual combination in granulomatosis with polyangiitis (myeloperoxidase-associated vasculitis)
Aortitis and pachymeningitis are uncommon manifestations of the antineutrophil cytoplasmic antibody-associated vasculitides, a group of systemic autoimmune diseases mainly affecting small vessels. We present a case of a 71-year-old woman with a remote history of idiopathic chronic granulomatous pachymeningitis complicated with aortic thickening due to autoimmune aortitis.
http://bit.ly/2CTQR5u
Hepatitis in patients with syphilis: an overlooked association
We present the case of a patient who sought treatment for fever and a maculopapular rash involving the trunk, limbs, palms and soles. The patient also presented with hepatomegaly and elevated levels of liver enzymes (with a higher increase of alkaline phosphatase). With the proposal of early syphilitic hepatitis, during the stage of secondary syphilis, a venereal disease research laboratory and Treponema pallidum haemagglutination tests were requested, which confirmed the diagnosis. All altered parameters improved with antibiotic treatment for secondary syphilis. Syphilitic hepatitis is an often overlooked presentation of syphilis and should be considered as a differential diagnosis in patients with elevated levels of liver enzymes and risk factors for syphilis.
http://bit.ly/2RXztXW
Actinomycosis of the omentum with invasion of the abdominal wall, small bowel and transverse colon mimicking malignancy
We report the case of a 59-year-old Russian man who presented with a painless, slow-growing, epigastric mass. CT revealed a large heterogeneous mass within the omentum infiltrating into adjacent tissues. During diagnostic laparoscopy, the omental mass was noted to be firm, raising the suspicion of malignancy. Surgical en-bloc resection of the mass, including the posterior rectus sheath, transverse colon and small bowel, was performed with primary anastomoses at laparotomy. Histological examination was inconsistent with malignancy and revealed the mass to be actinomycosis, confirmed by microscopy and gram staining. Surgical resection was followed by an 8-week course of penicillin and doxycycline antibiotic therapy. This treatment resulted in full clinical and radiological recovery with no complications. Although the clinical and radiological findings, in this case, were highly suspicious of malignancy, abdominal actinomycosis should be considered a differential diagnosis in patients with infiltrative abdominal masses and mild constitutional symptoms.
http://bit.ly/2CM1jfe
Largest giant juvenile fibroadenoma of the breast
Juvenile giant fibroadenoma is a rare benign tumour of the breast accounting for 0.5% of all fibroadenomas. The presentation can be very dramatic and may result in breast deformity and may mimic a rare malignant tumour. It is indeed a great challenge to provide the best treatment for these patients in terms of clinical and psychological care. Meticulous surgical planning is required to ensure a fine balance between adequate resection and the best cosmetic outcome for a developing breast. Every effort should be made to preserve the developing breast irrespective of the size of the tumour as it is in this case. We report the world's largest juvenile fibroadenoma of the breast in a 16-year-old girl who presented to our hospital with a 28x25 cm mass on her left breast in which breast conservation was done. A detailed literature search and management of these lesions are discussed.
http://bit.ly/2RXW86D
Very rare case of synchronous volvulus of the sigmoid colon and caecum causing large-bowel obstruction
Large-bowel obstruction caused by volvulus is potentially life threatening if not managed promptly. Sigmoid colon is the most common site of volvulus followed by caecum. Synchronous double colonic volvulus is an exceedingly rare entity, with only five cases published previously. We present the case of a 77-year-old man with a synchronous sigmoid and caecal volvulus. He underwent total colectomy with ileostomy formation with a view to reverse the ileostomy at a later date.
http://bit.ly/2CQrzFt
Even Short-Term Telmisartan Treatment Ameliorated Insulin Resistance But Had No Influence on Serum Adiponectin and Tumor Necrosis Factor-Alpha Levels in Hypertensive Patients with Metabolic Syndrome
Metabolic Syndrome and Related Disorders, Ahead of Print.
http://bit.ly/2D13mMX
A Guide to Yellow Oral Mucosal Entities: Etiology and Pathology
Abstract
When faced with an uncertain clinical pathosis in the oral cavity, identifying the color of the mucosal lesion helps to narrow down a differential diagnosis. Although less common than red and white lesions, yellow lesions encompass a small group of distinct mucosal pathologic entities. Adipose tissue, lymphoid tissue, and sebaceous glands are naturally occurring yellow constituents of the oral cavity and become apparent with associated developmental or neoplastic lesions. Reactive and inflammatory lesions can create a yellow hue due to purulence, necrosis, and calcification. Some systemic diseases are known to deposit yellow bi-products such as amyloid or bilirubin into the oral mucosa of an affected person, and while not always yellow, unusual entities like verruciform xanthoma and granular cell tumor fall under the umbrella of yellow lesions given their occasional propensity to demonstration the color. This chapter aims to explore the unique group that is yellow lesions presenting in the oral mucosa.
http://bit.ly/2TfsKp2
Tongue Lumps and Bumps: Histopathological Dilemmas and Clues for Diagnosis
Abstract
Exophytic lesions of the tongue encompass a diverse spectrum of entities. These are most commonly reactive, arising in response to local trauma but can also be neoplastic of epithelial, mesenchymal or miscellaneous origin. In most cases, the microscopic examination is likely to provide a straightforward diagnosis. However, some cases can still raise microscopic diagnostic dilemmas, such as conditions that mimic malignancies, benign tumors with overlapping features and anecdotal lesions. A series of "lumps and bumps" of the tongue are presented together with suggested clues that can assist in reaching a correct diagnosis, emphasizing the importance of the clinico-pathological correlations.
http://bit.ly/2G7qH2u
HPV-Related Papillary Lesions of the Oral Mucosa: A Review
Abstract
Human papillomaviruses (HPVs) are causative of a group of clinically papillary lesions. The HPV-related lesions of the oral cavity include squamous papilloma, condyloma acuminatum, verruca vulgaris, and multifocal epithelial hyperplasia. Benign entities, such as verruciform xanthoma or giant cell fibroma, as well as malignancies, such as papillary squamous cell carcinoma and verrucous carcinoma, may be considered in the clinical and/or histologic differential diagnoses of these lesions. Mechanisms of infection, epidemiology, clinical presentations, histologic features, and differential diagnoses of the HPV-related oral pathologies are discussed. Current concepts of viral transmission, especially as pertaining to lesions in pediatric patients, and the impacts of HPV vaccination are reviewed.
http://bit.ly/2FYoPtE
Candidiasis: Red and White Manifestations in the Oral Cavity
Abstract
Candidiasis is a very common malady in the head neck region. This review will concentrate on intraoral, pharyngeal and perioral manifestations and treatment. A history of the origins associated with candidiasis will be introduced. In addition, oral conditions associated with candidiasis will be mentioned and considered. The various forms of oral and maxillofacial candidiasis will be reviewed to include pseudomembranous, acute, chronic, median rhomboid glossitis, perioral dermatitis, and angular cheilitis. At the end of this review the clinician will be better able to diagnose and especially treat candidal overgrowth of the oral facial region. Of particular interest to the clinician are the various treatment modalities with appropriate considerations for side effects.
http://bit.ly/2G7qMmO
Non-HPV Papillary Lesions of the Oral Mucosa: Clinical and Histopathologic Features of Reactive and Neoplastic Conditions
Abstract
Excluding human papillomavirus (HPV)-driven conditions, oral papillary lesions consist of a variety of reactive and neoplastic conditions and, on occasion, can herald internal malignancy or be part of a syndrome. The objectives of this paper are to review the clinical and histopathological features of the most commonly encountered non-HPV papillary conditions of the oral mucosa. These include normal anatomic structures (retrocuspid papillae, lingual tonsils), reactive lesions (hairy tongue, inflammatory papillary hyperplasia), neoplastic lesions (giant cell fibroma), lesions of unknown pathogenesis (verruciform xanthoma, spongiotic gingival hyperplasia) and others associated with syndromes (for instance Cowden syndrome) or representing paraneoplastic conditions (malignant acanthosis nigricans). Common questions regarding differential diagnosis, management, and diagnostic pitfalls are addressed, stressing the importance of clinico-pathologic correlation and collaboration.
http://bit.ly/2FUqLDk
Lumps and Bumps of the Gingiva: A Pathological Miscellany
Abstract
Lesions of the gingivae are amongst the commonest lesions seen in patients and the vast majority are reactive hyperplasias, related to a number of chronic irritant stimuli. However, there are a number of entities that have a predilection for the gingivae, which are much less common in other parts of the oral cavity. The purpose of this paper is to discuss the clinical and histological differential diagnoses when presented with a lump on the gingivae, including the approach to diagnosis and diagnostic pitfalls.
http://bit.ly/2FWagql
Erythematous and Vascular Oral Mucosal Lesions: A Clinicopathologic Review of Red Entities
Abstract
Erythematous lesions of the oral mucosa are common and can reflect a variety of conditions, ranging from benign reactive or immunologically-mediated disorders to malignant disease. Together with vascular abnormalities, which can vary from reddish to bluish-purple in color, the differential diagnosis for erythematous oral mucosal change is quite diverse. This review focuses on salient clinical features and histopathologic findings of selected conditions which clinically present as red or vascular-like oral mucosal alterations, including oral vascular malformations and neoplasms, pyogenic granuloma, localized juvenile spongiotic gingival hyperplasia, denture stomatitis, benign migratory glossitis (geographic tongue), orofacial granulomatosis, granulomatosis with polyangiitis (Wegener granulomatosis), megaloblastic anemia, and erythroplakia. Recognition of the characteristic clinical features of these conditions, in conjunction with thorough patient history, will allow clinicians to narrow the differential diagnosis and guide appropriate clinical decision making, including the need for tissue biopsy, in order to complete the diagnostic process and initiate optimal patient care.
http://bit.ly/2G7qUmo
Black and Brown Oro-facial Mucocutaneous Neoplasms
Abstract
Black and brown-colored mucocutaneous lesions present a differential diagnostic challenge, with malignant melanoma being the primary clinical concern. The vast majority of pigmented lesions in the head and neck region are the result of benign, reactive factors such as post-inflammatory melanosis. However, it is not uncommon to discover a range of muco-cutaneous black and brown neoplasms in the oro-facial area. The majority of black/brown pigmented neoplasms are melanocytic in origin; these are neoplasms of neural crest derivation. Melanocytic nevi are a diverse group of benign neoplasms that are the result of specific oncogenic mutations. They are common on cutaneous surfaces but can manifest in mucosal sites. Currently, nevi are classified based on clinical and histological criteria. The most common cutaneous and oral mucosal nevus is the acquired melanocytic nevus; nevi do not pose an increased risk for the development of malignant melanoma. Emerging information on specific genetic differences supports the notion of biologically distinct nevi. This article will review the classic clinical and microscopic features of nevi commonly found in the head and neck region, and discuss emerging concepts in nevus pathogenesis and taxonomy. Melanoma is a malignant melanocytic neoplasm and is a result of cumulative genetic deregulation. The etiology of malignant melanoma (MM) is multifactorial and includes underlying genetic susceptibility, UV radiation, skin-type, and race. The majority of MM occurs on cutaneous surfaces and less commonly on mucosal and extra-cutaneous visceral organs. Regardless of location, MM exhibits clinical-pathological features that relate to horizontal or vertical tumor spread. Cutaneous and mucosal MM typically present as asymmetrical, irregularly bordered, large (> 0.5 cm), heterogeneous brown-black lesions with foci of erythema, atrophy or ulceration. As with melanocytic nevi, advances in melanomagenesis research have revealed primary oncogenic BRAF and NRAS mutations associated with cutaneous MM. Unlike their cutaneous counterparts, mucosal melanomas exhibit primary oncogenic alterations in c-KIT and other genes. This article will discuss the role of specific primary oncogenic and secondary/tertiary genetic defects in differential clinical presentation, anatomic distribution, future classification changes, and targeted therapy of melanoma. The clinical and microscopic features of mucosal melanomas and a summary of management guidelines will be discussed. Additionally, this article will cover the salient features of melanocytic neuroectodermal tumor of infancy, a neoplastic entity that can involve the oro-facial region, and the clinical-pathological features of selected, commonly occurring pigmented ectodermally-derived neoplasms that are often part of the clinical differential diagnosis of black–brown pigmented lesions.
http://bit.ly/2G6YR6q
A Guide to Yellow Oral Mucosal Entities: Etiology and Pathology
Abstract
When faced with an uncertain clinical pathosis in the oral cavity, identifying the color of the mucosal lesion helps to narrow down a differential diagnosis. Although less common than red and white lesions, yellow lesions encompass a small group of distinct mucosal pathologic entities. Adipose tissue, lymphoid tissue, and sebaceous glands are naturally occurring yellow constituents of the oral cavity and become apparent with associated developmental or neoplastic lesions. Reactive and inflammatory lesions can create a yellow hue due to purulence, necrosis, and calcification. Some systemic diseases are known to deposit yellow bi-products such as amyloid or bilirubin into the oral mucosa of an affected person, and while not always yellow, unusual entities like verruciform xanthoma and granular cell tumor fall under the umbrella of yellow lesions given their occasional propensity to demonstration the color. This chapter aims to explore the unique group that is yellow lesions presenting in the oral mucosa.
http://bit.ly/2TfsKp2
Black and Brown Oro-facial Mucocutaneous Neoplasms
Abstract
Black and brown-colored mucocutaneous lesions present a differential diagnostic challenge, with malignant melanoma being the primary clinical concern. The vast majority of pigmented lesions in the head and neck region are the result of benign, reactive factors such as post-inflammatory melanosis. However, it is not uncommon to discover a range of muco-cutaneous black and brown neoplasms in the oro-facial area. The majority of black/brown pigmented neoplasms are melanocytic in origin; these are neoplasms of neural crest derivation. Melanocytic nevi are a diverse group of benign neoplasms that are the result of specific oncogenic mutations. They are common on cutaneous surfaces but can manifest in mucosal sites. Currently, nevi are classified based on clinical and histological criteria. The most common cutaneous and oral mucosal nevus is the acquired melanocytic nevus; nevi do not pose an increased risk for the development of malignant melanoma. Emerging information on specific genetic differences supports the notion of biologically distinct nevi. This article will review the classic clinical and microscopic features of nevi commonly found in the head and neck region, and discuss emerging concepts in nevus pathogenesis and taxonomy. Melanoma is a malignant melanocytic neoplasm and is a result of cumulative genetic deregulation. The etiology of malignant melanoma (MM) is multifactorial and includes underlying genetic susceptibility, UV radiation, skin-type, and race. The majority of MM occurs on cutaneous surfaces and less commonly on mucosal and extra-cutaneous visceral organs. Regardless of location, MM exhibits clinical-pathological features that relate to horizontal or vertical tumor spread. Cutaneous and mucosal MM typically present as asymmetrical, irregularly bordered, large (> 0.5 cm), heterogeneous brown-black lesions with foci of erythema, atrophy or ulceration. As with melanocytic nevi, advances in melanomagenesis research have revealed primary oncogenic BRAF and NRAS mutations associated with cutaneous MM. Unlike their cutaneous counterparts, mucosal melanomas exhibit primary oncogenic alterations in c-KIT and other genes. This article will discuss the role of specific primary oncogenic and secondary/tertiary genetic defects in differential clinical presentation, anatomic distribution, future classification changes, and targeted therapy of melanoma. The clinical and microscopic features of mucosal melanomas and a summary of management guidelines will be discussed. Additionally, this article will cover the salient features of melanocytic neuroectodermal tumor of infancy, a neoplastic entity that can involve the oro-facial region, and the clinical-pathological features of selected, commonly occurring pigmented ectodermally-derived neoplasms that are often part of the clinical differential diagnosis of black–brown pigmented lesions.
http://bit.ly/2G6YR6q
HPV-Related Papillary Lesions of the Oral Mucosa: A Review
Abstract
Human papillomaviruses (HPVs) are causative of a group of clinically papillary lesions. The HPV-related lesions of the oral cavity include squamous papilloma, condyloma acuminatum, verruca vulgaris, and multifocal epithelial hyperplasia. Benign entities, such as verruciform xanthoma or giant cell fibroma, as well as malignancies, such as papillary squamous cell carcinoma and verrucous carcinoma, may be considered in the clinical and/or histologic differential diagnoses of these lesions. Mechanisms of infection, epidemiology, clinical presentations, histologic features, and differential diagnoses of the HPV-related oral pathologies are discussed. Current concepts of viral transmission, especially as pertaining to lesions in pediatric patients, and the impacts of HPV vaccination are reviewed.
http://bit.ly/2FYoPtE
Candidiasis: Red and White Manifestations in the Oral Cavity
Abstract
Candidiasis is a very common malady in the head neck region. This review will concentrate on intraoral, pharyngeal and perioral manifestations and treatment. A history of the origins associated with candidiasis will be introduced. In addition, oral conditions associated with candidiasis will be mentioned and considered. The various forms of oral and maxillofacial candidiasis will be reviewed to include pseudomembranous, acute, chronic, median rhomboid glossitis, perioral dermatitis, and angular cheilitis. At the end of this review the clinician will be better able to diagnose and especially treat candidal overgrowth of the oral facial region. Of particular interest to the clinician are the various treatment modalities with appropriate considerations for side effects.
http://bit.ly/2G7qMmO
Non-HPV Papillary Lesions of the Oral Mucosa: Clinical and Histopathologic Features of Reactive and Neoplastic Conditions
Abstract
Excluding human papillomavirus (HPV)-driven conditions, oral papillary lesions consist of a variety of reactive and neoplastic conditions and, on occasion, can herald internal malignancy or be part of a syndrome. The objectives of this paper are to review the clinical and histopathological features of the most commonly encountered non-HPV papillary conditions of the oral mucosa. These include normal anatomic structures (retrocuspid papillae, lingual tonsils), reactive lesions (hairy tongue, inflammatory papillary hyperplasia), neoplastic lesions (giant cell fibroma), lesions of unknown pathogenesis (verruciform xanthoma, spongiotic gingival hyperplasia) and others associated with syndromes (for instance Cowden syndrome) or representing paraneoplastic conditions (malignant acanthosis nigricans). Common questions regarding differential diagnosis, management, and diagnostic pitfalls are addressed, stressing the importance of clinico-pathologic correlation and collaboration.
http://bit.ly/2FUqLDk
Tongue Lumps and Bumps: Histopathological Dilemmas and Clues for Diagnosis
Abstract
Exophytic lesions of the tongue encompass a diverse spectrum of entities. These are most commonly reactive, arising in response to local trauma but can also be neoplastic of epithelial, mesenchymal or miscellaneous origin. In most cases, the microscopic examination is likely to provide a straightforward diagnosis. However, some cases can still raise microscopic diagnostic dilemmas, such as conditions that mimic malignancies, benign tumors with overlapping features and anecdotal lesions. A series of "lumps and bumps" of the tongue are presented together with suggested clues that can assist in reaching a correct diagnosis, emphasizing the importance of the clinico-pathological correlations.
http://bit.ly/2G7qH2u
Lumps and Bumps of the Gingiva: A Pathological Miscellany
Abstract
Lesions of the gingivae are amongst the commonest lesions seen in patients and the vast majority are reactive hyperplasias, related to a number of chronic irritant stimuli. However, there are a number of entities that have a predilection for the gingivae, which are much less common in other parts of the oral cavity. The purpose of this paper is to discuss the clinical and histological differential diagnoses when presented with a lump on the gingivae, including the approach to diagnosis and diagnostic pitfalls.
http://bit.ly/2FWagql
Influence of the Maillard Reaction on the Allergenicity of Food Proteins and the Development of Allergic Inflammation
Abstract
Purpose of Review
The Maillard reaction (MR) is a non-enzymatic reaction between reducing sugars and compounds with free amino groups such as proteins and takes place during thermal processing and storage of foods. This review aims to discuss potential effects of dietary MR products on the pathological mechanisms of allergic diseases.
Recent Findings
Since the MR leads to modification of proteins with various types of glycation structures, the impact of the MR on the immunogenicity and potential allergenicity of food proteins in many allergenic foods has been assessed. In addition, recent studies have suggested that the MR products, in particular "advanced glycation end products (AGEs)," contained in the diet may be involved in the development of chronic inflammation by acting as inflammatory components and affecting the gut microbiome.
Summary
This review found that the biological, immunological, and allergic properties of dietary MR products are diverse due to the complexity of the MR.
http://bit.ly/2B7oCAp
Next-Generation Approaches for the Treatment of Food Allergy
Abstract
Purpose of Review
IgE-mediated food allergies are an increasing health concern, and current management includes food avoidance and use of emergency medications. Effective treatment of food allergy is highly desirable. Next generation approaches for the treatment of food allergy aim to improve both safety and efficacy, potentially including long-term tolerance.
Recent Findings
Oral immunotherapy (OIT) and epicutaneous immunotherapy (EPIT) will likely be integrated into clinical practice as part of food allergy management in the near future. Newer approaches, such as sublingual immunotherapy (SLIT), modified proteins, lysosomal-associated membrane protein DNA (LAMP DNA) vaccines, and the use of immunomodulatory agents, are early in development and depending on results, could also become important treatment options.
Summary
This is a review of novel approaches to the treatment of food allergy that are currently under investigation, including the use of SLIT, modified proteins, probiotics, Chinese herbal supplements, biologic therapies, and DNA vaccines, as well as a summary of the current status of OIT and EPIT.
http://bit.ly/2Tgz53j
Comment on: ‘Treatment of psoriasis with ustekinumab in a patient with HIV‐related Kaposi sarcoma’
Abstract
We read with great interest the recent article by Wang et al.1 reporting on a psoriatic patient co‐affected by HIV‐related Kaposi's sarcoma (KS), whose poorly controlled psoriasis was successfully treated with ustekinumab, a fully monoclonal antibody that targets the common p40 subunit shared by interleukins (IL)‐12 and IL‐23. Interestingly, despite the evidences supporting the role of IL‐12 in inhibiting tumorigenesis,2 the authors reported no KS progression after a 16‐month follow‐up.
This article is protected by copyright. All rights reserved.
http://bit.ly/2TltEjC
Vulvar squamous cell carcinoma: a clinico‐dermoscopic correlation
Abstract
Squamous cell carcinoma (SCC) is the most common malignant vulvar tumor.1 It primarily affects post‐menopausal women; its precursor lesions are vulvar intraepithelial neoplasia (VIN), in particular the "differentiated" subtype, and/or human papillomavirus (HPV) infection.1 The final diagnosis of vulvar SCC is made by histopathology, which is similar to that of SCC affecting other body areas, distinguishing between well differentiated forms and poorly differentiated tumors.
This article is protected by copyright. All rights reserved.
http://bit.ly/2BaxOEa
Liquid chromatography–mass spectrometry is effective for Analysis of Ergosterol in Fungus Infected Nails
Abstract
Background
The identification of onychomycosis is mainly based on clinical diagnosis with auxiliary diagnostic methods such as KOH microscopy, PAS staining, or mold culture. However, they are limited by the sensitivity and specificity of each type of method. Therefore, our aim is to develop a new test method using the common end product – ergosterol – test to see if it can be used as a new diagnostic tool.
Materials and Methods
We collected consecutive data from 20 subjects with nail problems. After the clinical diagnosis, the subjects received a KOH microscopy test and the extraction of specimens for the mass spectrometer test to check for the presence of ergosterol.
Results
Among the 20 cases collected, seven came out positive by the mass spectrometry test. Four of them were suspected as onychomycosis, whereas one of the remaining three subjects was presumed to be dry nail and the other two as onycholysis. It is obvious that it is easier for the mass spectrometer test to find composites.
Conversely, among the five clinically diagnosed onychomycosis, four came out positive by mass spectrometer whereas the other one was detected negative by KOH and mass spectrometer. Three other subjects were positive with KOH test with mass spectrometer test also resulting to be positive.
Conclusion
The detection of the presence of ergosterol by a mass spectrometer is one of the good tools for confirming onychomycosis. However, there is a need to conduct studies to verify the sensitivity and specificity of the mass spectrometer method.
This article is protected by copyright. All rights reserved.
http://bit.ly/2Tird1p
Eccrine Porocarcinoma in a patient with Schöpf–Schulz–Passarge syndrome
Abstract
Histological analysis of the lesion proved to be challenging. An initial punch biopsy showed an ulcerated tumour comprised of islands of monomorphic cells with duct formation pushed deep into the dermis, and a lace‐like pattern of infiltration. At this point a diagnosis of eccrine porocarcinoma was favoured over poroma due to the presence of desmoplastic response and focal infiltrative growth pattern.
This article is protected by copyright. All rights reserved.
http://bit.ly/2B8bmLD
A retrospective review of twelve patients with trichotillomania treated in a psychodermatology service
Summary
Trichotillomania is a condition characterised by the pulling of hair from anywhere on the body and is classified as an obsessive‐compulsive and related disorder. Patients with hair disorders are commonly referred to psychodermatology services, and can represent a management challenge. Few publications exist that report outcomes for patients with trichotillomania in real clinical practice. We report twelve such patients seen within our own psychodermatology service, who were managed using a variety of treatment strategies. The rate of defaulting of appointments was high, but improvements were seen in patients engaging with services.
This article is protected by copyright. All rights reserved.
http://bit.ly/2Tpc8vb
Lower limb cellulitis: low diagnostic accuracy and underdiagnosis of risk factors
Abstract
Accurate diagnosis and recognition of predisposing factors has been shown to be challenging in lower limb cellulitis. Assessment of 1746 consecutive cellulitis patients presenting to a UK university hospital showed increasing overdiagnosis with only 31.9% of referred patients with confirmed lower‐limb cellulitis between 2015‐2018. Recognition of at least one predisposing factor increased from 61% to 89% following introduction of more specific screening questions. This identified a need for better primary care dermatology education and the benefit of a proforma with specific screening questions for reversible predisposing factors for lower limb cellulitis.
This article is protected by copyright. All rights reserved.
http://bit.ly/2Bal1Bq
Comment on: ‘Treatment of psoriasis with ustekinumab in a patient with HIV‐related Kaposi sarcoma’
Abstract
We read with great interest the recent article by Wang et al.1 reporting on a psoriatic patient co‐affected by HIV‐related Kaposi's sarcoma (KS), whose poorly controlled psoriasis was successfully treated with ustekinumab, a fully monoclonal antibody that targets the common p40 subunit shared by interleukins (IL)‐12 and IL‐23. Interestingly, despite the evidences supporting the role of IL‐12 in inhibiting tumorigenesis,2 the authors reported no KS progression after a 16‐month follow‐up.
This article is protected by copyright. All rights reserved.
http://bit.ly/2TltEjC
Vulvar squamous cell carcinoma: a clinico‐dermoscopic correlation
Abstract
Squamous cell carcinoma (SCC) is the most common malignant vulvar tumor.1 It primarily affects post‐menopausal women; its precursor lesions are vulvar intraepithelial neoplasia (VIN), in particular the "differentiated" subtype, and/or human papillomavirus (HPV) infection.1 The final diagnosis of vulvar SCC is made by histopathology, which is similar to that of SCC affecting other body areas, distinguishing between well differentiated forms and poorly differentiated tumors.
This article is protected by copyright. All rights reserved.
http://bit.ly/2BaxOEa
Liquid chromatography–mass spectrometry is effective for Analysis of Ergosterol in Fungus Infected Nails
Abstract
Background
The identification of onychomycosis is mainly based on clinical diagnosis with auxiliary diagnostic methods such as KOH microscopy, PAS staining, or mold culture. However, they are limited by the sensitivity and specificity of each type of method. Therefore, our aim is to develop a new test method using the common end product – ergosterol – test to see if it can be used as a new diagnostic tool.
Materials and Methods
We collected consecutive data from 20 subjects with nail problems. After the clinical diagnosis, the subjects received a KOH microscopy test and the extraction of specimens for the mass spectrometer test to check for the presence of ergosterol.
Results
Among the 20 cases collected, seven came out positive by the mass spectrometry test. Four of them were suspected as onychomycosis, whereas one of the remaining three subjects was presumed to be dry nail and the other two as onycholysis. It is obvious that it is easier for the mass spectrometer test to find composites.
Conversely, among the five clinically diagnosed onychomycosis, four came out positive by mass spectrometer whereas the other one was detected negative by KOH and mass spectrometer. Three other subjects were positive with KOH test with mass spectrometer test also resulting to be positive.
Conclusion
The detection of the presence of ergosterol by a mass spectrometer is one of the good tools for confirming onychomycosis. However, there is a need to conduct studies to verify the sensitivity and specificity of the mass spectrometer method.
This article is protected by copyright. All rights reserved.
http://bit.ly/2Tird1p
Eccrine Porocarcinoma in a patient with Schöpf–Schulz–Passarge syndrome
Abstract
Histological analysis of the lesion proved to be challenging. An initial punch biopsy showed an ulcerated tumour comprised of islands of monomorphic cells with duct formation pushed deep into the dermis, and a lace‐like pattern of infiltration. At this point a diagnosis of eccrine porocarcinoma was favoured over poroma due to the presence of desmoplastic response and focal infiltrative growth pattern.
This article is protected by copyright. All rights reserved.
http://bit.ly/2B8bmLD
A retrospective review of twelve patients with trichotillomania treated in a psychodermatology service
Summary
Trichotillomania is a condition characterised by the pulling of hair from anywhere on the body and is classified as an obsessive‐compulsive and related disorder. Patients with hair disorders are commonly referred to psychodermatology services, and can represent a management challenge. Few publications exist that report outcomes for patients with trichotillomania in real clinical practice. We report twelve such patients seen within our own psychodermatology service, who were managed using a variety of treatment strategies. The rate of defaulting of appointments was high, but improvements were seen in patients engaging with services.
This article is protected by copyright. All rights reserved.
http://bit.ly/2Tpc8vb
Lower limb cellulitis: low diagnostic accuracy and underdiagnosis of risk factors
Abstract
Accurate diagnosis and recognition of predisposing factors has been shown to be challenging in lower limb cellulitis. Assessment of 1746 consecutive cellulitis patients presenting to a UK university hospital showed increasing overdiagnosis with only 31.9% of referred patients with confirmed lower‐limb cellulitis between 2015‐2018. Recognition of at least one predisposing factor increased from 61% to 89% following introduction of more specific screening questions. This identified a need for better primary care dermatology education and the benefit of a proforma with specific screening questions for reversible predisposing factors for lower limb cellulitis.
This article is protected by copyright. All rights reserved.
http://bit.ly/2Bal1Bq
Effects of Musical Training and Hearing Loss on Fundamental Frequency Discrimination and Temporal Fine Structure Processing: Psychophysics and Modeling
Abstract
Several studies have shown that musical training leads to improved fundamental frequency (F0) discrimination for young listeners with normal hearing (NH). It is unclear whether a comparable effect of musical training occurs for listeners whose sensory encoding of F0 is degraded. To address this question, the effect of musical training was investigated for three groups of listeners (young NH, older NH, and older listeners with hearing impairment, HI). In a first experiment, F0 discrimination was investigated using complex tones that differed in harmonic content and phase configuration (sine, positive, or negative Schroeder). Musical training was associated with significantly better F0 discrimination of complex tones containing low-numbered harmonics for all groups of listeners. Part of this effect was caused by the fact that musicians were more robust than non-musicians to harmonic roving. Despite the benefit relative to their non-musicians counterparts, the older musicians, with or without HI, performed worse than the young musicians. In a second experiment, binaural sensitivity to temporal fine structure (TFS) cues was assessed for the same listeners by estimating the highest frequency at which an interaural phase difference was perceived. Performance was better for musicians for all groups of listeners and the use of TFS cues was degraded for the two older groups of listeners. These findings suggest that musical training is associated with an enhancement of both TFS cues encoding and F0 discrimination in young and older listeners with or without HI, although the musicians' benefit decreased with increasing hearing loss. Additionally, models of the auditory periphery and midbrain were used to examine the effect of HI on F0 encoding. The model predictions reflected the worsening in F0 discrimination with increasing HI and accounted for up to 80 % of the variance in the data.
http://bit.ly/2SdY0au
“To Biologic or Not to Biologic?: The Question of Cost-Effectiveness”
As of 2018, the FDA had approved five biologics for the treatment of asthma – omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab. All five of these biologics are designated for the treatment of severe asthma in patients with a TH2-driven phenotype, either allergic or eosinophilic. In clinical trials, biologics have demonstrated efficacy to decrease the frequency of asthma exacerbations, unplanned health utilization including ED visits and hospitalizations, and chronic oral steroid use in severe asthmatic patients1.
http://bit.ly/2sRvUnp
Economic burden of food allergy- A systematic review
Food allergy (FA) is a life-threatening condition that is a growing health concern worldwide. Currently in the United States, 8% of children have a parent-reported FA.1 Much of the epidemiological work on FA has focused primarily on children; however, recent estimates have found that 10.8% of adults in the US have a self-reported FA.2 Furthermore, numerous studies have estimated the prevalence of FA in children from countries across Europe including France (6.7%),3 Greece (5.2%),4 and Sweden (6.8%).
http://bit.ly/2MDDFpX
Effects of Musical Training and Hearing Loss on Fundamental Frequency Discrimination and Temporal Fine Structure Processing: Psychophysics and Modeling
Abstract
Several studies have shown that musical training leads to improved fundamental frequency (F0) discrimination for young listeners with normal hearing (NH). It is unclear whether a comparable effect of musical training occurs for listeners whose sensory encoding of F0 is degraded. To address this question, the effect of musical training was investigated for three groups of listeners (young NH, older NH, and older listeners with hearing impairment, HI). In a first experiment, F0 discrimination was investigated using complex tones that differed in harmonic content and phase configuration (sine, positive, or negative Schroeder). Musical training was associated with significantly better F0 discrimination of complex tones containing low-numbered harmonics for all groups of listeners. Part of this effect was caused by the fact that musicians were more robust than non-musicians to harmonic roving. Despite the benefit relative to their non-musicians counterparts, the older musicians, with or without HI, performed worse than the young musicians. In a second experiment, binaural sensitivity to temporal fine structure (TFS) cues was assessed for the same listeners by estimating the highest frequency at which an interaural phase difference was perceived. Performance was better for musicians for all groups of listeners and the use of TFS cues was degraded for the two older groups of listeners. These findings suggest that musical training is associated with an enhancement of both TFS cues encoding and F0 discrimination in young and older listeners with or without HI, although the musicians' benefit decreased with increasing hearing loss. Additionally, models of the auditory periphery and midbrain were used to examine the effect of HI on F0 encoding. The model predictions reflected the worsening in F0 discrimination with increasing HI and accounted for up to 80 % of the variance in the data.
http://bit.ly/2SdY0au
Predictors of time to relapse following ustekinumab withdrawal in patients with psoriasis who had responded to therapy: An eight-year multicenter study
1. The vast majority of patients with psoriasis flared after stopping ustekinumab treatment. Treatment response, patient characteristics and use of immunosuppressants after cessation of ustekinumab were predictors of time to relapse while off ustekinumab.2. Given high rates of psoriasis relapse, withdrawal of ustekinumab cannot be recommended.
http://bit.ly/2S7vPtZ
Patient Satisfaction with the Veteran’s Administration Teledermatology Service
This study adds to the limited fund of knowledge regarding patient attitudes towards and satisfaction with teledermatology services. Patients who struggle with access to advanced dermatologic care should be encouraged to consider teledermatology, as they are highly satisfied across multiple consult outcomes.
http://bit.ly/2S7HKYI
Role of imaging in low grade cutaneous B-cell lymphoma presenting in the skin
•Whole body imaging is the current standard of care as part of staging work-up for all patients presenting with skin lesion(s) of B-cell lymphomas, however the incidence of extracutaneous involvement in indolent cutaneous B-cell lymphoma is unknown. Imaging is effective in identifying the small subset of patients with systemic involvement at staging. After negative initial staging, primary cutaneous marginal zone lymphoma patients may be followed clinically without routine imaging.
http://bit.ly/2HzkPBh
Risk Factors for Keratinocyte Carcinoma Skin Cancer In Nonwhite Individuals: A Retrospective Analysis
The presence of a single skin cancer lesion in a nonwhite individual may be associated with greater morbidity and mortality than in a White patient. Emphasize skin examination and increased vigilance of sun-protected areas in nonwhite patients, particularly the anogenital area, and counsel all patients on smoking cessation.
http://bit.ly/2S7vvvh
Patient-Reported Outcomes are Important Elements of Psoriasis Treatment Decision Making: A Discrete Choice Experiment Survey of Dermatologists in the United States
•Physician-evaluated measures of psoriasis severity are the primary assessments in psoriasis trials; however, U.S. dermatologists also consider patient-reported outcome (PRO) data when selecting a biologic for moderate-to-severe psoriasis patients PRO evaluations should be integrated into psoriasis clinical trials to obtain the information needed to facilitate treatment decision making
http://bit.ly/2HBhKRj
Treatment of Morphea With Hydroxychloroquine: A Retrospective Review of 84 Patients at Mayo Clinic, 1996-2013
Data are sparse on the efficacy of hydroxychloroquine as therapy for morphea. Of our 84 patients, 81% had a complete response or a partial response greater than 50% to hydroxychloroquine. Hydroxychloroquine should be considered a treatment option for morphea.
http://bit.ly/2SgbWRi
Treatment and survival of Merkel cell carcinoma since 1993: a population-based cohort study in the Netherlands
•Merkel cell carcinoma (MCC) is a potentially lethal skin-cancer with a rapidly increasing incidence in the Netherlands. The 5-year survival of 63% did not improve over time and is worse for males, elderly and advanced disease. Our results emphasise need for implementation of new therapies and research in this field.
http://bit.ly/2S7T1IB
Age as key factor for pattern, timing and extent of distant metastasis in patients with cutaneous melanoma. A study of the German Central Malignant Melanoma Registry
•Older age correlates with better response to immunotherapy in stage IV melanoma patients but the impact of aging on distant metastasis is unclear. This study found an inverse relationship between age at diagnosis and the number of metastatic sites; these findings may have implications for optimizing outcomes of melanoma patients.
http://bit.ly/2HCW6MN
Modeling the relationship between gross capital formation and CO 2 (a)symmetrically in the case of Pakistan: an empirical analysis through NARDL approach
Abstract
This paper tries to ensure the relationship between gross capital formation (GCF) and carbon dioxide (CO2) emissions in the case of Pakistan for the period 1980–2016 by employing Non-Linear Auto Regressive Distribution Lag (NARDL) model under the expansion of Environmental Kuznets hypothesis (EKC) while controlling for coal and oil consumption variables as a potential factors of CO2 emissions. Our main objective is to check whether or not the effect of changes in GCF on CO2 emissions is asymmetric or symmetric for Pakistan that is among one of the main contributors to CO2 emissions in Asia, as the emissions were grown by 15.6 million tonnes or 8.5% increase in percentage terms in 2016. Our result confirms the existence of an asymmetric effect of GCF shocks on CO2 emissions both in the short and long-terms. Moreover, our empirical finding also suggests that coal and oil consumptions have a significant contribution to CO2 emissions both in the short and long-terms. Further, our results also significantly support the existence of the EKC hypothesis both in the long and short-terms. That confirms the inverted U-shaped connection among per capita growth and CO2 emissions in Pakistan. In the last, our study suggests that the implementation and use of clean energies and technologies are vital for controlling pollution in Pakistan.
http://bit.ly/2Rn4TSt
Factors associated with suicidal ideation risk in head and neck cancer: A longitudinal study
Objectives/Hypothesis
The risk factors associated with suicidal ideation among patients with head and neck cancer (HNC) have rarely been investigated. Thus, this study proposed an effective screening model to facilitate the identification of patients with HNC who are at risk of committing suicide.
Study Design
Retrospective longitudinal study.
Methods
We recruited 286 inpatients with HNC who were referred to the psychiatry department for an emotional distress assessment during cancer treatment. Sociodemographic and clinical factors, as well as Distress Thermometer (DT) scoring, were gathered and analyzed using multivariate logistic regression.
Results
Among the patients, 27 (9.4%) were recognized as having suicidal ideation. A logistic regression analysis revealed five significant indicators associated with suicidal ideation, namely depression (odds ratio [OR]: 42.83), dysphoria (OR: 8.06), hypopharyngeal cancer (OR: 4.61), cancer history (OR: 4.53), and average DT scores (OR: 1.84). Based on the receiver operating characteristic and logistic regression, the model can predict suicidal ideation with 93.4% accuracy (area under the curve value).
Conclusions
Our findings provide strong evidence that patients with depression, hypopharyngeal cancer, higher DT scores, and previous cancer history can be quickly screened for suicidal ideation, which may help to prevent suicide events in patients with HNC.
Level of Evidence
3b Laryngoscope, 2019
http://bit.ly/2TgGQ9u
Phytoremediation potential and control of Phragmites australis as a green phytomass: an overview
Abstract
Phragmites australis (common reed) is one of the most extensively distributed emergent plant species in the world. This plant has been used for phytoremediation of different types of wastewater, soil, and sediments since the 1970s. Published research confirms that P. australis is a great accumulator for different types of nutrients and heavy metals than other aquatic plants. Therefore, a comprehensive review is needed to have a better understanding of the suitability of this plant for removal of different types of nutrients and heavy metals. This review investigates the existing literature on the removal of nutrients and heavy metals from wastewater, soil, and sediment using P. australis. In addition, after phytoremediation, P. australis has the potential to be used for additional benefits such as the production of bioenergy and animal feedstock due to its specific characteristics. Determination of adaptive strategies is vital to reduce the invasive growth of P. australis in the environment and its economic effects. Future research is suggested to better understand the plant's physiology and biochemistry for increasing its pollutant removal efficiency.
http://bit.ly/2G43wWR
The impact of sustainability performance indicators on financial stability: evidence from the Russian oil and gas industry
Abstract
Considering the dearth of research on the impact of sustainability reporting practices on financial stability in the context of transition economies, this study aims to explore sustainability reporting practices of top oil and gas companies in Russia and investigate the effects of sustainability performance indicators on financial stability in the context of a given emerging economy. The study is based on panel data analysis of sustainability performance indicators and financial data of forty-five largest oil and gas companies listed on the Russian Trading Stock Exchange over the period 2012–2016. Data on sustainability performance were collected through analyzing sustainability reports and annual reports, while financial data were obtained from audited financial statements downloaded from company websites. The empirical results indicate that companies improve their sustainability performance indicators in order to manage risk and improve their financial stability. The results also show that firm-specific characteristics, such as financial capacity, leverage, firm size, and firm age, are important underlying factors affecting the degree of financial distress and financial stability. The findings of the study provide managers and practitioners with useful aspects of sustainability performance indicators to improve financial stability and mitigate financial distress. Additionally, investors and practitioners should consider other underlying factors, including financial capacity, leverage, firm size, and firm age, that may influence financial stability. Finally, the findings are useful for policymakers and regulators in promoting Global Reporting Initiative guidelines which will ultimately lead to sustainable development and financial stability in the context of emerging markets.
http://bit.ly/2FTEPNt
Seasonal ecotoxicological monitoring of freshwater zooplankton in Bir Mcherga dam (Tunisia)
Abstract
Dams represent large semi-closed reservoirs of pesticides and various organic and inorganic pollutants from agricultural and human activities, and their monitoring should receive special attention. This study evaluated the environmental health status of Bir Mcherga dam using zooplankton species. The dam has a capacity of 130 Mm3 and its waters are used for irrigation, water drinking supply, and fishery. Copepods and cladocerans (crustaceans) were collected in situ monthly between October and August 2012. Oxidative stress (CAT, MDA), neurotoxicity (AChE), and genotoxicity (micronucleus test) biomarkers were analyzed in two zooplankton species: Acanthocyclops robustus and Diaphanosoma mongolianum. High values of cells with a micronucleus were observed during summer. AChE activities were inhibited during early winter and summer. The high seasonal variability of CAT and MDA levels indicates that zooplankton is continuously exposed to different oxidative stresses. These results suggest that there is an obvious and continuous multi-faceted stress in Bir Mcherga reservoir and, consequently, an urgent monitoring of freshwater environments in Tunisia is needed, particularly those intended for human consumption and irrigation.
http://bit.ly/2RSlkv8
Effect of Vicia faba L. var. minor and Sulla coronaria (L.) Medik associated with plant growth-promoting bacteria on lettuce cropping system and heavy metal phytoremediation under field conditions
Abstract
Researches involving the use of association between legumes and PGPBs (plant growth-promoting bacteria) in heavy metal phytoremediation process were mainly performed for soils highly contaminated. However, even in agriculture soils, with moderate or low contamination levels, plants can accumulate high rates of heavy metals. So, food chain contamination by these metals presents a real threat to animal and human health. This work aimed to evaluate the use of two legumes/PGPB symbioses; Vicia faba var. minor and Sulla coronaria have been inoculated with specific heavy metal-resistant inocula in a crop rotation system with Lactuca sativa as a following crop, in order to assess their effects on soil fertility, lettuce yield, and heavy metal content. Our results showed that legume inoculation significantly enhanced their biomass production, nitrogen and phosphorus content. The use of our symbioses as green manure before lettuce cultivation, as a rotation cropping system, affected positively soil fertility. In fact, we recorded a higher organic matter content, with rapid decomposition in the soil of inoculated plots. Besides, results demonstrated a greater nitrogen and phosphorus content in this soil, especially in the plot cultivated with inoculated V. faba var. minor. The improvement of soil fertility enhanced lettuce yield and its nitrogen and phosphorus content. Moreover, inoculated legumes extracted and accumulated more heavy metals than non-inoculated legumes. Our symbioses play the role of organic trap for heavy metals, making them unavailable for following crops. These facts were supported by lettuce heavy metal content, showing a significant decrease in metal accumulation, mainly zinc and cadmium, in edible parts. Results showed the usefulness of the studied symbioses, as a main part of a rotation system with lettuce. Our symbioses can be suggested for agriculture soil phytoremediation, aiming to enhance non-legume crop yield and limit heavy metal translocation to food chain.
http://bit.ly/2CPGrnu
Improved Jayaweera-Mikkelsen model to quantify ammonia volatilization from rice paddy fields in China
Abstract
Current estimates of China's ammonia (NH3) volatilization from paddy rice differ by more than twofold, mainly due to inappropriate application of chamber-based measurements and improper assumptions within process-based models. Here, we improved the Jayaweera-Mikkelsen (JM) model through multiplying the concentration of aqueous NH3 in ponded water by an activity coefficient that was determined based on high-frequency flux observations at Jingzhou station in Central China. We found that the improved JM model could reproduce the dynamics of observed NH3 flux (R2 = 0.83, n = 228, P < 0.001), while the original JM model without the consideration of activity of aqueous NH3 overstated NH3 flux by 54% during the periods of fertilization and pesticide application. The validity of the improved JM model was supported by a mass-balance-based indirect estimate at Jingzhou station and the independent flux observations from the other five stations across China. The NH3 volatilization losses that were further simulated by the improved JM model forced by actual wind speed were in general a half less than previous chamber-based estimates at six stations. Difference in wind speed between the inside and outside of the chamber and insufficient sampling frequency were identified as the primary and secondary causes for the overestimation in chamber-based estimations, respectively. Together, our findings suggest that an in-depth understanding of NH3 transfer process and its robust representation in models are critical for developing regional emission inventories and practical mitigation strategies of NH3.
http://bit.ly/2Biu43B
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