Subcutaneous methotrexate in patients with moderate to severe psoriasis: a critical appraisal

Summary

Aim

Warren et al¹ set out to assess the effect of an intensified dosing schedule of subcutaneous methotrexate in patients with moderate to severe chronic plaque psoriasis.

Setting and design

This is a prospective, double-blind, randomised (3:1), placebo-controlled study, conducted across 16 centres in Germany, France, the Netherlands, and the UK.

Study exposure

Methotrexate-naïve adults with a diagnosis of moderate to severe chronic plaque psoriasis for at least 6 months before baseline were randomly assigned to receive weekly subcutaneous injections of either methotrexate at a starting dose of 17.5 mg, or placebo for 16 weeks (first phase).Dose escalation to 22.5 mg/week was implemented after 8 weeks if patients did not achieve PASI 50. Treatment was combined with folic acid 5 mg/week. The first phase of the study was followed by an open-label period from 16-52 weeks (second phase), in which both groups received weekly methotrexate injections. At week 24, dose escalation to 22.5 mg/week was possible in patients not achieving PASI 50.

Outcomes

Psoriasis severity was measured using the PASI (Psoriasis Area and Severity Index). The authors also used two other psoriasis severity measures and two quality of life measures, looked at safety indices and performed a sub-study analysing paired skin biopsies at baseline and week 16 (histopathology, immunohistochemistry and expression of interleukin (IL)17A, interferon-γ and tumour necrosis factor-α).

Primary outcome measures

The primary outcome was the proportion of patients reaching PASI 75 at week 16.

Results

120 patients were included in this trial, most of whom were middle-aged white men with longstanding psoriasis and a mean BMI of 30.1 kg/m². PASI 75 was achieved in 41% of patients receiving methotrexate vs. 10% of patients receiving placebo (RR 3.93, 95% CI 1.31–11.81; p=0.0026) at week 16. Subcutaneous methotrexate was generally well tolerated, with no serious adverse events related to this treatment over the 52-week study.

Conclusions

Warren et al conclude that the 52-week risk-benefit profile of subcutaneous methotrexate is favourable in patients with psoriasis.

This article is protected by copyright. All rights reserved.

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Oral retinoids and depression

Abstract

We are concerned about the content and possible misinterpretation of a research letter by Le Moigne et al. published on 19 June 2017 in the British Journal of Dermatology online.[1]

We share the concern expressed by the authors about possible psychiatric effects of oral retinoids. However, case reports rank low in the hierarchy of evidence, as a result of their inherent limitations, including publication bias and a lack of control groups.

This article is protected by copyright. All rights reserved.

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A new mobile learning module using smartphone wallpapers in identification of medical fungi for medical students and residents

Abstract

Introduction

Medical students and residents will encounter many cutaneous fungal infections in medical practice. However, the training for identification of medical fungi has been insufficient due to limited lecture-based courses. The objective of this study was to evaluate the impact of using smartphone-based wallpapers in learning the microscopic morphology and colony characteristics of medical fungi for medical students and residents.

Methods

A smartphone-based wallpaper learning module using a wallpaper-changing software application (app) was introduced in this 3-week training course. Twenty-six participants were enrolled and divided into two groups: nondermatology trainees, including medical students and postgraduate year one (PGY-1) doctors who have not yet specialized, and dermatology trainees (dermatology residents). All of the participants completed a 3-week training course, and the effectiveness of the module was evaluated by pre- and post-course multiple-choice examinations.

Results

Both nondermatology and dermatology trainees scored significantly higher in post-course examinations than pre-course examinations (P < 0.001). The dermatology trainees performed better than nondermatology trainees in the pre-course examinations (P < 0.001). In the post-course examinations, no significant difference in scores was noted between dermatology and nondermatology trainees (P = 0.573).

Discussion

The smartphone-based wallpaper learning module was effective in helping medical students and residents learn and memorize morphologic characteristics of fungi. In comparison to conventional lecture-based learning, this new mobile module was more readily accessible and convenient for learners to engage in learning.

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Disseminated actinomycetoma due to Nocardia wallacei

Abstract

Background

Actinomycetoma caused by Nocardia usually responds well to antibiotics. Emerging species of Nocardia, such as N. wallacei, can be a therapeutic challenge.

Aims

Confirm the therapeutic effectivity of linezolid in multidrug resistant Nocardia Wallacei actinomycetoma.

Materials and Methods

We evaluated the medical management of an 18-year-old man with multidrug resistant actinomycetoma of the left leg caused by N. transvalensis complex treated 17 years ago with linezolid 1200 mg a day. This bacteria was recently reclassified as Nocardia Wallacei by specific molecular biology technique.

Results

The infection was cured after 3 months of treatment; the patient remained asymptomatic for the past 17 years. No adverse effects were found.

Discussion

Frequently, strains of N. transvalensis complex have aminoglycoside resistance; in this case, we highlight the effectiveness of linezolid for the successful medical management of multidrug resistant actinomycetoma.

Conclusion

Linezolid can be an alternative for the treatment of multidrug resistant Nocardia Wallacei.

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Treatment response to omalizumab in patients with refractory chronic spontaneous urticaria

Abstract

Background

Previous clinical trials have demonstrated the efficacy and safety of the anti-IgE monoclonal antibody omalizumab in chronic spontaneous urticaria (CSU) not responding to antihistamine treatment. The primary aim of our study was to describe the response patterns of patients with refractory CSU treated with omalizumab in a real-world clinical setting.

Methods

A retrospective analysis of medical records of 20 patients with refractory CSU was performed. Demographic, clinical, and laboratory features were retrieved and analyzed in correlation with treatment data.

Results

Mean age of our patient population was 54.5 years, while the majority were females (15/20 cases, 75%). Mean disease duration prior to omalizumab administration was 21.8 months. All patients had a history of chronic urticaria, refractory to high antihistamine and corticosteroid treatment, and responded favorably to omalizumab after administration of 1–5 doses of omalizumab; complete response was observed in 17/20 patients (85%) and well-controlled disease in the remaining 3/20 patients (15%). In a subset of cases (6/20, 30%), best response to omalizumab was achieved after interval administration of a 9-day course of methylprednisolone (total dose of 188 mg). Late response to omalizumab (after three-month treatment) was significantly correlated (P = 0.026) with shorter disease duration before initiation of omalizumab.

Conclusion

In the present series, omalizumab, either alone or in combination with a short-term course of corticosteroids, was highly effective in resolution of refractory CSU. Furthermore, disease duration prior to omalizumab had a significant effect on timing of response.

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Role of Eustachian Dysfunction and Primary Sclerotic Mastoid Pneumatisation Pattern in Aetiology of Squamous Chronic Otitis Media: A Correlative Study

Abstract

Squamous chronic otitis media (COM) implies formation of a retraction pocket (inactive form) or frank cholesteatoma (active form) in pars tensa or pars flaccida of tympanic membrane. A retraction pocket or frank cholesteatoma are believed to occur due to tubal dysfunction. The present study was undertaken to investigate the pattern of mastoid pneumatisation and Eustachian dysfunction by dynamic slow motion videoendoscopy (DSVE) in cases of both, active and inactive type of squamous chronic otitis media (COM). 52 patients (65 ears) comprising of twenty-six ears with pars flaccida squamous disease and 39 ears with Pars Tensa squamous disease were enrolled for the study. DSVE findings, in terms of grade and type of Eustachian dysfunction were noted. Mastoid pneumatization pattern on CT-scans, and peroperative status of mastoid pneumatisation, especially contracted mastoid with anteriorly placed sigmoid sinus or low lying dura were also recorded for every case while performing tympano-mastoidectomy. Primary sclerotic/diploic type of mastoid pneumatisation pattern and Eustachian dysfunction were found to have inverse relationship in the cases of squamous otitis media. Eustachian dysfunction, diagnosed on DSVE, had significant association with both pars flaccida (P = 0.0001) and pars tensa disease (P = 0.0007). Primary sclerotic or diploic mastoid were found to be more common in ears with pars flaccida squamous disease than pars tensa COM (46.15% vs. 38.46%, P < 0.05).

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Phase 1/2 study assessing the safety and efficacy of dabrafenib and trametinib combination therapy in Japanese patients with BRAF V600 mutation-positive advanced cutaneous melanoma

Abstract

The combination of dabrafenib and trametinib demonstrated encouraging antitumor activity and tolerability, at initial analysis, in Japanese patients with BRAF V600 mutant advanced melanoma warranting further investigation. This study evaluated the safety and tolerability, pharmacokinetics (PK) and preliminary efficacy of dabrafenib 150 mg b.i.d. plus trametinib 2 mg q.d. in Japanese patients with BRAF V600E/K mutant solid tumors (phase 1) and melanoma (phase 2). Phase 1 was primarily intended to assess safety and tolerability as assessed by adverse events (AE), and the primary end-point in phase 2 was to assess confirmed overall response rate (ORR). The secondary end-points in phase 1 included PK, confirmed/unconfirmed ORR and duration of response (DOR). The secondary end-points in phase 2 were PK, unconfirmed ORR, DOR, safety and tolerability. A total of 12 cutaneous melanoma patients were enrolled in the study (six in phase 1 and six in phase 2) and received the combination therapy of dabrafenib and trametinib. Common AE (≥50.0%) included pyrexia (75%), increased aspartate aminotransferase (67%), peripheral edema (50%) and nasopharyngitis (50%). The investigator-assessed ORR was reported in five patients (83%) in phase 1 and was also reported in five patients (83%; 95% confidence interval, 35.9–99.6; P < 0.0001) in phase 2. Plasma concentrations of both dabrafenib and trametinib seemed to a reach steady state by week 3. Overall, efficacy and PK properties for the dabrafenib plus trametinib combination in Japanese patients were comparable with those seen in global studies.

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Efficacy of oral cholecalciferol on rhododendrol-induced vitiligo: A blinded randomized clinical trial

Abstract

Rhododendrol (RD), 4-(4-hydroxyphenyl)-2-butanol, inhibits melanin synthesis and has been used for skin-whitening cosmetic products. RD has been very effective in lightening skin pigmentation, but some persons have developed so-called RD vitiligo, in which vitiligo starts on the face, neck and hands where topical RD has been applied and even extended over skin areas where RD has not been applied. RD vitiligo lesions in some patients have lasted for years and have been resistant to conventional vitiligo treatments. We examined the effects of cholecalciferol on RD vitiligo in a blinded randomized clinical trial. Forty-eight female RD vitiligo patients were recruited for the trial and were randomized into two groups: the vitamin D (VD)-intervention group that received daily 5000 IU cholecalciferol for 5 months and the control group. Three blinded investigators scored vitiligo improvement by comparing photographic images of baseline and at 5-month observation. Serum 25(OH)D3 of RD vitiligo patients was not significantly different from age-matched healthy volunteers. Twenty-two in the VD-intervention group and 23 in the control group completed the 5-month observation. Serum 25(OH)D3 levels were significantly increased after the 5-month VD intervention, while the control group did not change. The improvement scores were significantly higher in the VD-intervention group than the control group. The improvement scores were positively correlated with the serum 25(OH)D3 levels after the 5-month intervention period but not before the treatment. This blinded randomized clinical trial showed favor in administrating 5000 IU cholecalciferol daily to RD vitiligo patients.

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Case of atopic dermatitis concurrent with idiopathic thrombocytopenic purpura, whose serum thymus and activation-regulated chemokine level remained undetectable

Abstract

We report a 9-year-old Japanese female patient with atopic dermatitis associated with idiopathic thrombocytopenic purpura. She demonstrated high serum immunoglobulin (Ig)E and IgE specific to several environmental allergens, but extremely low serum thymus and activation-regulated chemokine (TARC) levels regardless of the disease progression. This case suggests platelets as the main source of serum TARC.

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The Potential Role of Bile Acids in Acquired Laryngotracheal Stenosis

Objective

Gastroesophageal reflux is thought to be a risk factor for laryngotracheal stenosis. Bile acids are a component of gastric refluxate and have previously been implicated in the development of fibrosis in other airway subsites. There is clear evidence that bile acids reflux into the upper airway. We therefore investigated the potential role of bile acids in the pathophysiology of laryngotracheal fibrosis and stenosis, specifically investigating the highly conserved process of epithelial–mesenchymal transition (EMT).

Study Design

Translational research study.

Methods

Human primary tracheal epithelial cells (PTECs) were challenged with the four most common digestive bile acids (cholic, chenodeoxycholic, deoxycholic, and lithocholic). EMT markers transforming growth factor (TGF)-β1, Matrix metalloproteinase (MMP)-9, and procollagen proteins were measured in the supernatant at 48 hours via enzyme-linked immunosorbent assay. Real-time polymerase chain reaction was also used to measure E-cadherin and fibronectin expression.

Results

Significantly greater concentrations of TGF-β1 and MMP-9 were measured in the culture supernatants of cells treated with each bile acid at 10 µmol/L. Lithocholic acid and deoxycholic acid induced significantly increased expression of procollagen protein. Upregulation of fibronectin and downregulation of E-cadherin were observed with all bile acids, except for deoxycholic acid.

Conclusion

This is the first proof of principle demonstration that physiologically relevant bile acid challenge induces EMT mechanisms in PTECs. This implies a potential role for bile acids in laryngotracheal scarring and airway remodeling of potential translational significance in laryngotracheal stenosis.

Level of Evidence

NA. Laryngoscope, 00:000–000, 2018

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In Response to Should Infants Who Fail Their Newborn Hearing Screen Undergo Cytomegalovirus Testing?

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The survival impact of surgical therapy in squamous cell carcinoma of the hard palate

Objective

To describe the incidence and determinants of survival of patients with squamous cell carcinoma of the hard palate (SCCHP) between the years of 1973 to 2014 using the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

Retrospective, population-based cohort study of patients in the SEER tumor registry who were diagnosed with SCCHP from 1973 to 2014. Outcomes and measures included overall survival (OS) and disease-specific survival (DSS).

Results

A total of 1,489 cases of primary SCCHP were identified. Of those, 53.2% were females and 47.8% presented with stage IV disease. The mean age at diagnosis was 69.8 years. Overall survival at 2, 5, and 10 years was 44%, 33%, and 21%, respectively. A total of 66.2% of patients underwent surgery (with or without radiation therapy [RT]); 20.1% received RT; and 22.4% had both surgical and RT. On multivariate analysis, RT, advanced age, stage, and grade were associated with worse OS and DSS (P < 0.05). Surgical therapy (with or without radiation) was an independent favorable predictor of OS and DSS (P < 0.05).

Conclusion

SCCHP is relatively infrequent tumor that portends an overall poor prognosis when advanced stage and a greater prognosis when early stage. Surgical therapy was found to be an independent predictor for improved OS and DSS, whereas RT was associated with reduced OS and DSS.

Level of Evidence

4. Laryngoscope, 2018

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Stem cells enhance reperfusion following ischemia: Validation using laser speckle imaging in predicting tissue repair

Objectives

The lack of real-time assessment of vascular perfusion changes remains a major weakness in assessing the efficacy of bone marrow stromal cells (BMSC) therapeutic ischemia reperfusion (I/R) injury. This study provides for the first time the real-time in vivo perfusion monitoring in I/R mice with BMSC therapy.

Study Design

Animal model.

Methods

Surgically created cutaneous flaps perfused by the inferior epigastric vessels were subjected to 3.5 hours of ischemia/reperfusion. Wound healing and vascular perfusion were assessed by Image-J and laser speckle contrast analysis (LSCA) in three groups (sham, I/R, and I/R + BMSC). BMSC tracking was quantified in an additional two groups (with/without I/R) using intravital fluorescent microscopy. The histopathology of skin flaps was examined by hematoxylin and eosin stain. Infiltrated macrophages were analyzed by confocal immunofluorescent microscopy.

Results

Postischemic tissues treated with BMSC demonstrated significantly greater survival than I/R control. On days 3 to 7 postreperfusion, both proximal and distal areas in BMSC-treated flaps demonstrated greater levels of perfusion than untreated I/R flaps (P < 0.05). Intravital fluorescent microscopy revealed that numbers of labeled BMSC were significantly increased in the distal area compared to the proximal area in both with and without ischemic mice. Histological examination showed lower necrosis and infiltrated inflammatory cells in I/R + BMSC-treated mice versus I/R controls.

Conclusion

BMSC accumulated in I/R flaps and exerted beneficial effects including: 1) improving vascular perfusion and 2) attenuating inflammatory cell infiltration. LSCA facilitates monitoring of the real-time restitution of perfusion during flap wound healing in experimental animals and could also similarly applied in clinical investigations.

Level of Evidence

NA. Laryngoscope, 2018

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Circadian anosmia: A rare clinical presentation

We report the case of a 27-year-old female who presented with a peculiar story of anosmia fluctuating in a circadian manner. Olfactory function appeared an hour after breakfast, was normal during daytime, and disappeared in the early evening. Imaging confirmed chronic rhinosinusitis (CRS). Initial systemic, followed by topical steroid treatment, rapidly and sustainably reversed this condition. The olfactory fluctuation paralleled the endogenous steroid production. This suggests that slight congestion changes in a chronically inflamed nasal mucosa may have been sufficient to induce this circadian anosmia. The importance of identifying fluctuation of olfactory function as a sign of CRS is emphasized and discussed. Laryngoscope, 2018

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Double-blind, placebo-controlled study with alginate suspension for laryngopharyngeal reflux disease

Objective

Treatment for laryngopharyngeal reflux disease (LPRD) is challenging because of delays in recognition and poor responsiveness to proton-pump inhibitor therapy. The aim of this study was to determine the efficacy and safety of liquid alginate suspension for treating LPRD.

Methods

A double-blind, placebo-controlled, prospective study comparing 8 weeks of treatment with Alginos Oral Suspension (TTY Biopharm Co. Ltd., Taipei, Taiwan) (sodium alginate 1,000 mg three times daily) with a placebo was conducted on patients who fulfilled the criteria of at least one symptom consistent with LPRD, a total reflux symptom index (RSI) score of > 10, and a total reflux finding score (RFS) of > 5. Those with erosive gastroesophageal reflux disease, as evidenced through screened transnasal upper gastrointestinal endoscopy, were excluded. Efficacy was assessed by RSI, RFS, and ambulatory multichannel intraluminal impedance and pH (MII-pH) monitoring.

Results

A total of 80 patients aged 22 to 72 years were enrolled. Compared with baseline, both Alginos (TTY Biopharm Co. Ltd.) and the placebo significantly reduced the total RSI (P < 0.001) and the total number of reflux episodes shown by MII-pH monitoring (P < 0.05) after 8 weeks of treatment. However, liquid alginate suspension was unable to show superiority over the placebo. The incidence of various adverse events from Alginos (TTY Biopharm Co. Ltd.) was relatively low (7.7%) and mild.

Conclusion

This study showed that liquid alginate suspension was well tolerated by LPRD patients. It effectively improved symptoms and reflux numbers but was unable to show superiority over placebo. As observed in previous studies, a great placebo effect was present. The importance of lifestyle modification could not be overlooked.

Level of Evidence

2. Laryngoscope, 00:000–000, 2018

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Role of Eustachian Dysfunction and Primary Sclerotic Mastoid Pneumatisation Pattern in Aetiology of Squamous Chronic Otitis Media: A Correlative Study

Abstract

Squamous chronic otitis media (COM) implies formation of a retraction pocket (inactive form) or frank cholesteatoma (active form) in pars tensa or pars flaccida of tympanic membrane. A retraction pocket or frank cholesteatoma are believed to occur due to tubal dysfunction. The present study was undertaken to investigate the pattern of mastoid pneumatisation and Eustachian dysfunction by dynamic slow motion videoendoscopy (DSVE) in cases of both, active and inactive type of squamous chronic otitis media (COM). 52 patients (65 ears) comprising of twenty-six ears with pars flaccida squamous disease and 39 ears with Pars Tensa squamous disease were enrolled for the study. DSVE findings, in terms of grade and type of Eustachian dysfunction were noted. Mastoid pneumatization pattern on CT-scans, and peroperative status of mastoid pneumatisation, especially contracted mastoid with anteriorly placed sigmoid sinus or low lying dura were also recorded for every case while performing tympano-mastoidectomy. Primary sclerotic/diploic type of mastoid pneumatisation pattern and Eustachian dysfunction were found to have inverse relationship in the cases of squamous otitis media. Eustachian dysfunction, diagnosed on DSVE, had significant association with both pars flaccida (P = 0.0001) and pars tensa disease (P = 0.0007). Primary sclerotic or diploic mastoid were found to be more common in ears with pars flaccida squamous disease than pars tensa COM (46.15% vs. 38.46%, P < 0.05).

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Intrathecal Drug Delivery and Spinal Cord Stimulation for the Treatment of Cancer Pain

Abstract

Purpose of Review

The purpose of the present investigation is to summarize the body and quality of evidence including the most recent studies in support of intrathecal drug delivery systems and spinal cord stimulation for the treatment of cancer-related pain.

Recent Findings

In the past 3 years, a number of prospective studies have been published supporting intrathecal drug delivery systems for cancer pain. Additional investigation with adjuvants to morphine-based analgesia including dexmedetomidine and ziconotide support drug-induced benefits of patient-controlled intrathecal analgesia. A study has also been recently published regarding cost-savings for intrathecal drug delivery system compared to pharmacologic management, but an analysis in the Ontario, Canada healthcare system projects additional financial costs. Finally, the Polyanalgesic Consensus Committee has updated its recommendations regarding clinical guidelines for intrathecal drug delivery systems to include new information on dosing, trialing, safety, and systemic opioid reduction. There is still a paucity of clinical evidence for spinal cord stimulation in the treatment of cancer pain. There are new intrathecal drugs under investigation including various conopeptides and AYX1.

Summary

Large, prospective, modern, randomized controlled studies are still needed to support the use of both intrathecal drug delivery systems as well as spinal cord stimulation for cancer pain populations. There are multiple prospective and small randomized controlled studies that highlight a potential promising future for these interventional modalities. Related to the challenge and urgency of cancer pain, the pain practitioner community is moving toward a multimodal approach that includes discussions regarding the role of intrathecal therapies and spinal cord stimulation to the individualized treatment of patients.

http://ift.tt/2FMGn7T

The Effect of Ketamine Infusion in the Treatment of Complex Regional Pain Syndrome: a Systemic Review and Meta-analysis

Abstract

Purpose of Review

Complex regional pain syndrome (CRPS) is a painful debilitating neurological condition that accounts for approximately 1.2% of adult chronic pain population. Ketamine, an NMDA receptor antagonist, is an anesthetic agent that has been used by some pain specialists for CRPS. There is a growing body of clinical evidence to support the use of ketamine in the treatment of neuropathic pain, especially CRPS. This meta-analysis study was aimed to examine the efficacy of ketamine in the treatment of CRPS.

Recent Findings

A search of Embase, Pubmed, Web of Knowledge, Cochrane, Clinical Trial.gov, and FDA.gov between Jan 1, 1950, and August 1, 2017, was conducted to evaluate ketamine infusion therapy in the treatment of CRPS. We selected randomized clinical trials or cohort studies for meta-analyses. I² index estimates were calculated to test for variability and heterogeneity across the included studies. The primary outcome is pain relief. The effect of ketamine treatment for complex regional pain syndrome was assessed by 0–10 scale numerical rating pain score. The secondary outcome is the pain relief event rate, which is defined as the percentage of participants who achieved 30% or higher pain relief in each of the qualified studies. Our meta-analysis results showed that the Ketamine treatment led to a decreased mean of pain score in comparison to the self-controlled baseline (p < 0.000001). However, there is a statistical significance of between-study heterogeneity. The immediate pain relief event rate was 69% (95% confidence interval (CI) 53%, 84%). The pain relief event rate at the 1–3 months follow-ups was 58% (95% CI 41%, 75%).

Summary

The current available studies regarding ketamine infusion for CRPS were reviewed, and meta-analyses were conducted to evaluate the efficacy of ketamine infusion in the treatment of CRPS. Our findings suggested that ketamine infusion can provide clinically effective pain relief in short term for less than 3 months. However, because of the high heterogeneity of the included studies and publication bias, additional random controlled trials and standardized multicenter studies are needed to confirm this conclusion. Furthermore, studies are needed to prove long-term efficacy of ketamine infusion in the treatment of CRPS.

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Migraine and the Hippocampus

Abstract

Purpose of Review

The hippocampus is involved in pain processing, pain-related attention and anxiety, and stress response. The present review compiles the present knowledge of hippocampal volume, activity, and connectivity regarding migraine.

Recent Findings

For hippocampal volume, a longitudinal study discovered decreased volume in newly diagnosed migraine patients after 1 year. Two cross-sectional studies suggested an adaptive increase of volume at low headache frequency and a maladaptive decrease of volume at higher headache frequency. Patients who carried a COMT Val homozygous were found to have larger hippocampi on both sides compared with healthy controls with the same polymorphism. For hippocampal activation, one study showed greater nociceptive activation in patients with migraine compared to healthy controls, with the activity correlated to headache frequency. Another study showed greater deactivation and higher functional connectivity linked to other pain-processing regions in low frequency compared to high-frequency migraineurs. At resting state, intraregional functional connectivity of hippocampus was demonstrated to be lower, and connectivity of the hippocampus with other brain regions was different in patients carrying specific genetic variants. For structural connectivity, two studies suggest a stronger connectivity between the hippocampus and other corticolimbic regions, and the altered connectivities are responsible for migraine-associated allodynia or placebo effect of migraine.

Summary

Factors including headache frequency, accumulative number of migraine attacks, anxiety score, depression score, and genetic variants are related to hippocampal morphology and functional changes in people with migraine. Future studies should select participants precisely and appropriately control for genetic variants to investigate the complex relationship between the hippocampus and migraine.

http://ift.tt/2FMCeRx

Chronification of Pain: Mechanisms, Current Understanding, and Clinical Implications

Abstract

Purpose of Review

The development of acute to chronic pain involves distinct pathophysiological changes in the peripheral and central nervous systems. This article reviews the mechanisms, etiologies, and management of chronic pain syndromes with updates from recent findings in the literature.

Recent Findings

Chronic post-surgical pain (CPSP) is not limited to major surgeries and can develop after smaller procedures such as hernia repairs. While nerve injury has traditionally been thought to be the culprit for CPSP, it is evident that nerve-sparing surgical techniques are not completely preventative. Regional analgesia and agents such as ketamine, gabapentinoids, and COX-2 inhibitors have also been found to decrease the risks of developing chronic pain to varying degrees. Yet, given the correlation of central sensitization with the development of chronic pain, it is reasonable to utilize aggressive multimodal analgesia whenever possible.

Summary

Development of chronic pain is typically a result of peripheral and central sensitization, with CPSP being one of the most common presentations. Using minimally invasive surgical techniques may reduce the risk of CPSP. Regional anesthetic techniques and preemptive analgesia should also be utilized when appropriate to reduce the intensity and duration of acute post-operative pain, which has been correlated with higher incidences of chronic pain.

http://ift.tt/2EeIzI3

Complex Regional Pain Syndrome, Current Concepts and Treatment Options

Abstract

Purpose of Review

Complex regional pain syndrome (CRPS) refers to a chronic pain condition that is characterized by progressively worsening spontaneous regional pain without dermatomal distribution. The symptomatology includes pain out of proportion in time and severity to the inciting event. The purpose of this review is to present the most current information concerning epidemiology, diagnosis, pathophysiology, and therapy for CRPS.

Recent Findings

In recent years, discovery of pathophysiologic mechanisms of CRPS has led to significant strides in the understanding of the disease process.

Summary

Continued elucidation of the underlying pathophysiological mechanisms will allow for the development of more targeted and effective evidence-based therapy protocols. Further large clinical trials are needed to investigate mechanisms and treatment of the disorder.

http://ift.tt/2FKK9P8

Primary purulent bacterial pericarditis due to Streptococcus intermedius in an immunocompetent adult: a case report

Acute purulent bacterial pericarditis is of rare occurrence in this modern antibiotic era. Primary involvement of the pericardium without evidence of underlying infection elsewhere is even rarer. It is a rapid...

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Horizontal and vertical sections of scalp biopsy specimens from dermatomyositis patients with scalp involvement

Scalp involvement in dermatomyositis manifests as a pruritic eruption with erythema and scaling associated with nonscarring alopecia. We characterized the histologic features of scalp dermatomyositis using horizontal and vertical sections. Characteristic findings of scalp dermatomyositis include preserved follicular architecture, hair counts consistent with chronic telogen effluvium, telangiectasia and mucin.

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Skin in the Game: Existing and Upcoming Physician Payment Models in Dermatology

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Efficacy and Safety of Topical Oxymetazoline Cream 1.0% for Treatment of Persistent Facial Erythema Associated With Rosacea: Findings From the Two Phase 3, 29-Day, Randomized, Controlled REVEAL Trials

Most rosacea treatments targeting inflammatory lesions do not improve persistent facial erythema.Topical oxymetazoline hydrochloride cream 1.0% effectively reduced erythema versus vehicle in patients with moderate to severe persistent facial erythema of rosacea, with favorable tolerability.Topical oxymetazoline represents a new treatment option for patients with persistent erythema of rosacea.

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Consultative Teledermatology in the Emergency Department and Inpatient Wards: A Survey of Potential Referring Providers.

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Does drug-induced sleep endoscopy predict surgical success of limited palatal muscle resection in patients with obstructive sleep apnea?

The aims of this study were to determine the associated factors affecting the success rate of limited palatal muscle resection (LPMR), and to investigate whether drug-induced sleep endoscopy (DISE) could predict the therapeutic response to LPMR in patients with obstructive sleep apnea obstructive sleep apnea (OSA).

http://ift.tt/2s7vY4M

Prevention and Management of Complications in Otosclerosis Surgery

Surgical management of otosclerosis is a relatively safe and effective procedure, with a high rate of hearing improvement and a low rate of undesirable outcomes and complications. Many of these potential complications are common to any middle ear surgery, but many are unique to surgery involving the stapes footplate. Preventing complications with stapes surgery and minimizing their impact may be achieved by preparation as well as surgical experience.

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Special Anatomic Considerations in Otosclerosis Surgery

The anatomy of the vestibular organs together with considerations of the middle and inner ear anatomy relevant to stapes surgery is discussed. An archival collection of macerated and freshly frozen human temporal bones underwent micro–computed tomography (CT) with subsequent volume-rendering. Three-dimensional (3D) reconstructions and the topographic anatomy of the oval window were considered. Micro-CT and 3D rendering revealed the relationship between the otolith organs and the oval window. Anatomic variations were extensive and included the distance between the footplate and the reconstructed macula margins. A "no-go" zone is suggested for the surgeon to avoid injury during stapes surgery.

http://ift.tt/2E0Z8Eh

Eosinophilic esophagitis and symptoms possibly related to eosinophilic esophagitis in oral immunotherapy

Food allergy is seen in 2% to 8% of the US population and continues to increase.1–3 Patients with food allergy often have an impaired quality of life and may experience nutritional deficiencies.4,5 Currently, there are no US Food and Drug Administration–approved treatments for food allergy, and it is recommended that patients practice allergen avoidance and carry epinephrine for use in case of severe reaction to unintentional allergen exposure.6 The lifestyle of allergen avoidance presents a challenge and often causes anxiety for patients and caregivers.

http://ift.tt/2s3N6IL