Secukinumab-induzierter subakut-kutaner Lupus erythematodes

Zusammenfassung

Wir berichten über eine 52-jährige Patientin, die unter der Therapie mit Secukinumab einen medikamenteninduzierten subakut kutanen Lupus erythematodes („drug induced lupus erythematodes" [SC-DILE]) entwickelte. Unter einer lokalen Therapie mit einem Steroid der Klasse 3 zeigte sich innerhalb von 4 Wochen eine wesentliche Besserung. Die Systemtherapie wurde auf Ustekinumab umgestellt. DILE („drug induced lupus erythematodes") ist eine seltene, aber zu bedenkende Nebenwirkung unter Biologikatherapie bei 0,5–1 % aller Patienten, die auch bei IL(Interleukin)-17-Blockade auftreten kann. Eine Umstellung der Biologikatherapie ist in den meisten Fällen notwendig.

http://ift.tt/2zERJaW

Juvenile pityriasis rubra pilaris: successful treatment with methotrexate

http://ift.tt/2zHb7Ea

Keeping an Open Mind: Cognitive Bias in the Evaluation of an Infant with Posterior-Lateral Rib Fractures

A four-month-old former premature male is incidentally found to have posterior-lateral rib fractures during evaluation of a febrile illness. This finding led to the initiation of a workup for nonaccidental trauma. A thorough history and physical exam ultimately led to the diagnosis, which was not related to abuse. This case highlights a rare sequela of patent ductus arteriosus repair, cautions medical teams to remain aware of how cognitive bias can affect diagnostic decision-making, and emphasizes the importance of a thorough history, physical exam, and medical record review in cases of suspected nonaccidental trauma.

http://ift.tt/2xpjnbf

HLA-Cw6 and psoriasis

Abstract

Psoriasis is a multifactorial disease with a strong genetic background. HLA-Cw6 is one of the most strongly associated psoriasis susceptibility allele. It is repeatedly observed to affect disease course, phenotypic features, severity, comorbidities, and treatment outcomes. To the best of our knowledge, the roles of HLA-Cw6 in psoriasis have not yet been thoroughly reviewed. The worldwide frequency of HLA-Cw6 allele varies greatly, with HLA-Cw6 allele frequency being generally higher in Caucasians compared to Asians. The allele is associated with Type I early onset psoriasis. Stress, obesity, and streptococcal pharyngitis are commonly observed in HLA-Cw6 positive patients. Phenotypically, HLA-Cw6 is found to be associated with guttate psoriasis in some studies. In addition, patients carrying the allele are more likely to have arm, leg, trunk involvement, and Koebner's phenomenon. Psoriatic arthritis patients with HLA-Cw6 more often have early onset and tend to show cutaneous symptoms before musculoskeletal symptoms. HLA-Cw6 positive patients have been shown to be more responsive to methotrexate and ustekinumab in several studies. However, this difference in ustekinumab efficacy was only moderate in a post hoc analysis of phase III pivotal study. HLA-Cw6 positivity also tends to be less frequent in high-need patients who failed conventional therapy. Small studies have also investigated the role of HLA-Cw6 in remission of psoriasis during pregnancy, photosensitivity and atherosclerosis as comorbidity of psoriasis. Given the diverse nature of psoriasis pathogenesis, as well as the difference of HLA-Cw6 positivity in different ethnic groups, more studies are needed to confirm the role of HLA-Cw6 in psoriasis.

This article is protected by copyright. All rights reserved.

http://ift.tt/2yTyrRZ

The role of the microbiome in psoriasis: moving from disease description to treatment prediction?

Abstract

With several million microbes per cm² of skin, the task of mapping the physiological cutaneous microbiome is enormous. Indeed, the reliance on bacterial culture to identify cutaneous bacterial communities has led to a systematic under-appreciation of cutaneous microbial diversity, potentially limiting our understanding of common inflammatory skin diseases including psoriasis.

However, based heavily on developments in molecular biology and bioinformatics, including next generation sequencing, the last decade has witnessed a marked increase in our understanding of the extent and composition of the cutaneous microbiome. It is already clear that skin-specific (skin site and skin microenvironment), individual-specific (hygiene, sex, age, and hormonal status), disease-specific (atopic eczema, acne) and genetic factors can all influence the cutaneous microbiome, albeit to varying and, as yet ill-defined, extents. This review briefly describes the process of 16S ribosomal RNA sequencing, before charting our current understanding of the cutaneous microbiome in health and the alterations (dysbiosis) associated with chronic inflammatory diseases with particular reference to psoriasis. The possibility and clinical relevance of intra-individual cross-talk between the various microbiomes is discussed and potential mechanisms underpinning the interactions between resident skin flora and the immune system are highlighted. We outline how the power of microbiome studies can be harnessed to provide new insights into disease pathogenesis and treatment selection. Ultimately, in the age of personalized medicine, the integration of cutaneous microbiome signatures and comprehensive disease and drug response endotypes will herald a novel approach in the clinical management of chronic, multi-system inflammatory diseases.

This article is protected by copyright. All rights reserved.

http://ift.tt/2yOefz2

Continuous Pulse Oximetry and Capnography Monitoring for Postoperative Respiratory Depression and Adverse Events: A Systematic Review and Meta-analysis

BACKGROUND:Death and anoxic brain injury from unrecognized postoperative respiratory depression (PORD) is a serious concern for patient safety. The American Patient Safety Foundation has called for continuous electronic monitoring for all patients receiving opioids in the postoperative period. These recommendations are based largely on consensus opinion with currently limited evidence. The objective of this study is to review the current state of knowledge on the effectiveness of continuous pulse oximetry (CPOX) versus routine nursing care and the effectiveness of continuous capnography monitoring with or without pulse oximetry for detecting PORD and preventing postoperative adverse events in the surgical ward. METHODS:We performed a systematic search of the literature databases published between 1946 and May 2017. We selected the studies that included the following: (1) adult surgical patients (>18 years old); (2) prescribed opioids during the postoperative period; (3) monitored with CPOX and/or capnography; (4) primary outcome measures were oxygen desaturation, bradypnea, hypercarbia, rescue team activation, intensive care unit (ICU) admission, or mortality; and (5) studies published in the English language. Meta-analysis was performed using Cochrane Review Manager 5.3. RESULTS:In total, 9 studies (4 examining CPOX and 5 examining continuous capnography) were included in this systematic review. In the literature on CPOX, 1 randomized controlled trial showed no difference in ICU transfers (6.7% vs 8.5%; P = .33) or mortality (2.3% vs 2.2%). A prospective historical controlled trial demonstrated a significant reduction in ICU transfers (5.6–1.2 per 1000 patient days; P = .01) and rescue team activation (3.4–1.2 per 1000 patient days; P = .02) when CPOX was used. Overall, comparing the CPOX group versus the standard monitoring group, there was 34% risk reduction in ICU transfer (P = .06) and odds of recognizing desaturation (oxygen saturation [SpO2] 1 hour) was 15 times higher (P

http://ift.tt/2xnv963

Perioperative Patient Blood Management to Improve Outcomes

Anemia is common in elective surgery and is an independent risk factor for morbidity and mortality. Historical management of anemia has focused on the use of allogeneic blood transfusion but this in itself is not without risk. It too has been independently associated with morbidity and mortality, let alone the costs and relative shortage of this resource. In recognition of this, patient blood management (PBM) shifts the focus from the product to the patient and views the patient's own blood as a resource that should be conserved and managed appropriately as a standard of care. It consists of 3 pillars: the optimization of red blood cell mass; reduction of blood loss and bleeding; and optimization of the patient's physiological tolerance toward anemia. Integration of these 3 pillars in the form of multimodal care bundles and strategies into perioperative pathways should improve care processes and patient outcome. Preoperative anemia is most commonly caused by functional iron deficiency and should be treated with oral iron, intravenous iron, and/or recombinant erythropoietin. An individualized assessment of the thrombotic risk of discontinuing anticoagulant and antiplatelet medication should be balanced against the risk of perioperative bleeding. Neuraxial anesthetic techniques should be considered and minimally invasive surgery undertaken where appropriate. Cell salvage should be used if significant blood loss is anticipated and pharmacological treatments such as tranexamic acid and fibrin sealants have been shown to reduce blood loss. Point of care tests can guide the perioperative management of dynamic coagulopathy. Blood testing sampling should be performed only when indicated and when taken, sample volume and waste should be minimized. Restrictive blood transfusion thresholds and reassessment after single unit transfusion should be incorporated into clinical practice where appropriate. For PBM to become standard practice in routine surgical care, national health care quality change initiatives must set the agenda for change but the patient-centered approach to PBM should be delivered in a way that is also hospital centered. Characterization of the current practice of PBM at each hospital is crucial to facilitate the benchmarking of performance. Barriers to effective implementation such as lack of knowledge should be identified and acted on. Continuous audit of practice with a focus on transfusion rates and patient outcomes can identify areas in need of improvement and provide iterative feedback to motivate and inspire the main stakeholders. Accepted for publication September 8, 2017. The authors declare no conflicts of interest. Funding: None. Reprints will not be available from the authors. Address correspondence to Neel Desai, FRCA, Department of Anaesthetics, Royal Free Hospital, Pond St, London, NW3 2QG, London, United Kingdom. Address e-mail to neel_d83@hotmail.com. © 2017 International Anesthesia Research Society

http://ift.tt/2zSd15Y