Early Stage olfactory neuroblastoma and the impact of resecting dura and olfactory bulb

Objective

Compare outcomes of patients with olfactory neuroblastoma (ONB) without skull base involvement treated with and without resection of the dura and olfactory bulb.

Methods

Retrospective review of ONB patients treated from 1992 to 2013 at the MD Anderson Cancer Center (The University of Texas, Houston, Texas, U.S.A.). Primary outcomes were overall and disease-free survival.

Results

Thirty-five patients were identified. Most patients had Kadish A/B. tumors (97%), Hyams grade 2 (70%), with unilateral involvement (91%), and arising from the nasal cavity (68%). Tumor involved the mucosa abutting the skull base in 42% of patients. Twenty-five patients (71%) received surgery and radiation, whereas the remainder had surgery alone. Five patients (14%) had bony skull base resection, and eight patients (23%) had resection of bony skull base, dura, and olfactory bulb. Surgical margins were grossly positive in one patient (3%) and microscopically positive in four patients (12%). The 5- and 10-year overall survival were 93% and 81%, respectively. The 5- and 10-year disease-free survival (DFS) were 89% and 78%, respectively. Bony cribriform plate resection was associated with better DFS (P = 0.05), but dura and olfactory bulb resection was not (P = 0.11). There was a trend toward improved DFS in patients with negative resection margins (P = 0.19). Surgical modality (open vs. endoscopic) and postoperative radiotherapy did not impact DFS.

Conclusion

Most Kadish A/B ONB tumors have low Hyams grade, unilateral involvement, and favorable survival outcomes. Resection of the dura and olfactory bulb is not oncologically advantageous in patients without skull base involvement who are surgically treated with negative resection margins and cribriform resection.

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2AJvyCb

Transcutaneous immunization with pneumococcal surface protein A in mice

Objective

Pneumococcal infection caused by Streptococcus pneumoniae is a major upper respiratory tract disease that causes severe illness and mortality. Therefore, it is important to develop safe and effective vaccines to prevent pneumococcal infections. The goal of the study was to investigate the effectiveness of transcutaneous immunization (TCI) for induction of pneumococcal surface protein A (PspA) responses in the upper respiratory tract.

Methods

C57BL/6 mice were transcutaneously immunized with 1 μg of PspA and 2 μg of cholera toxin (CT) six times at weekly intervals and compared with transcutaneously treated controls (PBS alone/PspA alone/CT alone). Two weeks after the final immunization, nasal washes (NWs), saliva, and plasma samples were collected and subjected to a PspA-specific ELISA. Three weeks after the final immunization, mice were challenged with S. pneumoniae strain EF3030, and the numbers of CFUs in NWs and nasal passages (NPs) were determined.

Results

Higher levels of PspA-specific IgM, IgG, and IgA Abs were noted in plasma of TCI with PspA plus CT compared with controls. Transcutaneous immunization mice also had significantly increased PspA-specific S-IgA Ab responses in NWs and saliva and, importantly, showed significantly lower numbers of bacteria CFUs in NWs and NPs compared with controls.

Conclusion

These results show that TCI with PspA plus CT induces antigen-specific mucosal and systemic immune responses. This suggests that this method is an effective mucosal immunization strategy for induction of protective pneumococcal-specific Ab responses in blockade of S. pneumoniae colonization of the nasal cavity.

Level of Evidence

NA. Laryngoscope, 2017

http://ift.tt/2yehbTE

Immunohistologic analysis of spontaneous recurrent laryngeal nerve reinnervation in a rat model

Objective

After recurrent laryngeal nerve injury (RLN), spontaneous reinnervation of the larynx occurs with input from multiple sources. The purpose of this study was to determine the timing and efficiency of reinnervation across a resected RLN segment in a rat model of RLN injury.

Study Design

Animal study.

Methods

Twelve male 60-day-old Sprague Dawley rats underwent resection of a 5-mm segment of the right RLN. Rats were sacrificed at 1, 2, 4, and 12 weeks after nerve injury to harvest the larynx and trachea for immunohistologic analysis. The distal RLN segment was stained with neurofilament, and axons were counted and compared to the nonoperated side. Thyroarytenoid (TA) muscles were stained with alpha-bungarotoxin, synaptophysin, and neurofilament to identify intact neuromuscular junctions (NMJ). The number of intact NMJs from the denervated side was compared to the nonoperated side.

Results

Nerve fibers regenerated across the resected RLN gap into the distal recurrent laryngeal nerve to innervate the TA muscle. The number of nerve fibers in the distal nerve segment increased over time and reached the normal number by 12 weeks postdenervation. Axons formed intact neuromuscular junctions in the TA, with 48.8% ± 16.7% of the normal number of intact NMJs at 4 weeks and 88.3% ± 30.1% of the normal number by 12 weeks.

Conclusion

Following resection of an RLN segment in a rat model, nerve fibers spontaneously regenerate through the distal segment of the transected nerve and form intact NMJs in order to reinnervate the TA muscle.

Level of Evidence

NA. Laryngoscope, 2017

http://ift.tt/2ydJMIP

Tandem walking as a quick screening test for vestibular disorders

Objectives/Hypothesis

Although many screening tests of balance are available, few of them have been well validated for clinical or research uses. The goal of this study was to test an updated version of an old test, Tandem Walking, to determine how useful it is for screening patients with vestibular disorders.

Study Design

Case-control study.

Methods

Subjects were 90 adult patients with vestibular disorders and 292 healthy adult controls. They were tested on the number of correct tandem steps they could perform with arms crossed and eyes closed in a series of 10 steps. Correct steps could be nonconsecutive. Subjects were given one practice trial with eyes open and three experimental trials with eyes closed.

Results

Receiver operating characteristic (ROC), and sensitivity and specificity were calculated. ROC values, sensitivity, and specificity were, at best, only moderate, no matter how the age range was cut. Even for subjects in the age group with the highest ROC value (i.e., age less than 50 years), ROC = 0.8, sensitivity = 0.77, and specificity = 0.72.

Conclusions

These results indicate that 23% of patients will not be identified. Therefore, we recommend that if this test is used for screening patients in the clinic or healthy volunteers, the result should be interpreted with care.

Level of Evidence

3b Laryngoscope, 2017

http://ift.tt/2AJuGxo

A case of long-survival insulinoma with multiple neuroendocline tumour type 1 controlled by multimodal therapy

Abstract

Insulinomas with multiple neuroendocrine tumour type 1 (MEN1) sometimes have metachronous or recurrent tumours. However, the treatment for these tumours is controversial, and published reports regarding multimodal therapy for insulinomas are limited. We report a 73-year-old woman with recurrent insulinoma with MEN1 successfully controlled by multimodal therapy. She had several complications, and poor performance status. Her hypoglycaemia did not improve after 6-month octreotide LAR; as such, she underwent enucleation of the pancreatic tumour. Within 7 years after the first operation, she underwent four succeeding surgeries for recurrent tumours. Her medications during follow-up were octreotide-LAR and Everolimus. Insulinoma can be managed through various treatment options. Medical treatment includes octreotide-LAR and Everolimus, while surgical approach includes enucleation and pancreaticoduodenectomy. Some tumours, particularly those that are MEN1, can recur repeatedly. Thus, several treatments are needed to control them. We highlight the importance of multimodal therapy, including repeated surgery, for the control of the disease.

http://ift.tt/2ByDCZR

Functional outcome after hand replantation in Guatemala

Abstract

Amputations of a traumatic origin are very frequent in developing countries, in the case of Guatemala these are a result of work accidents very closely related to poor work conditions existing for manual workers, as well as social violence and the lack of security that governs society. The present case shows a patient that suffered a left hand amputation at wrist level. Amputated hand was transported swiftly and in adequate conditions, maintaining cold chain at all times until arrival at Hospital for replantation. After 14 months, patient has evolved satisfactorily and obtained functional result of the hand.

http://ift.tt/2B2o9QT

Histoplasmosis hepatitis after orthotopic liver transplantation

Abstract

Histoplasmosis is an endemic mycosis in the Ohio and Mississippi River valleys and can cause disseminated infection in immunocompromised hosts. Disseminated histoplasmosis is often respiratory in nature and most cases in transplant patients occur within 2 years post-transplantation. A 32-year-old male on mycophenolate and tacrolimus who underwent an orthotopic liver transplantation 10 years prior presented with generalized body aches, fevers, mild congestion, dysuria and elevated transaminases. Liver biopsy revealed epithelioid granulomas with narrow-based budding yeast, suggesting histoplasma. Liver involvement in disseminated histoplasmosis is well characterized however the disease is usually pulmonary in origin. Only three other case reports describe isolated granulomatous hepatitis, and this is the first to our knowledge to occur in a liver transplant allograft. A high index of suspicion is essential for diagnosis and prompt treatment of histoplasmosis in transplant patients considering their immunocompromised state.

http://ift.tt/2BytGQ7

Clinical characteristics of Japanese patients with psoriatic arthritis: Comparison with East Asian countries

Abstract

To determine the characteristics and current status of Japanese patients with psoriatic arthritis, the Japanese Society for Psoriasis Research have started to conduct retrospective questionnaire surveys. The results collected from over a thousand patients with psoriatic arthritis have revealed several characteristics. The newly visited psoriatic arthritis patients accounted for approximately 10% of all new psoriatic patients who visited the dermatology department in many referral centers. The prevalence was nearly 15% of psoriatic patients, which was similar to a recent rheumatology and dermatology study in Japan with a large cohort. There was a male predominance. The mean age of onset for cutaneous psoriasis was in the late 30s, while that of arthritis was in the late 40s. If we compare the precedence of cutaneous psoriasis versus arthritis, the psoriasis precedent group accounted for nearly 75%, while arthritis accounted for 5% of cases. The mean duration in patients who developed psoriasis prior to arthritis was over 10 years, while that in patients preceded by arthritis was less than 5 years. According to the Moll and Wright criteria, polyarthritis type was most common, followed by distal interphalangeal type and oligoarthritis type. Biologics were used in over 50% of psoriatic arthritis patients, and TNF inhibitors were currently used in approximately 70% among biologics. Switching to other biologics or discontinuance was seen in 15%. This review shows the current status of psoriatic arthritis in Japan, as well as a comparison of the prevalence among East Asian countries.

http://ift.tt/2kUPyht

Systemic sclerosis

Abstract

Systemic sclerosis (SSc) is a multisystem autoimmune disease characterized by vasculopathy and tissue fibrosis of the skin and various internal organs. A series of genetic and epidemiological studies have demonstrated that SSc onset is determined by the accumulation of predisposing factors related to environmental influences, while genetic factors affect the susceptibility to and the severity of this disease. This notion has been confirmed by recent advance in animal models. The initial trigger of SSc is believed to be autoimmune attacks to endothelial cells, which occur in individuals with the genetic susceptibility to autoimmune diseases and/or the cumulative exposure to certain SSc-related environmental influences. Then, endothelial cells are aberrantly activated or damaged, leading to the development of vascular structural changes, such as destructive vasculopathy and proliferative obliterative vasculopathy, and tissue fibrosis. In parallel, inflammatory cells activate SSc fibroblasts and modify the metabolism of extracellular matrix by soluble factors and autoantibodies. Prior to or during these processes, SSc fibroblasts acquire the ability to selectively respond to profibrotic growth factors and cytokines, persistently producing excessive amount of extracellular matrix. SSc fibroblasts also modify immune responses, at least those of CD4⁺ T cells, in the microenvironment through the secretion of immune regulatory molecules. Thus, various types of individually activated cells interact with each other and coordinately drive an SSc-specific disease cascade, leading to the development of unique clinical symptoms. This article provides an overview of the current understanding of the pathogenesis of SSc with the recent advance in the research field of this disease.

http://ift.tt/2iN7KFw

Safety of biologics in psoriasis

Abstract

The advent of biologics brought a paradigm shift in ways to treat psoriatic patients because they have dramatic efficacy. At the same time, safety concerns about biologics have been raised. In this paper, we focus on the safety profile of biologics for psoriasis. As of 2017, six biologics are available in Japan. Two tumor necrosis factor-α inhibitors; infliximab and adalimumab, one anti-interleukin (IL)-12/23p40 antibody; ustekinumab, and IL-17 inhibitors; secukinumab, ixekizumab and brodalumab. Secukinumab and ixekizumab are anti-IL-17A antibodies. Brodalumab is an anti-IL17RA antibody. In this review, we pick up topics which have drawn attention regarding the safety of biologics and discuss them with recent published work.

http://ift.tt/2kZBJys

Mouse models of psoriasis and their relevance

Abstract

Psoriasis is an inflammatory skin disorder that includes dynamic interactions between the immune system and skin and is clinically characterized by keratinocyte proliferation and distinct inflammatory cell infiltrates. Cross-talk between keratinocytes and immunocytes is essential for the development of psoriasis given that it mediates the production of cytokines, chemokines and growth factors. To resolve the pathogenesis of psoriasis, numerous experimental animal models have been generated. In this review, we discuss recent findings from mouse models, their relevancy to psoriasis and use, including the discovery of new therapies.

http://ift.tt/2iOeh2B

Pathogenesis of psoriasis and development of treatment

Abstract

The pathogenesis of psoriasis can be explained by dysregulation of immunological cell function as well as keratinocyte proliferation/differentiation. Recently, the immunological pathomechanism has been clarified substantially. Whereas T-helper (Th)1 overactivation was thought to induce occurrence of psoriasis, it has been demonstrated that Th17 cells play a key role. Th17 development is maintained by interleukin (IL)-23 mainly produced by dendritic cells. Th17 cells produce various cytokines, including IL-17A, IL-17F and IL-22. IL-17A and IL-22 induce not only keratinocyte proliferation, but also tumor necrosis factor (TNF)-α, chemokine (C-X-C motif) ligand (CXCL)1 and CXCL8 production. TNF-α accelerates the infiltration of inflammatory cells, including lymphocytes, monocytes and neutrophils, from the peripheral blood into skin with dendritic cell activation. In addition, antimicrobial peptides are overexpressed in psoriatic skin lesions, and the antimicrobial peptide, LL-37, activates dendritic cells, which leads to the development of inflammation. Furthermore, activation of nuclear factor-κB signal induces the expression of keratins 6 and 16 in keratinocytes, which are associated with acanthosis and reduced turnover time in the epidermis. The progression of the pathomechanism contributes to the development of new therapies for psoriasis.

http://ift.tt/2kUNjuy

Internal herniation through lesser omentum hiatus and gastrocolic ligament with malrotation: a case report

Internal herniation through lesser omentum hiatus and gastrocolic ligament with malrotation is extremely rare. This type of internal hernia has rarely been described before. Preoperative diagnosis is difficult...

http://ift.tt/2BUTAJT

Development, characterization, and evaluation of sunscreen cream containing solid lipid nanoparticles of silymarin

Summary

Background

Most of the sunscreen formulations mainly contain chemicals or synthetic molecules. Nowadays, researchers are mainly focussing on herbal formulations due to toxicity of the synthetic molecules. Silymarin is a natural flavonoids having excellent antioxidant properties. Solid lipid nanoparticles are novel drug carriers which improve the drug stability and tolerance effect and also enhance the permeation effect.

Aims

This study aimed at the preparation of solid lipid nanoparticles containing silymarin that will be incorporated into a sunscreen cream and determine its sun protection factor.

Methods

The solid lipid nanoparticles were prepared by micro-emulsion method; here, the glyceryl monostearate was used as lipid, and Tween 80 was used as an emulsifier. The solid lipid nanoparticles were evaluated for drug entrapment, particle size and morphology, zeta potential, and polydispersity index. The dispersion was formulated into sunscreen cream and evaluated for various parameters, such as extrudability, viscosity, spreadability, drug content, in vitro drug release, ex vivo permeation of drug, in vitro and in vivo sun protection factor determination, in vivo skin irritation test, and accelerated stability studies.

Results

The results suggested that as the concentration of emulsifier increased, the entrapment efficiency of silymarin increased. In vitro and in vivo sun protection factor determination showed that SPF of 13.80 and 14.1, respectively. Stability studies were performed under accelerated conditions, and it did not show any appreciable change in parameters.

Conclusion

These results indicated that the sunscreen containing silymarin solid lipid nanoparticles exhibited better photoprotective action.

http://ift.tt/2nOxLJF

Microneedling combined with platelet-rich plasma or trichloroacetic acid peeling for management of acne scarring: A split-face clinical and histologic comparison

Summary

Background

Minimally invasive procedures provide effective, safe, relatively long-lasting, and natural results without large damage to the skin. A combination treatment is considered an approach that includes at least 2 different and unrelated modalities.

Objectives

This study aims to evaluate the use and effectiveness of some combined minimally invasive procedures for management of acne scarring.

Patients/methods

Twenty-four volunteers with postacne atrophic scars were randomly divided into 3 equal groups according to performed procedure on each side of the face (microneedling by dermaroller alone or combined with platelet-rich plasma [PRP] or trichloroacetic acid [TCA] 15% peeling) and received 6 bi-weekly sessions of treatment. Photography and punch biopsies were taken before and after 3 months of treatment for clinical, histological, and histometrical evaluation.

Results

Combined treatment of dermaroller and PRP or dermaroller and TCA 15% showed significant improvement when compared with dermaroller alone (P = .015 and .011 respectively). Epidermal thickness showed statistically significant increase in studied groups, mainly after dermaroller and TCA 15%. Moreover, the 3 studied groups showed more organized collagen bundles and newly formed collagen formation and markedly decreased abnormal elastic fibers.

Conclusions

Based on the clinical, histometrical, and histochemical assessment, inspite that most volunteers showed significant improvement after treatment, however, the combined use of dermaroller and TCA 15% was more effective in postacne atrophic scars than the use of dermaroller and PRP or dermaroller only.

http://ift.tt/2C23k5Z

Effects of Rhodomyrtus tomentosa extract on virulence factors of Candida albicans and human neutrophil function

Publication date: Available online 10 December 2017
Source:Archives of Oral Biology
Author(s): Jutharat Hmoteh, Khadar Syed Musthafa, Supayang Piyawan Voravuthikunchai
Objective: Candida albicans has become a major problem of oral candidiasis due to increase in antibiotic resistance. Rhodomyrtus tomentosa, a medicinal plant possessing several phytochemical constituents, has been considered as a potential source of antimicrobial and immunomodulatory agents. The aim of this study was to investigate anti-virulence and immunostimulatory activity of R. tomentosa ethanolic leaf extract against C. albicans.MethodsThe effects of the extract on C. albicans were assessed on germ tube production, adherence of the organisms to surfaces, and biofilm. In addition, the effects of the extract on phagocytosis and killing activity of neutrophils against the pathogen were investigated.ResultsSuppression of germ tube production following 30min exposure to the extract at 256μg/mL was significantly increased in comparison with that of the unexposed cells (p <0.05). The pathogens demonstrated a significant reduction in adherence ability to surfaces in a dose dependent manner, compared with the control (p <0.05). At 48h, the extract at 512−1024μg/mL significantly reduced biofilm forming ability of the organisms up to 42.31−64.58% (p <0.05). Compared with the control group, a significant inhibition of mature biofilm after treated with the extract at 256μg/mL was observed (p<0.05). The extract at 50μg/mL significantly enhanced phagocytosis and killing activity of neutrophils against the organism, compared with the control (p<0.05).ConclusionsThe findings suggest that R. tomentosa extract displayed a dual mode of action, inhibiting virulence factors of C. albicans and enhancing neutrophil functions. Further pharmaceutical development of the extract might be useful as an alternative therapeutic agent against oral candidiasis.



http://ift.tt/2kh943G

Reliability of a new test food to assess masticatory function

Publication date: Available online 9 December 2017
Source:Archives of Oral Biology
Author(s): Laura Khoury-Ribas, Raul Ayuso-Montero, Bernat Rovira-Lastra, Maria Peraire, Jordi Martinez-Gomis.
ObjectiveThis study assessed the reliability and validity of masticatory function assessment using a new test food, Optozeta.DesignThirty-five adults participated in the cross-sectional clinical part of the study; ten of them performed a retest. They performed two free-style masticatory tests consisting of five trials of 20 cycles each chewing three pieces of Optosil or Optozeta placed in a latex bag. Optozeta was created by mixing 50% Optosil with 50% of Zetalabor. Masticatory performance, masticatory laterality and chewing rate were assessed. Reliability and construct validity were assessed using the intraclass correlation coefficient (ICC) and Spearman correlations, respectively.ResultsHigher ICC values were observed for each aspect of masticatory function as assessed using Optozeta compared with Optosil. All the participants showed a lower median particle size value using Optozeta than Optosil. For each masticatory parameter, a high correlation was observed between using Optosil or Optozeta.ConclusionsOptozeta seems to have good construct validity and appears to be more reliable than Optosil as a test food to assess masticatory function.



http://ift.tt/2AILu7R

Dysphagia and Pharyngeal Obstruction in a Nonsmoker.

Related Articles

Dysphagia and Pharyngeal Obstruction in a Nonsmoker.

JAMA Otolaryngol Head Neck Surg. 2017 Dec 07;:

Authors: Nuyen BA, Berry G, Megwalu U

PMID: 29222562 [PubMed - as supplied by publisher]

http://ift.tt/2nKkFNF

Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia: A Systematic Review and Meta-analysis.

Related Articles

Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia: A Systematic Review and Meta-analysis.

JAMA Otolaryngol Head Neck Surg. 2017 Dec 07;:

Authors: Loughrey DG, Kelly ME, Kelley GA, Brennan S, Lawlor BA

Abstract
Importance: Epidemiologic research on the possible link between age-related hearing loss (ARHL) and cognitive decline and dementia has produced inconsistent results. Clarifying this association is of interest because ARHL may be a risk factor for outcomes of clinical dementia.
Objectives: To examine and estimate the association between ARHL and cognitive function, cognitive impairment, and dementia through a systematic review and meta-analysis.
Data Sources and Study Selection: A search of PubMed, the Cochrane Library, EMBASE, and SCOPUS from inception to April 15, 2016, with cross-referencing of retrieved studies and personal files for potentially eligible studies was performed. Keywords included hearing, cognition, dementia, and Alzheimer disease. Cohort and cross-sectional studies published in peer-reviewed literature and using objective outcome measures were included. Case-control studies were excluded.
Data Extraction and Synthesis: One reviewer extracted and another verified data. Both reviewers independently assessed study quality. Estimates were pooled using random-effects meta-analysis. Subgroup and meta-regression analyses of study-level characteristics were performed.
Main Outcomes and Measures: Hearing loss measured by pure-tone audiometry only and objective assessment measures of cognitive function, cognitive impairment, and dementia. Cognitive function outcomes were converted to correlation coefficients (r value); cognitive impairment and dementia outcomes, to odds ratios (ORs).
Results: Forty studies from 12 countries met our inclusion criteria. Of these, 36 unique studies with an estimated 20 264 unique participants were included in the meta-analyses. Based on the pooled maximally adjusted effect sizes using random-effects models, a small but significant association was found for ARHL within all domains of cognitive function. Among cross-sectional studies, a significant association was found for cognitive impairment (OR, 2.00; 95% CI, 1.39-2.89) and dementia (OR, 2.42; 95% CI, 1.24-4.72). Among prospective cohort studies, a significant association was found for cognitive impairment (OR, 1.22; 95% CI, 1.09-1.36) and dementia (OR, 1.28; 95% CI, 1.02-1.59) but not for Alzheimer disease (OR, 1.69; 95% CI, 0.72-4.00). In further analyses, study, demographic, audiometric, and analyses factors were associated with cognitive function. Vascular dysfunction and impaired verbal communication may contribute to the association between hearing loss and cognitive decline.
Conclusions and Relevance: Age-related hearing loss is a possible biomarker and modifiable risk factor for cognitive decline, cognitive impairment, and dementia. Additional research and randomized clinical trials are warranted to examine implications of treatment for cognition and to explore possible causal mechanisms underlying this relationship.

PMID: 29222544 [PubMed - as supplied by publisher]

http://ift.tt/2nLl7vh

Sensory Changes and the Hearing Loss-Cognition Link: The Cognitive Ear.

Related Articles

Sensory Changes and the Hearing Loss-Cognition Link: The Cognitive Ear.

JAMA Otolaryngol Head Neck Surg. 2017 Dec 07;:

Authors: Panza F, Quaranta N, Logroscino G

PMID: 29222539 [PubMed - as supplied by publisher]

http://ift.tt/2nINY32

Angioleiomyoma of the Auricle: An Unusual Tumor on a Rare Location

Cutaneous angioleiomyomas (ALMs) (also known as vascular leiomyomas or angiomyomas) are unusual benign tumors of the skin deriving from the muscle layer of dermal blood vessels. They usually manifest as tender subcutaneous nodules, mostly encountered on the legs of adult women in their fifth or sixth life decade. ALMs rarely develop on the head/neck area, and even more rarely (

http://ift.tt/2ybQDT1