Issue Information

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Quantitative survey into value clarification of discussed treatment options among patients treated for basal‐cell carcinoma

Abstract

There are many effective treatment options for basal‐cell carcinoma (BCC). To ensure a shared treatment decision, it is essential to understand patient preferences, values, and experience with treatments. We evaluated patients' recollections of the treatment choices for their BCC and what kind of information they valued most by doing a quantitative survey via the largest Dutch patient federation ('Patiëntenfederatie Nederland', PFN). The PFN includes a 25,000 member patient‐panel; their medical history is not reported. A survey was developed by the Dermatology department of the Maastricht University Medical Center in collaboration with BCC

This article is protected by copyright. All rights reserved.

http://bit.ly/2Qr9zX8

Serum and blister‐fluid elevation and decreased epidermal content of HMGB1 protein in drug‐induced Stevens Johnson syndrome/toxic epidermal necrolysis

Abstract

High‐mobility group box 1 (HMGB1) is a damage‐associated molecular‐pattern protein indicative of cell/tissue injury and innate immune response. Stevens‐Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) are serious, immune‐mediated skin‐blistering conditions characterised by widespread keratinocyte death and epidermal detachment.

The purpose of the study was to determine: a) serum and/or blister‐fluid total HMGB1 levels in independent SJS/TEN cohorts: and b) HMGB1 expression in formalin‐fixed, paraffin‐embedded SJS/TEN skin vs. healthy and maculopapular exanthema (MPE).

Total serum HMGB1 was quantified by enzyme‐linked immunosorbent assay (ELISA) in 3 cohorts: i) Malawian, nevirapine‐induced hypersensitivity (51 cases, 102 tolerant); ii) Taiwanese SJS/TEN (n=73) (acute, maximal and recovery stage); iii) Spanish SJS/TEN (n=23) (acute reaction (blister‐fluid (n=13)). FFPE skin (5 healthy, 7 maculopapular exanthema (MPE), 7 SJS/TEN) was immunohistochemically (IHC) stained and semi‐quantitatively assessed for HMGB1 expression.

Serum total HMGB1 was not significantly elevated in nevirapine‐induced SJS/TEN (3·98ng/ml±2·17), MPE (3·92ng/ml±2·75) or DRESS (4·73ng/ml±3·00)) patients vs. tolerant controls (2·97ng/ml±3·00). HMGB1 was significantly elevated in Taiwanese SJS/TEN patients, highest during the acute phase 32·6ng/ml±26·6 vs. maximal (19·7ng/ml±23·2; p=0·007) and recovery (24·6ng/ml±25·3; p=0·027) phases. In blister fluid from Spanish SJS/TEN patients, HMGB1 (486·8ng/ml±687·9) was significantly higher than in serum (8·8ng/ml±7·6; p<0·0005). Pre‐blistered SJS/TEN skin demonstrated decreased epidermal nuclear HMGB1 expression in upper epidermis vs. healthy or MPE skin but retained basal/suprabasal expression.

Epidermal HMGB1 expression was decreased in SJS/TEN skin which may account for elevated serum and blister‐fluid levels. Retained basal/suprabasal epidermal HMGB1 expression, from resident keratinocytes/ infiltrating inflammatory cells, may exacerbate localised injury in SJS/TEN, though further evaluation is required.

This article is protected by copyright. All rights reserved.

http://bit.ly/2VAb4po

Osseointegrated Auditory Devices

Osseointegrated auditory devices (OADs) are hearing devices that use an external receiver/processor that stimulates bone conduction of sound via a titanium prosthesis that is drilled into the bone of the cranium. Since their introduction in 1977, OADs have undergone substantial evolution, including changes in manufacturing of the implant, improvements in the external sound processor, and simplification of implantation techniques. Expansion of criteria for patient candidacy for implantation has occurred corresponding with changes in the implants and processors.

http://bit.ly/2SDeZjD

Electroacoustic Stimulation

Electric acoustic stimulation (EAS), also known as hybrid stimulation, is indicated for individuals with intact low-frequency hearing and profound high-frequency hearing loss. Although low frequencies contribute to speech perception, these individuals are usually only able to detect vowels, but few or no consonants, and thus have difficulty with word understanding and hearing in noise. EAS uses the cochlear implant electrode array to stimulate the high frequencies within the basal turn of the cochlea coupled with a hearing aid to convey the low frequencies at the apical turn in the same ear.

http://bit.ly/2Ayt3DR

Clinical Thyroidology®Top-Read Articles

FREE ACCESS through January 17, 2019
Read Now:

Levothyroxine Replacement for Primary Hypothyroidism Can Be Given Between Meals with Similar Effectiveness at Various Times of the Day
Charles H. Emerson

Most "Recurrences" of Thyroid Cancer Represent Persistent Rather Than Recurrent Disease
Martin Biermann, Katrin Brauckhoff 

Surgery for Hyperthyroidism Lowers Cardiovascular Mortality Compared with Radioactive Iodine
Andrew J. Day, Michael W. Yeh, Masha J. Livhits 

No Benefit of Levothyroxine Among Pregnant Hypothyroid and/or Hypothyroxinemic Women on Offspring IQ at Age 9 years
Angela M. Leung 

Current ATA Thyroid Cancer Guidelines Are Poor Predictors of the Extent of Thyroidectomy
Tracy S. Wang 

Using the American College of Radiology Thyroid Imaging Reporting and Data System Will Decrease the Number of Thyroid Nodule Biopsies While Improving Diagnostic Accuracy
Stephanie A. Fish

Levothyroxine Treatment Does Not Reduce Risk for Premature Delivery Among TPO-Negative Pregnant Women with a TSH of 2.5 to 10.0 mIU/L
Elizabeth N. Pearce 

Methimazole Has a Dose-Dependent Association With Congenital Malformations, but Switching to PTU in the First Trimester Seems Too Late
Tim I.M. Korevaar 

The post Clinical Thyroidology^®Top-Read Articles appeared first on American Thyroid Association.

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Pheochromocytoma presenting with severe hyperglycemia and metabolic acidosis following intra-articular glucocorticoid administration: a case report

There are several reports of pheochromocytoma crisis triggered by systemic glucocorticoid administration. However, pheochromocytoma crisis after intra-articular glucocorticoid administration has been rarely re...

http://bit.ly/2CRIuc8

Prophylactic sivelestat for esophagectomy and in-hospital mortality: a propensity score-matched analysis of claims database

Abstract

Purpose

Transthoracic esophagectomy is an invasive surgery, and the excessive surgical stress produces inflammatory cytokines, which provoke acute respiratory distress syndrome (ARDS). Sivelestat sodium hydrate—a selective neutrophil elastase inhibitor—is used to treat or prevent ARDS in patients undergoing esophagectomy, although clear evidence is lacking. We investigated the benefits and risk of prophylactic sivelestat.

Methods

This retrospective study used an administrative claims database in Japan. Adult patients who underwent transthoracic esophagectomy from 2010 to 2016 were identified and divided into a prophylactic sivelestat use group and a non-prophylactic use group that included both non-users and therapeutic users. The primary outcome was all-cause in-hospital mortality, and a secondary outcome included the proportion of ARDS. We used 1:1 propensity score matching. For sensitivity analyses, we conducted a 1:2 propensity score matching analysis and several analyses with various patient inclusion criteria.

Results

Of the 3391 patients with esophagectomy, 621 received prophylactic sivelestat. On unadjusted analysis, the sivelestat group had a higher proportion of in-hospital mortality (5.3% vs. 2.9%) compared with the control group. We created a matched cohort of 615 pairs, whose baseline characteristics were well balanced. On adjusted analysis using propensity score matching, prophylactic sivelestat administration was not associated with decreased in-hospital mortality [adjusted odds ratio (aOR) 1.65; 95% confidence interval (CI) 0.95–2.88], ARDS rate (aOR 1.25; 95% CI 0.49–3.17). The findings were also consistent with other sensitivity analyses.

Conclusion

Because mortality and postoperative complications were similar, our findings do not support prophylactic sivelestat administration for patients undergoing esophagectomy.

http://bit.ly/2RBV1by

Melkersson–Rosenthal syndrome: a case report of a rare disease with overlapping features

Melkersson–Rosenthal syndrome (MRS) is a rare, neuro-mucocutaneous disease which presents as orofacial swelling, facial palsy and fissured tongue. These symptoms may occur simultaneously or, more frequently, w...

http://bit.ly/2VvYlEw

IL2RG hypomorphic mutation: identification of a novel pathogenic mutation in exon 8 and a review of the literature

Atypical X-linked severe combined immunodeficiency (X-SCID) is a variant of cellular immunodeficiency due to hypomorphic mutations in the interleukin 2 receptor gamma (IL2RG) gene. Due to a leaky clinical phenoty...

http://bit.ly/2Qre2J4

Cancer Stem Cell based molecular predictors of tumor recurrence in Oral squamous cell carcinoma

Publication date: Available online 4 January 2019

Source: Archives of Oral Biology

Author(s): Simple Mohanta, Samanta Sekhar Khora, Amritha Suresh

Abstract

Objective

This study aimed to identify the cancer stem cell specific biomarkers that can be effective candidate prognosticators of oral squamous cell carcinoma.

Design

Microarray-based meta-analysis derived transcriptional profile of head and neck cancers was compared with the cancer stem cell database to arrive at a subset of markers. This subset was further co-related with clinico-pathological parameters, recurrence and survival of oral cancer patients (n = 313) in The Cancer Genome Atlas database and in oral cancer (n = 28) patients.

Results

Meta-analysis in combination with database comparison identified a panel of 221 genes specific to head and neck cancers. Correlation of expression levels of these markers in the oral cancer cohort of The Cancer Genome Atlas (n = 313) with treatment outcome identified 54 genes (p < 0.05 or fold change >2) associated with disease recurrence, 8 genes (NQO1, UBE2C, EDNRB, FKBP4, STAT3, HOXA1, RIT1, AURKA) being significant with high fold change. Assessment of the efficacy of the subset (n = 54) as survival predictors identified an additional 4 genes (CDK1, GINS2, PHF5 A, ERBB2) that co-related with poor disease-free survival (p < 0.05). CDK1 showed a significant association with the clinical stage, margin status and with advanced pathological parameters. Initial patient validation indicated that CDK1 and NQO1 significantly co-related with the poor disease-free and overall survival (p < 0.05).

Conclusion

This panel of oral cancer specific, cancer stem cell associated markers identified in this study, a subset of which was validated, is of clinical benefit subject to large scale validation studies.

http://bit.ly/2C1gG3a

Assessing the educational quality of ‘YouTube’ videos for facelifts

Publication date: Available online 4 January 2019

Source: American Journal of Otolaryngology

Author(s): Adeeb Derakhshan, Linda Lee, Prabhat Bhama, Eric Barbarite, David Shaye

Abstract

Objectives

Facelifts are among the most common facial plastic procedures performed. Given the existence of a variety of surgical approaches and the proximity of key anatomical structures, the development of proper surgical skills and knowledge is necessary to ensure positive outcomes. Many surgical learners utilize YouTube videos as supplemental tools in their education. Our aim was to gauge the quality and quantity of available YouTube videos describing the surgical approach to rhytidectomy.

Methods

The YouTube video platform was searched using predefined keywords. Videos meeting inclusion criteria were reviewed and scored by 3 practicing facial plastic and reconstructive surgeons. Thirteen different intraoperative, pre/postoperative, and video quality characteristics were scored on a binary scale by each grader. Descriptive statistics were obtained and interrater reliability was assessed using Kappa's coefficient.

Results

Thirteen videos met criteria for analysis. A high degree of interrater reliability was confirmed using Kappa's coefficient, with κ values = 0.73, 0.75, and 0.59 for each combination of scorers. In general, YouTube videos were found to be deficient in discussing key criteria of rhytidectomy, particularly with regards to pre/postoperative points such as indications, patient selection, and possible complications. Intraoperative benchmarks were also lacking, with 8/13 videos not discussing the facial nerve and 8/13 failing to demonstrate an appropriate facelift incision.

Conclusions

YouTube instructional videos depicting rhytidectomy lack discussion of key tenets of successful facelift surgery. Until improvement in the educational quality of such material occurs, surgical trainees should implement discretion when choosing YouTube videos to complement their learning.

Level of Evidence: Not Applicable.

http://bit.ly/2TsiM3d

Recomendaciones de la Guía de Práctica Clínica de la exploración de la vía aérea superior para pacientes adultos con sospecha de síndrome de apnea-hipoapnea obstructiva del sueño (versión reducida)

Publication date: Available online 5 January 2019

Source: Acta Otorrinolaringológica Española

Author(s): Eduard Esteller, Marina Carrasco, Miguel Ángel Díaz-Herrera, Javier Vila, Gabriel Sampol, Joan Juvanteny, Ramon Sieira, Alex Farré, Isabel Vilaseca

Resumen

En noviembre 2014 la Sociedad Española de Otorrinolaringología, la Sociedad Española de Sueño y la Sociedad Española de Cirugía Maxilofacial propusieron y avalaron la elaboración de una Guía de Práctica Clínica sobre la exploración física de la vía aérea superior en pacientes con apnea obstructiva del sueño.

La Guía ha seguido de forma estricta en toda su elaboración las recomendaciones del manual de elaboración de guías de práctica clínica del Sistema Nacional de Salud 2007 y 2009 y el manual de la Scottish Intercollegiate Guidelines Network (SIGN) 2015.

El documento final puede ser altamente útil para los fines que se propuso inicialmente: ser un referente para unificar las regiones que deben ser exploradas en los pacientes con síndrome de apnea-hipoapnea obstructiva del sueño, mediante qué tipo de exploración y cómo gradarla, y expresada para todos los ámbitos asistenciales a los que estos pacientes pueden acudir.

Las conclusiones y recomendaciones están basadas en una revisión exhaustiva y actualizada de la bibliografía con alto nivel de evidencia, además de la experiencia y conocimientos demostrados de todos los integrantes del grupo de elaboración.

Dicho grupo se constituyó pensando siempre en la transversalidad del proyecto, y, por tanto, han participado especialistas de todos los ámbitos implicados (cirugía maxilofacial, medicina de familia, neumología, neurofisiología clínica, odontología y otorrinolaringología). Con la misma idea se seleccionaron los revisores externos del texto final.

Abstract

In November 2014 the Spanish Society of Otolaryngology, the Spanish Sleep Society and the Spanish Society of Maxillofacial Surgery proposed and endorsed the development of a Clinical Practice Guideline on the physical examination of the upper airway in patients with obstructive sleep apnoea.

The Guideline strictly followed the recommendations of the manual for the preparation of clinical practice guidelines of the National Health System 2007 and 2009 and the manual of the Scottish Intercollegiate Guidelines Network (SIGN) 2015.

The final document could be highly useful for the purposes that were originally proposed: to act as a reference to unify the regions that should be explored in patients with obstructive sleep apnoea-hypopnoea syndrome, the type of examination and how to grade it, and specific to all the care areas to which these patients have access.

The conclusions and recommendations are based on a thorough and up-to-date review of the literature with a high level of evidence, as well as the experience and knowledge demonstrated by all the members of the drafting group.

This group was formed bearing in mind at all times the transversality of the project, and, therefore, specialists from all the involved areas participated (maxillofacial surgery, family medicine, pneumology, clinical neurophysiology, odontology and otolaryngology). The external reviewers of the final text were selected along the same lines.

http://bit.ly/2Axw0Vv

Application of Implantable Hearing Aids and Bone Conduction Implant System in patients with bilateral congenital deformation of the external and middle ear

Publication date: Available online 5 January 2019

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Yiqing Zheng, Junfeng Lin, Suijun Chen, Huasong Zhang, Haiwen Ye, Hao xiong, Zhigang Zhang, Maojin Liang, Xueyuan Zhang

Abstract

Objective

To determine the efficacy of the application of the Implantable Hearing Aids and Bone Conduction Implant System in patients with bilateral congenital deformation of the external and middle ear.

Methods

twenty patients with bilateral congenital malformation of the external and middle ear were included in the study. Implantable Hearing Aids implantation was performed in ten patients, and Bone Conduction Implant System implantation was performed in ten patients. Audiometric tests, including pure-tone audiometry and speech discrimination in the free field were performed pre-operatively and post-operatively.

Results

Implantable Hearing Aids and Bone Conduction Implant System implantation were performed successfully in all patients. The mean pure-tone threshold improvement with Implantable Hearing Aids or Bone Conduction Implant System activation in the free filed pure tone audiometry was 25 dB and ranged from 0.25 to 4 kHz. Mean free field speech discrimination in quiet was 80% at 65 dB compared to 18% pre-operatively. The mean pure-tone threshold improvement with Bone Conduction Implant System was 25.5 dB better than 18.2 dB with Implantable Hearing Aids. The mean free filed speech discrimination in quite improvement with Bone Conduction Implant System was 66% better than 58% with Implantable Hearing Aids.

Conclusion

Implantable Hearing Aids or Bone Conduction Implant System are effective options for improving hearing in patients with bilateral congenital deformation of the external and middle ear. The procedure is safe and effective, and its indications are wider than those of tympanoplasty for such cases. Furthermore, the Bone Conduction Implant System is better than Implantable Hearing Aids, tympanoplasty and hearing aids.

http://bit.ly/2LSyj9R

Immediate versus Delayed Surgery in Congenital Choanal Atresia: A Systematic Review

Publication date: Available online 4 January 2019

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Scott Murray, Lindy Luo, Alexandra Quimby, Nick Barrowman, Jean-Philippe Vaccani, Lisa Caulley

Abstract

Objectives

To evaluate immediate versus delayed surgical intervention on treatment outcomes in the management of congenital choanal atresia.

Methods

This study adhered to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines in reporting a systematic review of the literature. OVID Medline, EMBASE and Pubmed databases were searched using relevant key terms. Inclusion and exclusion criteria were designed to capture studies examining immediate versus delayed primary surgery for congenital choanal atresia. Timing of surgery was classified as immediate or delayed based on median age of intervention stratified by type of obstruction. Primary outcomes were primary treatment failure, respiratory function and mortality rates.

Results

A total of 2765 abstracts were identified and screened by 2 independent reviewers. Of the 688 articles reviewed in full text, 23 articles met the study criteria and were subjected to quality assessment. The full study assessment and quality control measures yielded 23 studies (representing 362 patients) for pooled patient-level analysis in the systematic review. Primary treatment failures occurred in 24.8% of patients that underwent immediate surgery and 42.6% of patients that underwent delayed surgery for bilateral choanal atresia (p=0.01). There were no differences in mortality rates (5.6% vs 4.2%; p=1.00) or qualitative measures of respiratory function. There were no difference in treatment outcomes for patients with unilateral choanal atresia (p>0.05).

Conclusions

Through an analysis of pooled individual patient data, this systematic review of the literature demonstrated that there was significantly higher rates of treatment failure in patients that underwent delayed surgery for bilateral choanal atresia. Clinical trials and large prospective cohort studies investigating outcomes following immediate and delayed surgical intervention will provide further insight into treatment strategies.

http://bit.ly/2sa0Qi2

Soft Palate Subacute Necrotising Sialadenitis: A Case Report

Abstract

Subacute Necrotising Sialadenitis (SANS) is a self-limiting, inflammatory disorder of minor salivary glands of unknown etiology. Minor salivary glands over soft and hard palate are most commonly affected. SANS shares considerable clinical features with necrotizing sialometaplasia, which is also the commonest differential diagnosis. We present an intriguing case of soft palate SANS in a 55 year old lady.

http://bit.ly/2FbB3hk

Soft Palate Subacute Necrotising Sialadenitis: A Case Report

Abstract

Subacute Necrotising Sialadenitis (SANS) is a self-limiting, inflammatory disorder of minor salivary glands of unknown etiology. Minor salivary glands over soft and hard palate are most commonly affected. SANS shares considerable clinical features with necrotizing sialometaplasia, which is also the commonest differential diagnosis. We present an intriguing case of soft palate SANS in a 55 year old lady.

http://bit.ly/2FbB3hk

Immunologic mediators of outcome for irradiated oropharyngeal carcinoma based on human papillomavirus status

Publication date: February 2019

Source: Oral Oncology, Volume 89

Author(s): Jessica Meshman, Maria A. Velez, Pin-Chieh Wang, Elliot Abemayor, Maie St. John, Deborah Wong, Sunita Bhuta, Allen M. Chen

Abstract

Purpose

To investigate the prognostic value of pre-treatment immune parameters including white blood cell count (WBC) and circulating lymphocyte count (CLC) among patients with oropharyngeal carcinoma treated by radiation therapy.

Methods and Materials

A total of 136 consecutive patients were treated by radiation therapy for locally advanced (stage III/IV) squamous cell carcinoma of the oropharynx with known human papillomavirus (HPV) status. Medical records were reviewed to identify patients with documented pre-treatment laboratory bloodwork. The Kaplan-Meier method and linear regression models were used to evaluate the association between pre-treatment CBC and CLC values with survival endpoints.

Results

One hundred and eleven patients satisfied inclusion criteria. Median age was 62 years (range, 22–91). Eighty-four patients were HPV-positive (76%) and 27 (24%) were HPV-negative. There was no difference in WBC and CLC mean values at baseline between HPV-positive and HV-negative (p > 0.05, for both). Trends were detected in the HPV-positive cohort favoring patients with higher CLC, with respect to 2-year local-regional control (93% vs. 82%, p = 0.06) and distant control (88% vs. 82%, p = 0.10) using the median CLC as cut-off. HPV-positive patients with CLC values in the lowest quartile had inferior local-regional control compared to those in the upper 3 quartiles (69% vs. 89%, p = 0.01).

Conclusion

Low pre-treatment CLC was correlated with local-regional recurrence and distant failure among HPV-positive patients. These associations were not observed in the HPV-negative cohort.

http://bit.ly/2C1fnkP

Editorial Board/Aims & Scope

Publication date: January 2019

Source: Oral Oncology, Volume 88

Author(s):

http://bit.ly/2R7jzd2

Unexpected response with palliative conventional therapy in head and neck squamous cell carcinoma after anti‐programmed death‐1 progression

Abstract

Background

The application of anti‐programmed death‐1 (PD‐1) therapies for recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) has found promising results. It is the first "second‐line therapy" in this setting to impact on prognosis. The studies demonstrated overall response rates in the range of 20%. Therefore, HNSCC showed 60%‐80% progression at first evaluation with better overall survival, suggesting regained efficacy of treatments given thereafter.

Methods

We report three clinical cases treated with anti‐PD‐1 after platinum‐based chemotherapy.

Results

Our case reports achieved an unforeseen response to conventional therapies supporting the hypothesis of restored responses to conventional therapies after immunotherapy.

Conclusions

We believe that the inhibition of the PD‐1/PD‐ligand 1 checkpoint may synergize with both chemotherapy or radiotherapy through immunologic interplay, reversing the HNSCC‐induced immune suppression.

http://bit.ly/2VpbUFw

Cetuximab‐associated pulmonary toxicity in concurrent chemoradiation for the treatment of a squamous cell carcinoma of the head and neck

Abstract

Background

Cetuximab is a common EGFR monoclonal antibody used with radiotherapy to treat head‐and‐neck cancer. Severe pulmonary toxicity, including interstitial lung disease (ILD), caused by cetuximab is rare.

Methods

We describe a patient who developed ILD and acute respiratory failure after concurrent chemoradiation with cetuximab for oropharyngeal squamous cell carcinoma, and review the literature.

Results

A patient developed acute respiratory failure 2 months after starting concurrent chemoradiation with cetuximab and was hospitalized in intensive care after a procedure for progressive respiratory distress. Cultures and serology were negative for infection and radiologic findings were consistent with drug associated pneumonitits. Steroids were administered until the patient was stabilized. The patient fully recovered 1 month after the onset of respiratory distress, although he died of recurrent disease 10 months after completing treatment.

Conclusion

Although severe pulmonary toxicity caused by EGFR inhibitors has been well described in the literature, ILD caused by cetuximab, an EGFR monoclonal antibody, is rare and not well‐documented. Given its life‐threatening effects, awareness of this potential side effect and early diagnosis is critical.

http://bit.ly/2Qppx3O

Systemic lupus erythematosus‐associated neutrophilic dermatosis manifesting as an acneiform eruption and foot pain

http://bit.ly/2BZvYW9

Ultraviolet B irradiation increases the expression of trichohyalin‐like 1 protein in human skin xenotransplants

Summary

Trichohyalin‐like (TCHHL)1 is a member of the fused‐type S100 protein family. Its function remains unknown, although it has been reported to be expressed in the basal layer of the normal epidermis. The aim of this study was to investigate the effects of ultraviolet B (UVB) irradiation on the expression of TCHHL1 in human skin xenotransplants. Expression of TCHHL1 mRNA was increased in the UVB‐exposed skin 2 days after UVB irradiation. TCHHL1 was immunohistochemically detected in the basal layers after sham irradiation. However, on Day 2 after irradiation, the TCHHL1 signals were spread throughout the basal and spinous layers of the irradiated skin, with increased expression of cytokeratin 14 and a dramatic increase in the number of Ki67‐positive cells observed. These results show that TCHHL1 is a novel protein whose expression can be increased by UVB irradiation. In addition, this study experimentally shows that TCHHL1 is expressed in proliferative keratinocytes.

http://bit.ly/2Ra7DaK

Patch granuloma annulare:Clinicopathological characteristics and response to phototherapy

Abstract

Granuloma annulare (GA) is a benign cutaneous disease. Clinical variants include classic, generalized, perforating, subcutaneous and patch type GA. Patch GA shows a distinct clinical presentation of smooth erythematous to brownish macules surfacing on the extremities and trunk with no evidence of papules or induration. Diagnosis is usually made by histopathology revealing a pattern of interstitial GA.

This article is protected by copyright. All rights reserved.

http://bit.ly/2GWePT2

Incidence of melanoma and outcomes of longitudinal melanonychia in a cohort of cases referred to a London dermatology department

Abstract

Longitudinal melanonychia is a pigmented longitudinal band on the nail plate and may occur due to melanocyte activation, nail matrix nevus, lentigo or subungual melanoma.¹ In a racially diverse community, melanonychia is a relatively common presenting complaint. However, despite this, little is known about the incidence of melanoma in longitudinal melanonychia, as well as variations in management approaches.

This article is protected by copyright. All rights reserved.

http://bit.ly/2RvXVyJ

Incisional random skin biopsy, not punch biopsy, is an appropriate method for diagnosis of intravascular large B‐cell lymphoma: A clinicopathological study of 25 patients

Abstract

Intravascular large B‐cell lymphoma (IVLBCL) is a rare subtype of malignant lymphoma characterised by atypical lymphoid cell proliferation within small vessels. We previously reported that random skin biopsy (RSB) is useful for the early diagnosis of IVLBCL; we emphasised the importance of subcutaneous fat tissue in biopsied specimens because most IVLBCL lesions are found in the vessels of subcutaneous fat tissue. However, Maekawa et al. found that seven of nine patients (78%) had IVLBCL lesions in the dermis.

This article is protected by copyright. All rights reserved.

http://bit.ly/2H4ZUpQ

CONSORT 2010 statement: extension checklist for reporting within person randomised trials

Summary

Evidence shows that the quality of reporting of randomised controlled trials (RCTs) is not optimal. The lack of transparent reporting impedes readers from judging the reliability and validity of trial findings and researchers from extracting information for systematic reviews and results in research waste. The Consolidated Standards of Reporting Trials (CONSORT) statement was developed to improve the reporting of RCTs. Within person trials are used for conditions that can affect two or more body sites, and are a useful and efficient tool because the comparisons between interventions are within people. Such trials are most commonly conducted in ophthalmology, dentistry, and dermatology. The reporting of within person trials has, however, been variable and incomplete, hindering their use in clinical decision making and by future researchers. This document presents the CONSORT extension to within person trials. It aims to facilitate the reporting of these trials. It extends 16 items of the CONSORT 2010 checklist and introduces a modified flowchart and baseline table to enhance transparency. Examples of good reporting and evidence based rationale for CONSORT within person checklist items are provided.

http://bit.ly/2RCweEA

Prevalence and outcome of latent tuberculosis in patients receiving ixekizumab: Integrated safety analysis from 11 clinical trials of patients with plaque psoriasis

Abstract

Tuberculosis (TB) is one of the top ten causes of death worldwide, with approximately 10.0 million active TB cases in 2017 (range 9.0 to 11.1 million) occurring in all countries and age groups and estimates of 1.7 billion people having latent TB infection (LTBI). The lifetime risk for reactivation of LTBI is 5% to10%, and certain immunosuppressant therapies increase this risk. Data on TB risk following anti‐interleukin (IL)‐17A treatment in humans are limited, with no cases of LTBI reactivation reported thus far.

This article is protected by copyright. All rights reserved.

http://bit.ly/2GY2X2R

Nasal branch of the anterior ethmoid artery: a consistent landmark for a midline approach to the frontal sinus

Background

Frontal sinusotomy can be challenging when significant scarring or distorted anatomy is present. Identifying a reliable anatomic structure, when traditional landmarks or navigation are absent, may assist the surgeon in revision and complicated frontal sinusotomies via a midline approach. We aimed to characterize the anatomic relationship of the nasal branch of the anterior ethmoid artery (NBAEA) to the frontal infundibulum, specifically the first olfactory fili, posterior frontal infundibulum, and anterior cribriform plate.

Methods

Dissection of the NBAEA was carried out in 11 cadaveric heads, resulting in a total of 21 dissections (1 aplastic frontal). Mean with standard deviation and a range were established for 7 relative measurements.

Results

The total length of NBAEA cleft when present (mean 2.43 mm), the anterior edge of NBAEA cleft to anterior infundibulum coronal plane (mean 1.71 mm), the posterior edge of NBAEA cleft to posterior infundibulum coronal plane (mean 3.33 mm), the posterior edge of NBAEA cleft to 1st olfactory fili (mean 2.86 mm), and the first olfactory fili to posterior infundibulum coronal plane (mean 0.48 mm) were consistent measurements supporting the use of the NBAEA as a consistent anatomical landmark for the correct surgical coronal trajectory into the midline frontal sinus.

Conclusion

The NBAEA is a consistent anatomic landmark with minimal intercadaveric and intracadaveric variation. It can be used reliably as a "sentinel artery" notifying the surgeon when one is approaching the first olfactory fili, to determine the correct trajectory into the midline frontal sinus.

http://bit.ly/2F9pqID

Influence of a medialized middle turbinate on olfactory function: a prospective randomized double‐blind study

Background

Medialization of the middle turbinate (MT) is an effective technique to prevent recurrent rhinosinusitis but could, in theory, reduce olfactory function by interfering the odorants to reach the olfactory mucosae. We performed a prospective randomized double‐blind trial under the hypothesis that olfactory functions would be affected by the status of olfactory mucosae, not by MT medialization.

Methods

In randomly selected sides, the unilateral MT was medialized in 80 patients undergoing bilateral endoscopic sinus surgery for chronic rhinosinusitis. The status of the bilateral olfactory cleft (OC) was photodocumented intraoperatively and categorized into patent (normal or mucosal swelling with discharge) and congested (hypertrophied mucosae or nasal polyps) groups. The butanol threshold test (BTT) was conducted in each nostril before and 6 months after the surgery. Correlation between the BTT scores and MT medialization or the OC status was assessed. No smell identification test was conducted side by side, which might limit clinical implications.

Results

In total, 46 of 80 patients completed the trial. MT medialization was performed on the left and right side of the nose in 19 and 27 cases, respectively. The intraoperative OC status did not differ between the 2 sides. Perioperative changes in the BTT scores were similar between the medialized and intact MT sides, whereas the preoperative and postoperative BTT scores were higher in the patent OC group than in the congested OC group, regardless of side.

Conclusion

MT medialization does not impair olfactory function, and OC status is closely related to olfactory function.

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Childhood onset atrophic plaque on the chest of a woman with history of acral lentiginous melanoma

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Late‐onset psoriatic arthritis in Japanese patients

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Malignant solitary fibrous tumor in the subcutis: Report of a rare superficial malignant type and review of published work

Abstract

An 82‐year‐old Japanese man presented with a 90 mm × 80 mm subcutaneous nodule on the left chest, not connected to the pleura, described as hypointense on T₁‐weighted magnetic resonance imaging. Histologically, a well‐demarcated nodule demonstrated a patternless pattern composed of hemangiopericytoma‐like and short storiform patterns from the subcutis into deeper tissue. Antler‐like branching blood vessels and keloidal‐type collagen bundles were seen. Myxoid change was seen in hypocellular areas. Bizarre cells and multinucleated giant cells could be easily identified. Approximately 5 mitoses per 10 high‐power fields could be detected. The majority of proliferating spindle cells were positive for CD34, CD99 and BCL2 expression. Signal transducer and activator of transcription (STAT)6 was strongly expressed in the nuclei. The Ki‐67 proliferation index was 60%. We performed wide local excision with a 30‐mm margin, along with resection of intercostal muscles, fasciae and periostea. Neither local recurrence nor distant metastases have occurred in 16 months of follow up. The present case is consistent with malignant solitary fibrous tumor in the subcutis histologically mimicking myxofibrosarcoma or undifferentiated pleomorphic sarcoma, definitively diagnosed by immunoexpression of STAT6. We performed a review of the published work and identified six previously reported patients with malignant superficial solitary fibrous tumor to validate the characteristics of this rare type. Four men and two women were included. The sarcomas involved the head area, trunk and thigh. Only one tumor‐associated death occurred despite excision and radiotherapy. Complete excision is a possible treatment choice for this tumor type.

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Trichophytic closure for cicatricial alopecia on the scalp

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Genital elephantiasis possibly caused by chronic inguinal eczema with streptococcal infection

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Clinical value of 18F‐fluorodeoxyglucose positron emission tomography/computed tomography for interstitial lung disease and myositis in patients with dermatomyositis

Abstract

¹⁸F‐Fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) is usually used to screen malignancy in patients with dermatomyositis (DM). Additionally, it is well known that FDG‐PET/CT provides valuable information for evaluating the activity of several inflammatory diseases, such as sarcoidosis, atherosclerosis, inflammatory bowel disease and rheumatoid arthritis. Therefore, the objective of this study was to evaluate the clinical usefulness of FDG‐PET/CT for the detection of inflammatory lesions and disease activity of both myopathy and interstitial lung disease (ILD) in DM patients. We measured the maximum standardized uptake value (SUVmax) in the muscles and lungs in 22 DM patients, and compared with magnetic resonance imaging (MRI) and high‐resolution computed tomography (HRCT) findings in the same muscle and lung regions as well as with clinical findings. We found that the location of increased FDG uptake was nearly consistent with the region of ILD and myositis detected by HRCT or MRI, respectively. There was a significant positive correlation between lung HRCT score and SUVmax in each lung. Serum Krebs von den Lungen‐6 levels also revealed significant positive correlation with total SUVmax of right and left lungs. Regarding FDG‐PET/CT and myopathy, total SUVmax in the muscles was significantly correlated with serum cytokeratin levels. Our results suggest that FDG uptake (SUVmax) might be useful for not only the detection of malignant tumors, but also the evaluation of the location and activity of ILD and myositis in DM patients.

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Family and Community Medicine

A profile of physical activity, sedentary behaviors, sleep, and dietary habits of Saudi college female students Hana A Alzamil, Manan A Alhakbany, Nora A Alfadda, Sarah M Almusallam, Hazzaa M Al-Hazzaa Journal of Family and Community Medicine 2019 26(1):1-8 BACKGROUND: Few studies have reported valid comprehensive data on lifestyle habits of Saudi college females. In addition, studies on sedentary behaviors (SBs) and the duration of sleep of Saudi college students are rare. Saudi females appear to be less physically active and therefore, at a higher risk of noncommunicable diseases (NCDs). Therefore, the purpose of this study was to investigate lifestyle patterns of Saudi college females, including physical activity (PA), SBs, duration of sleep, and dietary habits. MATERIALS AND METHODS: A cross-sectional study was conducted among females attending health science colleges of King Saud University, using multistage stratified cluster sample (n = 456). Weight, height, PA, SB, sleep, and dietary habits were all assessed using a previously validated questionnaire. RESULTS: Nearly half of the college females were physically inactive. Females exercised mostly at home or alone at no specific time of day. Their activity was for health reasons (43.4%) for weight loss (28.7%); lack of time (71.2%) was the primary reason for inactivity. The majority (>85%) of females spent more time in sedentary activity (>3 h/day) while 95% of females had insufficient sleep (<8 h/night). Over 40% of the participants consumed breakfast or vegetables 5 days or more per week, whereas the corresponding proportions for fruit and milk/dairy products intake were 19.4% and 58.4%, respectively. The proportions of college females who consumed less healthy foods for 3+ days/week were fairly variable, ranging from 21.1% for French fries to 60.4% for chocolates/candy. The predictors of total PA time were increased the duration of sleep and reduced intake of French fries/potato chips. CONCLUSIONS: Unhealthy lifestyle habit appears prevalent among Saudi college females. Efforts toward promoting PA, decreasing SB, and insufficient sleep and improving dietary habits in Saudi females are needed to reduce future risks of NCDs.

Consistency of child self-reports with parent proxy reports on the quality of life of children with attention-deficit/hyperactivity disorder in Riyadh, 2016 Dina M Al-Habib, Fatima A Alhaidar, Ibrahem M Alzayed, Randa M Youssef Journal of Family and Community Medicine 2019 26(1):9-16 BACKGROUND: The quality of life (QoL) of children with attention-deficit/hyperactivity disorder (ADHD) has not been addressed in Saudi Arabia despite the considerable attention it has on account of its prevalence, duration of illness, and sociopsychological effects. The aim of this study was to report on the QoL of children with ADHD and test the concord between children's and parents' reports. MATERIALS AND METHODS: Using the generic PedsQL™ (version 4.0) from both children's and parents' perspectives, a cross-sectional study of 112 children was conducted on children aged 5–18 years with an established diagnosis of ADHD attending child psychiatry clinics of three referral hospitals in Riyadh between December 2015 and May 2016. RESULTS: A total of 112 children with an established diagnosis of ADHD were recruited from the Child Psychiatry Clinic of Al Amal Mental Health Complex (41.1%), Prince Sultan Military Medical City (PSMMC), (33%), and King Khalid University Hospital (KKUH), (25.9%). The majority were boys (74.1%) and Saudi nationals (93.8%). The mean age of children with ADHD was 10.45 ± 3.06 years (Range 5 - 18 years). One-fourth of the mothers of children with ADHD had completed high school and 41.1% had a diploma, university, or postgraduate degree. One-third of the fathers of these children had completed high school (34%) and 38.4% had a diploma, university, or postgraduate degree. The intra-class correlation coefficients between the scores of children and parents were good for physical functioning, fair for social functioning, but moderate for school, emotional, and psychosocial functioning. Children rated themselves significantly better than their parents for emotional, social, school, and psychosocial functioning. The standardized response means indicated a small difference for social functioning and medium differences for the other three domains. The only significant discrepancy was observed in social functioning in relation to the child's age. CONCLUSION: Parents mirrored adequately the observable physical component of the QoL of their children. The QoL report of children with ADHD with respect to communications and intellectual abilities should be taken into account whenever possible and their parents' report also should be sought to provide a more comprehensive view of the child's status.

The association between waiting time and patient satisfaction in outpatient clinics: Findings from a tertiary care hospital in Saudi Arabia Rasmah S Al-Harajin, Sara A Al-Subaie, Ahmed G Elzubair Journal of Family and Community Medicine 2019 26(1):17-22 BACKGROUND: Patient satisfaction is an important indicator for assessing the quality of health care because it affects the timely, efficient, and patient-centered delivery of quality health care, and patient satisfaction is associated with the clinical outcomes. This study aimed to examine the relationship between waiting time and patient satisfaction in a tertiary hospital in Saudi Arabia. MATERIALS AND METHODS: A cross-sectional study was conducted at family medicine and other specialized clinics. Data were collected through a structured, self-administered questionnaire distributed to patients seen at the outpatient clinics. Variables collected were sociodemographic information and patient satisfaction scores to evaluate the association between waiting time and satisfaction. RESULTS: A total of 406 patients participated in the study. Half of the patients reported being satisfied with the waiting time, while the remaining were dissatisfied (mean satisfaction score 38.4 ± 6.63). Family medicine clinic scored better in waiting time than other specialized clinics; between arrival and registration (P < 0.01), between registration and consultation (P < 0.01), consultation time (P < 0.01), and overall waiting time (P < 0.01). Patients treated at the family medicine clinic were more likely to be satisfied than those seen in other specialized clinics (61.2% vs. 40%, P < 0.01). CONCLUSION: Overall satisfaction was lower than shown in previous literature. Gender and clinic type were significantly associated with satisfaction score; those who attended the family medicine clinics were more satisfied than those attending other specialized clinics. Findings may be used to inform researchers, clinicians, and policy-makers' decisions on quality improvement programs.

The impact of using the term "Diabetic Ear" for the patients with skull base osteomyelitis Abdulaziz S AlEnazi, Salma S Al Sharhan, Laila M Telmesani, Nasser A Aljazan, Bander M Al Qahtani, Mohamed A Lotfy Journal of Family and Community Medicine 2019 26(1):23-29 BACKGROUND: Diabetes and ear disease are some of the most widespread health concerns. The focus here is on the impact of using the term “Diabetic Ear” for patients with skull base osteomyelitis (SBM) in the context of malignant otitis externa (MOE). The aim of this study was to discover the awareness of general practitioners (GPs), residents, specialists, and consultants at Primary Health Care Centers about necrotizing otitis externa (NOE), also known previously as malignant external otitis (MOE), assess their deficiencies and provide solutions; also assist them for the early detection and possible prevention of diabetes- related ear diseases and their complications. MATERIALS AND METHODS: A cross-sectional study was conducted among a random sample of physicians (residents, specialists, and consultants) working at the Primary Health Care Centers in Al-Khobar and Dammam cities of the Eastern Province, Saudi Arabia. Data was collected using a standardized questionnaire. SPSS was used for data entry and analysis. RESULTS: The total number of medical practitioners was 84. Their mean age was 33.97 (±9.55). The proportion of females was higher than males, only 28.3% of the participants responded correctly when asked about MOE. Similarly, very few were aware of the risks of MOE (2.5%), complications associated with it (17.3%) and the necessary procedures for managing patients (24.2%). The awareness of doctors in the primary health clinics about MOE was significantly better than those in hospitals (P = 0.002). CONCLUSION: There was a significant deficiency in the knowledge of GPs on MOE. Therefore, health education and awareness programs on MOE are recommended. Furthermore, we recommend that it is necessary to encourage the use of the term “Diabetic EAR “to increase the level of awareness of physicians about MOE.

Effect of Zamzam water on blood methemoglobin level in young rats Ahmed Badar, Abdullah O Bamosa, Mohammed Salahuddin, Abdullah Al Meheithif Journal of Family and Community Medicine 2019 26(1):30-35 BACKGROUND: Methemoglobin (MetHb) level in blood indicates exposure to nitrogenous compounds. Acquired methemoglobinemia as a result of exposure to nitrates in drinking water is primarily an issue for infants. The amount of nitrates in Zamzam water is said to be on the high side. This study was designed to determine the effect of prolonged use of Zamzam water on MetHb in rat pups. MATERIALS AND METHODS: Wistar rat pups (n = 52, 3 weeks old) were divided into four equal groups. All of them were given normal laboratory chow. The groups differed only in the exclusive source of water, that is ordinary bottled water, standardized mineral water, old Zamzam water (stored since 2008) or fresh Zamzam water. MetHb level was checked (using Avoximeter 4000) at the baseline, and then every week for 4 weeks from blood obtained from retro-orbital sinus. Other parameters tested were total haemoglobin, oxyhemoglobin and carboxyhemoglobin. ANOVA was used to compare the means between the groups. RESULTS: None of the rats in any of the four groups showed any sign of methemoglobinemia or toxicity. Both groups on Zamzam water showed higher increments in their total hemoglobin by the end of the study compared to their baseline (22%) than the ordinary water (9%) and the mineral water (5%) groups. None of the groups showed any significant difference in MetHb levels on intergroup comparison at any of the weekly readings and at the end of the study. CONCLUSION: Prolonged use of Zamzam water did not induce any significant difference in MetHb concentration in rat pups, which might indicate that it is safe for infants.

Determinants of energy drinks consumption among the students of a Saudi University Mahmoud H Alabbad, Mohammed Z AlMussalam, Ahmed M AlMusalmi, Mohammad M Alealiwi, Ali I Alresasy, Haidar N Alyaseen, Ahmed Badar Journal of Family and Community Medicine 2019 26(1):36-44 BACKGROUND: Energy drinks contain stimulants mainly caffeine. The use of these drinks by university students is on the rise despite concerns about their safety. This study identified the determinants of the consumption of energy drinks in a cohort of Saudi university students. MATERIALS AND METHODS: This cross-sectional study was carried out at Imam Abdulrahman Bin Faisal University in Saudi Arabia. The students who volunteered to participate (n = 1255) were asked to complete a pretested questionnaire soliciting information on gender, marital status, class and college of study, pattern of energy drinks use, reasons for use, any benefits as well as any untoward effects experienced. Data was analysed using IBM-SPSS (version 21) to determine frequencies and compare various categories of the energy drink users. Logistic regression analysis were performed to identify determinants of energy drinks consumption. RESULTS: Out of 1255 participants, 245 reported using energy drinks. Out of a total 1255 students, 903 (72%) were from medical and 352 (28%) from nonmedical colleges of the university. There were 890 junior and 365 senior students. The female participants were significantly more among both senior and junior medical students. The age of the participants (mean ± SD) was 20.2 ± 1.9 years. The frequency of energy drinks users was higher in the male nonmedical students (both senior and junior) compared to the medical students. The most significant determinants identified were male gender (odds ratio [OR] 4.2, 95% confidence interval [CI] =3.34, 6.12), and being single (OR = 2.8, CI = 1.98, 4.24). In addition, being in non-medical field of study (OR = 1.3, 95% CI=0.61-2.13) was also found to have a reasonable association with energy drink consumption. CONCLUSION: We report male gender, unmarried status, and studying in nonmedical colleges of the university as the main determinants of the consumption of energy drinks by university students. Scrutiny of the patterns and reasons for the consumption of energy drinks might help in developing educational interventions to ensure the appropriate use of energy drinks by young adults.

Medical students' perception of their educational environment at Imam Abdulrahman Bin Faisal University, Kingdom of Saudi Arabia Soban Q Khan, Mohammad Al-Shahrani, Abdul Khabeer, Faraz A Farooqi, Abdullah Alshamrani, Abdulrahman M Alabduljabbar, Ahmed S Bahamdan, Mohammad A Alqathani Journal of Family and Community Medicine 2019 26(1):45-50 OBJECTIVE: The purpose of this study was to investigate students' perception of the educational climate in a medical school in Dammam, Kingdom of Saudi Arabia (KSA). The difference in the perception of preclinical year students and clinical year students was also evaluated. MATERIALS AND METHODS: This cross-sectional study was conducted among 2nd to 6th year students at the medical college of Imam Abdulrahman Bin Faisal University. “Dundee Ready Educational Environment Measure” (DREEM) was used to evaluate the educational environment. RESULTS: Out of 518, 238 students participated in the study; participation rate of 45.9%. The average DREEM score was 112.38 with a SD of 22.4. Students' perception of atmosphere got the highest score (27.1 ± 6.7) of the five DREEM subscales. The 3rd year had the highest DREEM score compared to students of other levels, while the DREEM score of preclinical students was significantly higher than that of the clinical year students. CONCLUSION: Perception of medical students about the educational climate was more positive than negative. Although the DREEM score and its subdomains showed a positive educational environment, students still mentioned some problematic areas that need to be addressed. Findings of this study could encourage other medical colleges in the KSA to focus on weak areas and address the issues raised by students, especially clinical year students.

Prevalence of patients with epilepsy unfit to drive Esra' H Al Zaid Journal of Family and Community Medicine 2019 26(1):51-56 BACKGROUND: There is no consensus among medical experts as to whether patients with epilepsy (PWEs) should be permitted to drive. PWEs who have had uncontrolled seizures in the past year are at an increased risk of road traffic accidents, often leading to the destruction of property, injury, or death. Currently, there is no clear policy on whether PWEs can drive in Saudi Arabia. Existing policies attempt to balance the potentially harmful and beneficial aspects of the issue. The purpose of this study was to measure the prevalence of PWEs who are unfit to drive. MATERIALS AND METHODS: Data were collected by interviews, a structured validated questionnaire, and a review of the medical records of 140 PWEs, with a response rate of 84%. RESULTS: Fifty four percent of PWEs were found unfit to drive. Of the 118 participants, 17.7% did not drive and 97 (82.3%) drove. Of the 21 patients who did not drive, 14 (11.8% of the total sample) never drove and 7 (5.9% of the total sample) stopped driving because of epilepsy. Of the 104 patients who drove, 45 (43.2% of the total sample) had a history of seizures while they drove. These incidents had resulted in the involvement of 28 patients (26.9% of the total sample) in motor vehicle accidents and 17 (16.3% of the total sample) patients being admitted to the emergency room. CONCLUSION: Structured regulation and licensing procedures are necessary for PWEs to drive safely. Regulations in other countries demand that seizures be controlled for 1 year before epileptic patients are allowed unrestricted driving. Such regulations would improve road safety in Saudi Arabia.

Immune's-boosting agent: Immunomodulation potentials of propolis Mohammed Al-Hariri Journal of Family and Community Medicine 2019 26(1):57-60 With a concomitant increase in immune-related diseases such as allergic diseases, Type 1 diabetes mellitus, rheumatoid arthritis, multiple sclerosis, psoriasis, inflammatory bowel disease and other immune-related responses such as immunodeficiency, various infectious, diseases, vaccines, and malignancies, it has become very important to have a well-balanced and properly functioning immune system for the maintenance of human health. Recent scientific research has strongly suggested propolis as one of the most promising immunomodulation agents. This review describes recent findings with respect to propolis and its ingredients that show potential in this respect and evaluate their potential mechanisms. The author believes that propolis or/and its ingredients alone and in combination could be promising in manipulating the immune response and inducing immunomodulation. Further exploratory studies are needed to support large clinical trials toward further development of propolis.

Chest pain as a possible side effect of pitavastatin (Livalo) Nada R AlZahrani, Amna F Yassin Journal of Family and Community Medicine 2019 26(1):61-63 Coronary heart disease is a serious complication of dyslipidemia. Pitavastatin is a more commonly prescribed medication for the treatment of dyslipidemia. Here, we report the case of a 37-year-old female, a known patient with well-controlled bronchial asthma. She was recently found to be dyslipidemic and started on pitavastatin calcium 4 mg once a day (OD). On the 10th day of treatment, she began to have crushing chest pain and was admitted to the hospital. All investigations for coronary heart disease came out negative. Her symptoms improved dramatically when pitavastatin was stopped. Pitavastatin is reported to cause myalgia and muscle spasm, especially at higher doses. There is evidence in literature that this medication might cause chest pain in old obese ladies if taken at high doses. We report this case as a possibility of chest pain even in younger females.