Effects of stellate ganglion block on breast cancer-related lymphedema: comparison of various injectates

OBJECTIVE

To determine the effects of SGB in BCRL patients and the efficacy of corticosteroids in SGB.

STUDY DESIGN

A double-blinded, randomized, controlled trial.

SETTING

A single academic hospital, outpatient setting.

METHODS

In total, 32 patients with BCRL were recruited. Patients were divided randomly into 3 groups (Group A: 0.5% bupivacaine 5 mL, n = 12; Group B: 0.5% bupivacaine 4.5 mL + 20 mg of triamcinolone 0.5 mL, n = 10; and Group C: 0.5% bupivacaine 4 mL + 40 mg of triamcinolone 1 mL, n = 10). All patients received 3 consecutive SGBs, every 2 weeks. The primary outcomes were changes in forearm and upper arm circumference. Circumference was measured at baseline, 2 weeks (before the second injection), 4 weeks (before the third injection), and 8 weeks (one month follow-up after 3 consecutive SGBs). Moreover, subjective data were collected using EORTC C-30 at baseline and 8 weeks.

RESULTS

After 3 consecutive SGBs, forearm and upper arm circumferences were decreased significantly from baseline in all groups (P < 0.05/3). The upper arm circumference of group C was reduced significantly more than that of group A (P < 0.05/3). The subjective data by EORTC-C30 at baseline and one month after 3 consecutive SGBs revealed no statistically significant difference.

LIMITATIONS

Relatively few patients were enrolled. We did not compare SGB with any other BCRL treatment, such as complex decongestive therapy.

CONCLUSIONS

This study suggests that SGB may be an effective treatment for BCRL. Furthermore, it appears that corticosteroids could have an additive effect in SGB.

Effectiveness of ultrasound-guided carpal tunnel injection using in-plane ulnar approach: a prospective, randomized, single-blinded study

The objective of this study is to evaluate the degree of symptom improvement and the change of electrophysiological and ultrasonographic findings after sonographically guided local steroid injection using an in-plane ulnar approach in carpal tunnel syndrome (CTS). Seventy-five cases of 44 patients diagnosed with CTS were included and evaluated at baseline and at 4 and 12 weeks after injection. All patients received injection with 40 mg of triamcinolone mixed with 1 mL of 1% lidocaine into the carpal tunnel using an in-plane Ultrasound (US)-guided ulnar approach, out-plane US-guided approach, and blind injection. For clinical evaluation, we used the Boston Carpal Tunnel Questionnaire (BCTQ) and electrophysiological tests. The ultrasonographic findings were also evaluated with regard to cross-sectional area and the flattening ratio of the median nerve. Subjective symptoms measured by BCTQ and median nerve conduction parameters showed significant improvement at 4 weeks in the in-plane ulnar approach group compared with the out-plane ulnar approach and blind injection. This improvement was still observed at 12 weeks. The flattening ratio and cross-sectional area of the median nerve showed a more significant decrease with the in-plane ulnar approach than with the out-plane ulnar approach and blind injection (P < 0.05). US-guided local steroid injection using an in-plane ulnar approach in the CTS may be more effective than out-plane or blind injection.

Topical corticosteroids for treating phimosis in boys

BACKGROUND

Until recently, phimosis has been treated surgically by circumcision or prepuceplasty; however, recent reports of non-invasive treatment using topical corticosteroids applied for four to eight weeks have been favourable. The efficacy and safety of topical corticosteroids for treating phimosis in boys has not been previously systematically reviewed.

OBJECTIVES

We aimed to 1) compare the effectiveness of the use of topical corticosteroid ointment applied to the distal stenotic portion of the prepuce in the resolution of phimosis in boys compared with the use of placebo or no treatment, and 2) determine the rate of partial resolution (improvement) of phimosis, rate of re-stenosis after initial resolution or improvement of phimosis, and the rate of adverse events of topical corticosteroid treatment in boys with phimosis.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register through contact with the Trials' Search Co-ordinator using search terms relevant to this review. Date of last search: 16 June 2014.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared use of any topical corticosteroid ointment with placebo ointment or no treatment for boys with phimosis.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed titles, abstracts and the full-text of eligible studies, extracted data relating to the review's primary and secondary outcomes, and assessed studies' risk of bias. Statistical analyses were performed using the random-effects model and results were expressed as risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI). We contacted authors of primary articles asking for details of study design and specific outcome data.

MAIN RESULTS

We included 12 studies that enrolled 1395 boys in this review. We found that both types of corticosteroids investigated and treatment duration varied among studies.Compared with placebo, corticosteroids significantly increased complete or partial clinical resolution of phimosis (12 studies, 1395 participants: RR 2.45, 95% CI 1.84 to 3.26). Our analysis of studies that compared different types of corticosteroids found that these therapies also significantly increased complete clinical resolution of phimosis (8 studies, 858 participants: RR 3.42, 95% CI 2.08 to 5.62). Although nine studies (978 participants) reported that assessment of adverse effects were planned in the study design, these outcomes were not reported.Overall, we found that inadequate reporting made assessing risk of bias challenging in many of the included studies.Selection bias, performance and detection bias was unclear in the majority of the included studies: two studies had adequate sequence generation, none reported allocation concealment; two studies had adequate blinding of participants and personnel and one had high risk of bias; one study blinded outcome assessors. Attrition bias was low in 8/12 studies and reporting bias was unclear in 11 studies and high in one study.

AUTHORS' CONCLUSIONS

Topical corticosteroids offer an effective alternative for treating phimosis in boys. Although sub optimal reporting among the included studies meant that the size of the effect remains uncertain, corticosteroids appear to be a safe, less invasive first-line treatment option before undertaking surgery to correct phimosis in boys.

Use of targeted transversus abdominus plane blocks in pediatric patients with anterior cutaneous nerve entrapment syndrome

Anterior cutaneous nerve entrapment syndrome (ACNES) is a commonly overlooked source of chronic abdominal wall pain. A diagnosis of ACNES should be considered in cases of severe, localized abdominal pain that is accentuated by physical activity. Providers should consider diagnosing ACNES once a patient has both a positive result from a Carnett's test and precise localization of pain. We describe the use of transversus abdominus plane (TAP) blocks to treat ACNES in the pediatric patient population. TAP blocks are a treatment modality which have been described less frequently in the management of this syndrome, with rectus sheath blocks being used more commonly. TAP blocks can be used effectively for ACNES by targeting the site of maximal tenderness, which was identified using ultrasound guidance. Moreover, TAP blocks are an attractive procedure option for ACNES as they are less invasive than other commonly used techniques. We present 3 case series reports of pediatric patients evaluated at our institution for severe abdominal pain to describe the clinical manifestations, sequelae, and outcome of ACNES. Though the exact incidence of ACNES in the pediatric population is unknown, this condition has significant implications from chronic pain. Chronic pain can lead to significant emotional and social impacts on these pediatric patients, as well as their on their families. Further, the extensive utilization of health care resources is impacted when children with undiagnosed ACNES undergo invasive treatments when ACNES is not in the early differential. The purpose of this case series report is to prompt better recognition of the condition ACNES, and to highlight the efficacy of TAP blocks as a management strategy.

Intralesional triamcinolone alone and in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars

OBJECTIVE

To compare the use of intralesional triamcinolone acetonide and its combination with 5 flourouracil in the treatment of keloid and hypertrophic scars in terms of reduction in initial height of the scar.

METHODS

The randomised controlled trial was conducted at the Department of Plastic Surgery, King Edward Medical University, Lahore, from March 2011 to December 2012. It comprised patients of both genders having keloids or hypertrophic scars (1 cm to 5 cm in size) having no history of treatment for the scars in preceding 6 months. Those who were pregnant, planning pregnancy or lactating were excluded. The subjects were divided into two groups: Group A received intralesional triamcinolone acetonide alone; and Group B received triamcinolone acetonide + 5 flourouracil. Eight injections were given at weekly interval. Scars were assessed 4 weeks after the completion of treatment on a five-point scale. SPSS 16 was used for statistical analysis.

RESULTS

The 150 subjects in the study were divided into two equal groups of 75 (50%) each. Good to excellent results were seen in 51 (68%) cases in Group A compared to 63 (84%) in Group B. Frequency of complications was 18 (24%) and 6 (8%) in Group A and Group B respectively.

CONCLUSION

Combination of triamcinolone acetonide and 5 flourouracil is superior to triamcinolone acetonide therapy in the treatment of keloids and hypertrophic scars.

Interleukin-1 inhibitors for acute gout

BACKGROUND

Acute gout flares cause significant pain and disability and it is important to provide quick and effective pain relief. Traditional options for managing acute flares include colchicine, non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids.

OBJECTIVES

To assess the benefits and harms of interleukin-1 inhibitors (anakinra, canakinumab, rilonacept) in acute gout.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE and EMBASE on 19 June 2013. We applied no date or language restrictions. We performed a handsearch of the abstracts from the European League Against Rheumatism (EULAR) (2009 to 2012) and American College of Rheumatology (ACR) (2009 to 2011) conferences and of the references of all included trials. We also screened the Clinical Trials Registry Platform of the World Health Organization and Clinical Trials Registry Platform of the US National Institutes of Health.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-randomised clinical trials (controlled clinical trials (CCTs)) assessing an interleukin-1 inhibitor (anakinra, canakinumab or rilonacept) against placebo or another active treatment (colchicine, paracetamol, NSAIDs, glucocorticoids (systemic or intra-articular), adrenocorticotropin hormone, a different interleukin-1 blocking agent or a combination of any of the above) in adults with acute gout.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed the risk of bias and extracted the data. If appropriate, we pooled data in a meta-analysis. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included four studies (806 participants) in the review. The studies had an unclear risk of selection bias and low risk of performance and attrition biases. One study each had an unclear risk of detection and selection bias.Three studies (654 participants) compared subcutaneous canakinumab compared with intramuscular triamcinolone acetonide 40 mg in the treatment of acute gout flares of no more than five days' duration. Doses of canakinumab were varied (10 to 150 mg), but most people (255/368) were treated with canakinumab 150 mg. None of the studies provided data on participant-reported pain relief of 30% or greater. Moderate-quality evidence indicated that canakinumab 150 mg was probably superior to triamcinolone acetonide 40 mg in terms of pain relief, resolution of joint swelling and in achieving a good treatment response at 72 hours following treatment, but was probably associated with an increased risk of adverse events.Mean pain (0- to 100-mm visual analogue scale (VAS), where 0 mm was no pain) was 36 mm after triamcinolone acetonide treatment; pain was further reduced by a mean of 11 mm with canakinumab treatment (mean difference (MD) -10.6 mm, 95% confidence interval (CI) -15.2 to -5.9). Forty-four per cent of participants treated with canakinumab had resolution of joint swelling at 72 hours compared with 32% of participants treated with triamcinolone (risk ratio (RR) 1.39, 95% CI 1.11 to 1.74, number needed to treat for an addition beneficial outcome (NNTB) 9); 65% of participants treated with canakinumab assessed their response to treatment as good or excellent compare with 47% of participants treated with triamcinolone acetonide (RR 1.37, 95% CI 1.16 to 1.61, NNTB 6). Function or health-related quality of life were not measured. In both groups, 0.7% of participants withdrew from treatment (RR 1.1, 95% CI 0.2 to 7.2); there was one death and one alteration of laboratory results in each of the treatment groups. Adverse events were more frequent in participants receiving canakinumab (61%) compared with triamcinolone acetonide (51%; RR 1.2, 95% CI 1.1 to 1.4, number needed to treat for an addition harmful outcome (NNTH) 10).Low-quality evidence from one study (152 participants with an acute gout flare of no more than 48 hours' duration and affecting fewer than four joints) comparing rilonacept 320 mg with indomethacin (50 mg three times a day for three days followed by 25 mg three times a day for up to nine days) indicated that indomethacin may improve pain more than rilonacept at 24 to 72 hours, and there may be no evidence of a difference in withdrawal rates or adverse events. The mean change (improvement) in pain from baseline with indomethacin was 4.3 points (measured on a 0 to 10 numerical rating scale, where 0 was no pain); pain was improved by a mean of only 2.5 points with rilonacept (MD 2.52, 95% CI 0.29 to 4.75, 25% less improvement in absolute pain with rilonacept). Inflammation, function health-related quality of life and participant global assessment of treatment success were not measured. Rates of study withdrawals due to adverse events were low in both groups: 1/75 (1%) participants in the rilonacept group compared with 2/76 (3%) participants in the indomethacin group (RR 0.5, 95% CI 0.05 to 5.5). Adverse events were reported in 27/75 (36%) participants in the rilonacept group and 23/76 (30%) in the indomethacin group (RR 1.2, 95% CI 0.8 to 1.9).

AUTHORS' CONCLUSIONS

Moderate-quality evidence indicated that compared with a single suboptimal 40-mg dose of intramuscular injection of triamcinolone acetonide, a single subcutaneous dose of 150 mg of canakinumab probably results in better pain relief, joint swelling and participant-assessed global assessment of treatment response in people with an acute gout flare but is probably associated with an increased risk of adverse events. The cost of canakinumab is over 5000 times higher than triamcinolone acetonide; however, there are no data on the cost-effectiveness of this approach. We found no studies comparing canakinumab with more commonly used first-line therapies for acute gout flares such as NSAIDs or colchicine. Low-quality evidence indicated that compared with maximum doses of indomethacin (50 mg three times a day), 320 mg of rilonacept may provide less pain relief with a similar rate of adverse events.

Comparison of intra-articular glucocorticoid injections with DMARDs versus DMARDs alone in rheumatoid arthritis

BACKGROUND

Intra-articular triamcinolone in combination with DMARDs may be able to achieve faster and tighter control of disease activity in early rheumatoid arthritis that may be the key to preventing or minimizing later deformities.

OBJECTIVE

To compare the efficacy of a combination of Disease Modifying Anti-Rheumatoid Drugs (DMARDs) with Intra-articular Glucocorticoids versus only DMARDs in a group of patients with early Rheumatoid Arthritis (RA).

METHODS

Fifty patients diagnosed as Rheumatoid Arthritis (RA) by American Rheumatology Association (ARA) criteria (1987) with disease duration less than two years were randomized into two groups. The Control group received a combination of Methotrexate 15 mg daily with Sulfasalazine 2 gm daily for 3 months and the Study group received the above combination along with Intra-articular injections of Triamcinolone acetate (40 mg per ml) in each of the swollen joints at the start of the study. Outcome was assessed in terms of Disease Activity Score (DAS-28), American College of Rheumatology (ACR) 20/50/70 criteria and number of rescue medications used at the end of 3 months.

RESULTS

The study group had significant reductions in DAS 28 scores (3.39 versus 4.99 in control group) and significantly more subjects achieved the ACR 20/50/70 criteria at the end of 3 months (100/60/36% versus 84/20/0%) Secondary end-points like tender and swollen joint count, ESR, early morning stiffness, health assessment questionnaire (HAQ) scores and general health status were significantly reduced in the study group. Also, significantly lesser rescue medications were needed in the study group.

CONCLUSION

Combination of DMARDs with Intra-articular corticosteroids is significantly better than DMARDs alone in early RA.

Plasma Cell Cheilitis Treated with Intralesional Injection of Corticosteroids

Plasma cell cheilitis is an idiopathic, benign, inflammatory condition characterized by a dense band-like infiltrate of plasma cells in the oral mucosa. In addition to the lips, the disease can affect the penis, vulva, buccal mucosa, palate, gingiva, tongue, epiglottis, and larynx. Some authors have shown the effectiveness of topical or intralesional corticosteroids; however, there have been many reports describing poor therapeutic responses to topical steroids. We describe three patients with plasma cell cheilitis whose clinical condition responded rapidly to the intralesional injection of corticosteroids.

Effects of representative glucocorticoids on TNFα- and CD40L-induced NF-κB activation in sensor cells

Glucocorticoids are an important class of anti-inflammatory/immunosuppressive drugs. A crucial part of their anti-inflammatory action results from their ability to repress proinflammatory transcription factors such as nuclear factor-κB (NF-κB) and activator protein-1 (AP-1) upon binding to the glucocorticoid receptor (GR). Accordingly, sensor cells quantifying their effect on inflammatory signal-induced NF-κB activation can provide useful information regarding their potencies as well as their transrepression abilities. Here, we report results obtained on their effect in suppressing both the TNFα- and the CD40L-induced activation of NF-κB in sensor cells that contain an NF-κB-inducible SEAP construct. In these cells, we confirmed concentration-dependent NF-κB activation for both TNFα and CD40L at low nanomolar concentrations (EC50). Glucocorticoids tested included hydrocortisone, prednisolone, dexamethasone, loteprednol etabonate, triamcinolone acetonide, beclomethasone dipropionate, and clobetasol propionate. They all caused significant, but only partial inhibition of these activations in concentration-dependent manners that could be well described by sigmoid response-functions. Despite the limitations of only partial maximum inhibitions, this cell-based assay could be used to quantitate the suppressing ability of glucocorticoids (transrepression potency) on the expression of proinflammatory transcription factors caused by two different cytokines in parallel both in a detailed, full dose-response format as well as in a simpler single-dose format. Whereas inhibitory potencies obtained in the TNF assay correlated well with consensus glucocorticoid potencies (receptor-binding affinities, Kd, RBA, at the GR) for all compounds, the non-halogenated steroids (hydrocortisone, prednisolone, and loteprednol etabonate) were about an order of magnitude more potent than expected in the CD40 assay in this system.

[A novel method for testing sterility of injections based on biothermodynamics]

This study aims at trying to establish a novel method of sterility test for injections based on biothermodynamics, in order to overcome the deficiencies of routine sterility tests such as long detecting cycle, low sensitivity and prone to misjudgments. A biothermodynamics method was adopted to rapidly detect the microorganism contamination of injections by monitoring the heat metabolism during the growth of microbe. The growth rate equal to or greater than zero and the heat power difference of P(i) and P(0) with three folds higher than the noise of baseline were chosen as indexes to study the heat change rule of microbe. In this way, the effectiveness of the new method to detect strains required by conventional sterility test or in injection samples was also investigated. Results showed that the Gram-positive bacteria, Gram-negative bacteria and fungi demanded by sterility testing methodology could be detected by biothermodynamics method within 10 hours, with the sensitivity lower than 100 CFU x mL(-1). Meanwhile, this method was successfully applied to the sterility test of Compound Yinchen injection (FFYC), Shuanghuanglian powder injection (SHL) and Compound Triamcinolone injection (TAND) which were sterilized with different degrees. Therefore, the biothermodynamics method, with advantages of fast detection and high sensitivity, could be a complementary solution for conventional sterility tests.

A study to compare the efficacy of corticosteroid therapy with platelet-rich plasma therapy in recalcitrant plantar fasciitis: a preliminary report

BACKGROUND

Plantar fasciitis is one of the commonest, and most frustrating, foot ailments seen in a regular orthopaedic clinic. There are a number of modalities available to treat this condition, of which corticosteroid injection is, perhaps, the most popular. However, recent years have seen an increased interest in the use of platelet-rich plasma (PRP) injections in various clinical situations such as plantar fasciitis.

METHODS

We undertook a prospective non-randomized study to compare the efficacy of traditional corticosteroid injection (Steroid group) to PRP injection (PRP group), in a cohort of patients.

RESULTS

We studied both groups of patients before and after the injections using Visual Analogue Score (VAS), the Foot & Ankle Disability Index (FADI) and American Foot and Ankle Score (AFAS). Our study confirms that there is significant clinical improvement in PRP group at three months after the injection.

CONCLUSION

The use of PRP injection can be an attractive alternative in the treatment of disabling, recalcitrant plantar fasciitis.

STUDY DESIGN

Cohort study.

LEVEL OF CLINICAL EVIDENCE

Level 3.

Comparison of fumaric acid 5% cream versus triamcinolone 0.1% cream in the treatment of hand eczema

Hand eczema is a common distressing skin problem. It is an immune reaction to haptens. Thus, substances that inhibit Immune system can be effective in the treatment of hand eczema. In this study, topical fumaric acid 5% cream is compared with topical steroid in the treatment of hand eczema. Patients with hand eczema were randomly divided into two groups. One group received fumaric acid 5% in a cream base, and the other received triamcinolone 0.1% in the same cream base. Both groups used creams twice daily for one month. Patients were checked for erythema, excoriation, population and lichenification, EASI score, and pruritus before and after treatment. In both groups, the mean of all signs of the disease and EASI score decreased after one month of treatment. There was no significant difference between the two treatments in decreasing erythema, but excoriation, population, lichenification, EASI score and itching were all decreased more in triamcinolone 0.1 % group. Although fumaric acid can inhibit the immune system; it was less effective for the treatment of all signs of hand eczema except erythema in comparison to triamcinolone. These results may be justified for two reasons: low penetration of topical fumaric acid through the skin or a low concentration used in this study.

Comparative study of photodynamic therapy monotherapy versus triple management in age-related macular degeneration

AIM

To compare the effectiveness of photodynamic therapy (PDT) and PDT combined with intravitreal triamcinolone (IVTA) and vascular endothelial growth factor inhibition (anti-VEGF) in age-related macular degeneration (AMD).

MATERIALS AND METHODS

Eighty eyes of 80 patients diagnosed with choroidal neovascularization (CNV) caused by AMD were included in the study. PDT was carried out on 40 eyes in group I, and PDT combined with 4 mg IVTA and anti-VEGF (1.25 mg bevacizumab in 20 eyes, 0.3 mg pegaptanib sodium in 20 eyes) was carried out in group II. The primary efficacy endpoint was the mean change from baseline visual acuity at month 12.

RESULTS

Mean follow-up was 14.2 ± 2.18 months in group I and 12.45 ± 2.82 months in group II. In group I there was a 2.88 logMAR line decrease and 1.95 logMAR line increase in group II in vision between pretreatment and 12th month measurements (P < 0.05). Mean PDT session was 2.00 in group I and the mean combined treatment session was 1.15 in group II in the 12th month.

CONCLUSION

Combination of IVTA and anti-VEGF with PDT is more effective and safer than PDT monotherapy in the treatment of CNV secondary to AMD. Combination treatment decreases the frequency and number of treatment sessions for an improved visual prognosis.

Effects of two different doses of epidural steroid on blood glucose levels and pain control in patients with diabetes mellitus

BACKGROUND

A high incidence of diabetes mellitus has been reported among patients diagnosed with lumbar degenerative spinal diseases. Although epidural steroid injections are known to increase the postprocedure blood glucose level, it has not been investigated whether a lower steroid dose can reduce blood glucose excursions and still be effective in controlling patients' subjective pain.

OBJECTIVE

We compared the effects of 2 common doses of triamcinolone administered via epidural steroid injections on blood glucose levels and pain control in patients with diabetes mellitus to determine an adequate epidural steroid dose.

STUDY DESIGN

A prospective observational study.

METHODS

One hundred patients with diabetes mellitus were enrolled. They received lumbar transforaminal, lumbar interlaminar, or caudal epidural triamcinolone for radiculopathy, spinal stenosis, or failed back surgery syndrome. After the type of procedure was clinically determined, the doses of triamcinolone given were randomly chosen, either 40 mg (Group 40) or 20 mg (Group 20). The patients were asked to measure their finger stick blood glucose level twice daily (fasting and postprandial) for 3 days before the injection, on the day of the injection, for 7 days after the injection, and at 14 days after the injection. They also kept a blood glucose diary. Employment status and clinical outcome were evaluated at 8 weeks after the procedure.

RESULTS

There were significant increases in fasting blood glucose (FBG) level on postprocedure day (PPD) #1 to PPD #3 in Group 40, but on PPD #1 in Group 20. Moreover, there was a significant difference in FBG between groups on PPD #1 and PPD #2 (FBG on PPD #1: 179 [51]) mg/dL in Group 40 versus 146 [50] mg/dL in Group 20, P < 0.001]. Postprandial blood glucose (PBG) level was significantly elevated in both groups from PPD #0 to PPD #3. Notably, the increase in PBG was significantly greater in Group 40 than Group 20 on PPD #0 and #1 (PBG on PPD #0: 288 [57] mg/dL versus 242 [94] mg/dL in Groups 40 and 20, respectively, P = 0.004). The numeric rating scale for pain reported by the patients decreased for 2 weeks after treatment with no difference between groups. Employment status and clinical outcome was not different between groups.

LIMITATIONS

The patients who chose to participate in this study may be a cohort of well-controlled patients with diabetes mellitus. The type of procedure performed was determined by a clinical decision and not randomized. The different routes of administration and diagnosis of failed back surgery syndrome can result in different levels of systemic absorption, thereby influencing the degree and duration of hyperglycemia. In patients with FBSS, the epidural space may be destructed by surgery and adhesive changes in epidural space could be extensive. Therefore, we thought that the absorption of epidural space in these patients would be incomplete or slow compared with those without FBSS.

CONCLUSION

Epidural steroid injections were associated with statistically significant elevations in PBG in patients with diabetes for up to 4 days after the procedure. The higher dose of triamcinolone increased FBG and PBG greater than a lower dose did without affecting pain control, employment status, or clinical outcome. Thus, with respect to glucose and pain control, 20 mg of triamcinolone appears to be recommended rather than 40 mg in patients with diabetes. Clinical Trials registration : NCT01435707.

Mycobacterium poriferae infection in a psoriasis patient on anti-TNF-α therapy

Psoriasis is a chronic, auto-inflammatory disease affecting millions of individuals worldwide. In addition to classic cutaneous manifestations, the condition is linked to significant co-morbidities including cardiovascular disease, metabolic syndrome, melanoma and non-melanoma skin cancer, and psychiatric disease. Therefore, more aggressive treatment and multi-disciplinary care is critical. Measures of disease burden (quantified by anatomic location, body surface area (BSA) of involvement, and impact on daily life) assist in determining the severity of disease and have been integral in objective assessment of treatment regimens and new drug therapies. Biologic agents have entered the clinical armamentarium as treatment options for patients with moderate-to-severe psoriasis who have failed traditional systemic therapies. Three of the four FDA-approved biologic agents for psoriasis suppress TNF-α mediated pathways, which are essential for granuloma formation and maintenance, key components of host defenses against intracellular pathogens. Subsequently, the increased use of these agents is accompanied by increased reporting of granulomatous infectious diseases such as tuberculosis, histoplasmosis, nocardia, and nontuberculous mycobacteria. Report of any unusual infection is therefore vitally important in the care of this immune suppressed patient population.

An unusual presentation and distribution of generalized eruptive syringomas

A 19-year-old Caucasian man presented with numerous erythematous to flesh-colored papules that appeared in crops on his neck, axillae, buttocks, and lower back. The lesions started on his anterior neck at age 12. At 18 years, new crops of papules appeared on his axillae, back, and buttocks over several months. He reported pruritus in the lesions following exercise and perspiration. He denied any family history of similar lesions. His primary care physician treated him with topical triamcinolone 0.1% cream, which made the lesions smaller, less erythematous, and less pruritic; however, the papules never fully resolved. After discontinuation of the steroids, these erythematous pruritic papules gradually recurred in the same areas of his body. The patient denied any other medical complaints.

Management of central giant granuloma of mandible with intralesional triamcinolone injections: a case report

A 31-year-old female presented with a central giant cell granuloma of the mandible. The patient was successfully treated with intralesional triamcinolone for a period of six weeks. At a two-year follow-up, the patient showed no clinical or radiographic signs of the lesion.

Bone mineral density in patients with alopecia areata treated with long-term intralesional corticosteroids

BACKGROUND

Intralesional corticosteroid injections are a common treatment for patchy alopecia areata, the most prevalent subtype of this autoimmune hair disorder. To date, no studies have examined the potential adverse effects of this therapy on bone mineral density (BMD).

METHODS

In this retrospective, cross-sectional case series, 18 patients with patchy alopecia areata treated at 4- to 8-week intervals with intralesional triamcinolone acetonide for at least 20 months were evaluated for BMD using dual-energy x-ray absorptiometry (DXA). Follow-up DXA measurements were obtained in those with abnormal findings.

RESULTS

Nine out of 18 patients (50%) had abnormal DXA results. Patients with the following risk factors were more likely to have abnormal BMD: age older than 50 years, body mass index less than 18.5 kg/m2, lack of weight-bearing exercise, smoking history, postmenopausal status, past stress fracture, family history of osteopenia or osteoporosis, and a cumulative intralesional triamcinolone acetonide dose of greater than 500 mg.

CONCLUSION

Patients with patchy alopecia areata who receive chronic intralesional triamcinolone acetonide therapy should be counseled on preventive measures for osteoporosis and monitored for effects on BMD.

[Retinal vein occlusion in a young patient]

We present a case report of a 27 years old pacient with central retinal vein occlussion and macular edema. The pacient has a significant reduction of the macular aedema with complete recovery of vision after the treatment.