Diagnosis of Coronary Stent Dislodgement With Transthoracic Echocardiogram: A Case Report

Coronary stent dislodgment is a rare complication of percutaneous coronary intervention (PCI). Although stent dislodgment typically occurs immediately in the intraoperative or perioperative period, it can infrequently occur subacutely in the post-operative period. Diagnosis of stent dislodgment can be seen with various cardiac imaging modalities, from transthoracic and transesophageal echocardiogram to cardiac computed tomography or magnetic resonance imaging to direct visualization on fluoroscopy during cardiac catheterization. Given the rarity of this entity, there is a lack of established common practice, gold standard for treatment, and/or procedural data. Instances are managed on a case-by-case basis, using the imaging modalities readily available at the institution and treatment modalities the interventionalist or surgeon is most comfortable with. Therefore, management of stent dislodgment consists of conservative, percutaneous, or surgical interventions on a case-by-case basis. We present a case of right coronary artery stent migration that was incidentally diagnosed with routine transthoracic echocardiogram.

Relationship Between Marijuana Use and Hospitalization for Acute Coronary Syndrome

Background: Recreational marijuana use is rising, especially among young adults. The cardiovascular (CVD) effect of marijuana remains mostly unknown.

Methods: This is a retrospective study of 14,490 patients admitted to our hospital between 2012 and 2014 who had urine toxicology done for various reasons. Patients with a primary diagnosis of acute coronary syndrome (ACS) were queried in both the marijuana-positive group (n = 59) and the marijuana-negative group (n = 195). The risks of having ACS were compared in both groups.

Results: There was no difference in the risk of having ACS between the two groups in the population < 54 years of age (OR: 0.90, 95% CI: 0.67-1.20, p = 0.48). However, there was a significant difference in the risk of having ACS in the 18-36 age group (OR: 2.84, 95% CI: 1.14-7.07, p = 0.01). Multivariate analysis performed to adjust for the potential confounding effects of smoking and cocaine use showed that marijuana use (OR: 0.93, 95% CI: 0.68-1.25, p = 0.65) did not increase the likelihood of ACS for patients ≤ 54 years or for those in the 37-54 age group (OR: 1.11, 95% CI: 0.79-1.53, p = 0.50). However, among the 18-36 age bracket, marijuana use was independently associated with a higher risk of ACS (OR: 5.24, 95% CI: 1.84-16.93, p = 0.002).

Conclusion: In younger patients (age 18-36 years), marijuana use is independently associated with a five-fold higher risk of ACS.

Amino-terminal Pro-B-Type Natriuretic Peptide Among Patients Living With Both Human Immunodeficiency Virus and Heart Failure

BACKGROUND

Among persons living with human immunodeficiency virus (PHIV), incident heart failure (HF) rates are increased and outcomes are worse; however, the role of amino-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations among PHIV with HF has not been characterized.

METHODS

Patients were derived from a registry of those hospitalized with HF at an academic center in a calender year. We compared the NT-proBNP concentrations and the changes in NT-proBNP levels between PHIV with HF and uninfected controls with HF.

RESULTS

Among 2578 patients with HF, there were 434 PHIV; 90% were prescribed antiretroviral therapy and 62% were virally suppressed. As compared to controls, PHIV had higher admission (3822 [IQR, 2413-7784] pg/ml vs 5546 [IQR, 3257-8792] pg/ml, respectively; P < .001), higher discharge (1922 [IQR, 1045-4652] pg/ml vs 3372 [IQR, 1553-5452] pg/ml, respectively; P < .001), and lower admission-to-discharge changes in NT-proBNP levels (32 vs 48%, respectively; P = .007). Similar findings were noted after stratifying based on left ventricular ejection fraction (LVEF). In a multivariate analysis, cocaine use, a lower LVEF, a higher NYHA class, a higher viral load (VL), and a lower CD4 count were associated with higher NT-proBNP concentrations. In follow-up, among PHIV, a higher admission NT-proBNP concentration was associated with increased cardiovascular mortality (first tertile, 11.5; second tertile, 20; third tertile, 44%; P < .001). Among PHIV, each doubling of NT-proBNP was associated with a 19% increased risk of death. However, among patients living without HIV, each doubling was associated with a 27% increased risk; this difference was attenuated among PHIV with lower VLs and higher CD4 counts.

CONCLUSIONS

PHIV with HF had higher admission and discharge NT-proBNP levels, and less change in NT-proBNP concentrations. Among PHIV, VLs and CD4 counts were associated with NT-proBNP concentrations; in follow-up, higher NT-proBNP levels among PHIV were associated with cardiovascular mortality.

Robotic-assisted partial nephrectomy (RAPN) and standardization of outcome reporting: a prospective, observational study on reaching the "Trifecta and Pentafecta"

Partial nephrectomy (PN) for small renal masses is common, but outcomes are not reported in a standard manner. Traditionally, parameters such as 90-day mortality, blood loss, transfusion rates, length of stay, nephrometry scoring and complications are published but their collective impact on warm ischemia time (WIT) and post-surgery GFR is rarely determined. Thus, our aim was to assess if “Trifecta” and “Pentafecta” outcomes could be used as useful surgical outcome markers. A prospective database of 252 Robotic-Assisted PN (RAPN) cases (2008–2019) was analysed. “Pentafecta” was defined as achievement of “Trifecta” (negative surgical margin, no postoperative complications and WIT of < 25 min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1 year. Binary logistic regression analysis was conducted to predict factors which may prevent achieving a Trifecta/Pentafecta. Median tumour size was 3 cm and mean WIT was 15 min. Positive surgical margins (PSM) occurred in 2 cases. Overall, the intra-operative complication rate was 7%. One recurrence conferred 5-year cancer-free survival of 97%. Trifecta outcome was achieved in 169 (67%) and Pentafecta in 141 (56%) of cases. At logistic regression analysis, intraoperative blood loss was the only factor to affect Trifecta achievement (p = 0.018). Advanced patient age negatively impacted Pentafecta achievement (p = 0.010). The Trifecta and Pentafecta outcomes are easily applicable to PN data, and offer an internationally comparable PN outcome, quality measure. We recommend applying this standardization to national data collection to improve the quality of reporting and ease of interpretation of surgeon/centres’ outcomes.

Incidence, Predictors, and Outcomes of Implantable Cardioverter-Defibrillator Discharge Among People Living With HIV

Background

People living with HIV (PHIV) are at an increased risk for sudden cardiac death, and implantable cardioverter‐defibrillators (ICDs) prevent SCD. There are no data on the incidence, predictors, and effects of ICD therapies among PHIV.

Methods and Results

We compared ICD discharge rates between 59 PHIV and 267 uninfected controls. For PHIV, we tested the association of traditional cardiovascular risk factors and HIV‐specific parameters with an ICD discharge and then tested whether an ICD discharge among PHIV was associated with cardiovascular mortality or an admission for heart failure. The indication for ICD insertion was similar among groups. Compared with controls, PHIV with an ICD were more likely to have coronary artery disease and to use cocaine. In follow‐up, PHIV had a higher ICD discharge rate (39% versus 20%; P=0.001; median follow‐up period, 19 months). Among PHIV, cocaine use, coronary artery disease, QRS duration, and higher New York Heart Association class were associated with an ICD discharge. An ICD discharge had a prognostic effect, with a subsequent 1.7‐fold increase in heart failure admission and a 2‐fold increase in cardiovascular mortality, an effect consistent across racial/ethnic and sex categories.

Conclusions

ICD discharge rates are higher among PHIV compared with uninfected controls. Among PHIV, cocaine use and New York Heart Association class are associated with increased ICD discharge, and an ICD discharge is associated with a subsequent increase in admission for heart failure and cardiovascular mortality.

The Risk for Sudden Cardiac Death Among Patients Living With Heart Failure and Human Immunodeficiency Virus

OBJECTIVES

The aim of this study was to determine the incidence of sudden cardiac death (SCD) among persons living with human immunodeficiency virus infection (PHIV) with heart failure (HF), who were hospitalized for HF, and the risk factors associated with it.

BACKGROUND

HF is associated with an increased risk for SCD. PHIV are at heightened risk for HF.

METHODS

This was a retrospective study of 2,578 patients hospitalized with HF from a single academic center, of whom 344 were PHIV. The outcome of interest was SCD. Subgroup analyses were performed by strata of viral load (VL) and left ventricular ejection fraction (LVEF) <35%, 35% to 49%, and ≥50%.

RESULTS

Of 2,578 patients with HF, 2,149 (86%) did not have implantable cardioverter-defibrillators; of these, there were 344 PHIV and 1,805 uninfected control subjects. Among PHIV with HF, 313 (91%) were prescribed antiretroviral therapy and 64% were virally suppressed. There were 191 SCDs over a median follow-up period of 19 months. Compared with control subjects, PHIV had a 3-fold increase in SCD (21.0% vs. 6.4%; adjusted odds ratio: 3.0; 95% confidence interval: 1.78 to 4.24). Among PHIV, cocaine use, lower LVEF, absence of beta-blocker prescription, and VL were predictors of SCD. The SCD rate among PHIV with undetectable VL was similar to the rate among uninfected subjects. Similar findings were observed by LVEF strata. Among PHIV with HF without conventional indications for an implantable cardioverter-defibrillator, the rate of SCD was 10% per year.

CONCLUSIONS

PHIV hospitalized with HF are at a markedly increased risk for SCD. SCD risk was increased in patients with lower LVEFs, lower CD4 counts, and higher VL.

Carvedilol Among Patients With Heart Failure With a Cocaine-Use Disorder

OBJECTIVES

This study sought to assess the safety of carvedilol therapy among heart failure (HF) patients with a cocaine-use disorder (CUD).

BACKGROUND

Although carvedilol therapy is recommended among certain patients with HF, the safety and efficacy of carvedilol among HF patients with a CUD is unknown.

METHODS

This was a single-center study of hospitalized patients with HF. Cocaine use was self-reported or defined as having a positive urine toxicology. Patients were divided by carvedilol prescription. Subgroup analyses were performed by strata of ejection fraction (EF) ≤40%, 41% to 49%, or ≥50%. Major adverse cardiovascular events (MACE) were defined as cardiovascular mortality and 30-day HF readmission.

RESULTS

From a cohort of 2,578 patients hospitalized with HF in 2011, 503 patients with a CUD were identified, among whom 404 (80%) were prescribed carvedilol, and 99 (20%) were not. Both groups had similar characteristics; however, those prescribed carvedilol had a lower LVEF, heart rate, and N-terminal pro-B-type natriuretic peptide concentrations at admission and on discharge, and more coronary artery disease. Over a median follow-up of 19 months, there were 169 MACEs. The MACE rates were similar between the carvedilol and the non-carvedilol groups (32% vs. 38%, respectively; p = 0.16) and between those with a preserved EF (30% vs. 33%, respectively; p = 0.48) and were lower in patients with a reduced EF taking carvedilol (34% vs. 58%, respectively; p = 0.02). In a multivariate model, carvedilol therapy was associated with lower MACE among patients with HF with a CUD (hazard ratio: 0.67; 95% confidence interval; 0.481 to 0.863).

CONCLUSIONS

Our findings suggest that carvedilol therapy is safe for patients with HF with a CUD and may be effective among those with a reduced EF.

Protease Inhibitors and Cardiovascular Outcomes in Patients With HIV and Heart Failure

BACKGROUND

Incident heart failure (HF) is increased in persons with human immunodeficiency virus (PHIV). Protease inhibitors (PIs) are associated with adverse cardiac remodeling and vascular events; however, there are no data on the use of PIs in PHIV with HF.

OBJECTIVES

This study sought to compare characteristics, cardiac structure, and outcomes in PHIV with HF who were receiving PI-based versus non-PI (NPI) therapy.

METHODS

This was a retrospective single-center study of all 394 antiretroviral therapy-treated PHIV who were hospitalized with HF in 2011, stratified by PI and NPI. The primary outcome was cardiovascular (CV) mortality, and the secondary outcome was 30-day HF readmission rate.

RESULTS

Of the 394 PHIV with HF (47% female, mean age 60 ± 9.5 years, CD4 count 292 ± 206 cells/mm3), 145 (37%) were prescribed a PI, whereas 249 (63%) were prescribed NPI regimens. All PI-based antiretroviral therapy contained boosted-dose ritonavir. PHIV who were receiving a PI had higher rates of hyperlipidemia, diabetes mellitus, and coronary artery disease (CAD); higher pulmonary artery systolic pressure (PASP); and lower left ventricular ejection fraction. In follow-up, PI use was associated with increased CV mortality (35% vs. 17%; p < 0.001) and 30-day HF readmission (68% vs. 34%; p < 0.001), effects seen in all HF types. Predictors of CV mortality included PI use, CAD, PASP, and immunosuppression. Overall, PIs were associated with a 2-fold increased risk of CV mortality.

CONCLUSIONS

PI-based regimens in PHIV with HF are associated with dyslipidemia, diabetes, CAD, a lower left ventricular ejection fraction, and a higher PASP. In follow-up, PHIV with HF who are receiving a PI have increased CV mortality and 30-day HF readmission.

Continuity of care in dermatology residency programs in the United States

PURPOSE

As established by the AccreditationCouncil for Graduate Medical Education (ACGME),dermatology residents in the United States must participate in continuity clinic. This requirement may be achieved through multiple means, allowing for program variation. To better assess continuity clinic's role in resident learning, more data on this component of graduate medical education is needed.

METHODS

An anonymous online survey was distributed via the American Board of Dermatology list serv to all U.S. dermatology residents. Continuity clinic organization, setting, frequency, and patient and preceptor characteristics were assessed; resident satisfaction and learning were compared.

RESULTS

Of 231 responses, 7.8% reported continuity clinic daily, 77.1% weekly, 9.1% every other week, 3.0%monthly, 0.4% once every several months, and 2.2%only during certain blocks. Of the clinics reported,80.1% were "resident-run with attending" and 11.3%were attending-run. The rest were "resident-run with no attending" (0.9%), both resident and attending run(3.0%), or "other" (4.8%). Trainees in resident-run clinics (with attendings) reported greater continuity of care than those in attending-run clinics (p&lt;0.001).Residents reported better teaching with attending presence during patient encounters than when attendings were present only if concerns were raised(p&lt;0.01).

Filling in Pediatric Acne Practice Gaps: A Prospective Multicenter Study of Case-Based Education

PURPOSE

Studies have documented practice gaps in acne management between pediatricians and dermatologists. Evidence-based recommendations for acne management were published by the American Acne and Rosacea Society and the American Academy of Pediatrics in 2013. We assess the impact of a case-based learning intervention on pediatrician knowledge and treatment of acne in accordance with published recommendations.

METHODS

Participants were recruited at four conferences for pediatric providers. Knowledge of the recommendations and confidence in utilizing them was assessed. Five case-based questions were presented, with providers choosing acne treatments before, immediately after, and 3 months after a case-based educational presentation. Answer selections consistent with the recommendations were scored as correct, and all responses were evaluated for patterns of medication selection.

RESULTS

A total of 150 individuals participated, most with over 10 years experience. Knowledge of the recommendations and confidence in prescribing acne therapy was poor. The average preintervention management selections were 70% correct, increasing significantly to 86% 3 months after intervention (p < .01). The most significant improvements were demonstrated in provider's ability to choose regimens for moderate acne consistent with published recommendations, and in recommendation-consistent usage of retinoids and benzoyl peroxide (p < .05). Persisting practice gaps included a reluctance to use topical retinoids in preadolescents and lack of initiating oral combination therapies in patients with severe acne.

CONCLUSIONS

A case-based educational intervention significantly increased providers choosing acne treatments in accordance with evidence-based recommendations in an examination setting. Limitations of the study include an inability to assess actual provider prescribing behavior through this methodology.

Long-term follow-up of ninety eight Iranian patients with primary immune deficiency in a single tertiary centre

PURPOSE

The aim was to describe the clinical manifestations, complications and long-term outcome of a cohort of Iranian patients with primary immune deficiency (PID).

METHOD

We retrospectively studied the demographic, clinical and immunological characteristics of the PID patients in a single tertiary centre, from January 1989 to July 2014. The patients were classified according to the International Union of Immunological Societies Expert Committee on PID.

RESULTS

98 patients were diagnosed with and followed-up for 15 disorders. The mean age at onset and diagnosis and the diagnostic delay were 8±10, 14.2±13.1 and 6.1±7 years, respectively. Parental consanguinity rate was 57%. Predominantly Antibody Deficiency was the most common diagnosis (n=63), followed by congenital defects of phagocytes (n=16), combined immunodeficiencies (n=12), well defined syndromes (n=4) and defects in innate immunity (n=3). Recurrent sinopulmonary infection was the most common presentation. Active infections were treated appropriately, in addition to prophylactic therapy with IVIG and antimicrobials. Not all the patients were compliant with prophylactic regimens due to cost and unavailability. One SCID patient underwent successful bone marrow transplantation. The total mortality rate was 19% during the follow-up period (7.8±7.6 years). The mean age of living patients at the time of study was 23±11.7 years.

CONCLUSIONS

Physicians awareness of PID has been rising dramatically in Iran, ensuring an increasing number of patients being diagnosed and treated. More effective treatment services, including health insurance coverage and drug availability are needed to improve the outcome of PID patients.

[Binding of 1-substituted carbazolyl-3,4-dihydro-β-carbolines with DNA: Molecular dynamics simulation and MM-GBSA analysis]

Molecular Mechanics-Generalized Born-Solvent Accessibility free energy calculations were used to analyse DNA binding affinity of 1-substituted carbazolyl-3,4-dihydro-β-carboline molecules. In this study, DNA structure with sequence of d(CGATCG)2 was used for simulations. 15 ns molecular dynamics simulations of the studied complexes were performed. The calculated free energy was compared with experimental antitumor activity (IC(50)). The predicted free energies decreased with the increase of IC(50) values. It was shown that molecules 1-6 bind to DNA via intercalation mode, while molecules 7-9 bind through groove binding mode. Also, it was found that the vdW energy term (ΔE(vdW)) and the non-polar desolvation energy (ΔG(SA)) are the favorable terms for binding energy, whereas net electrostatic energies (ΔE(ele) + ΔG(GB)) and conformational entropy energy (TΔS) are unfavorable ones.

Athens QRS Score as a Predictor of Coronary Artery Disease in Patients With Chest Pain and Normal Exercise Stress Test

Background

The diagnostic value of the Athens QRS score to detect obstructive coronary artery disease CAD in patients with otherwise normal exercise stress test remains unclear.

Methods and Results

We analyzed 458 patients who underwent exercise stress test with or without myocardial perfusion imaging within 2 months of coronary angiography from 2008 to 2011. Patients (n=173) with abnormal stress test based on ST segment criteria were excluded. The Athens QRS score ≤5 was defined as abnormal. In our study cohort, 285 patients met the inclusion criteria and were divided into 2 groups: low Athens QRS score (LQRS, n=56), with QRS score ≤5 and normal Athens QRS score normal Athens QRS score, n=229), with QRS score >5. The presence of single‐vessel and multivessel obstructive CAD was higher in LQRS than in normal Athens QRS score patients (47% versus 7.5% and 30% versus 3.8%, respectively, all P<0.001). Logistic regression analysis showed that the likelihood of CAD was strongly and independently associated with LQRS (odds ratio=36.81, 95% CI: 10.77–120.47), diabetes (odds ratio=6.49, 95% CI: 2.41–17.49), lower maximum heart rate (odds ratio=0.92, 95% CI: 0.88–0.95, all P<0.001), and older age (odds ratio=1.93, CI: 1.88–1.97, P=0.002).

Conclusions

In a clinical cohort of patients with chest pain and normal exercise stress test, LQRS score is a strong independent predictor of presence of CAD. LQRS patients have a 6‐fold higher prevalence of CAD and may warrant further evaluation even with reassuring exercise stress test.

Additive manufacturing and mechanical characterization of graded porosity scaffolds designed based on triply periodic minimal surface architectures

Since the advent of additive manufacturing techniques, triply periodic minimal surfaces have emerged as a novel tool for designing porous scaffolds. Whereas scaffolds are expected to provide multifunctional performance, spatially changing pore patterns have been a promising approach to integrate mechanical characteristics of different architectures into a unique scaffold. Smooth morphological variations are also frequently seen in nature particularly in bone and cartilage structures and can be inspiring for designing of artificial tissues. In this study, we carried out experimental and numerical procedures to uncover the mechanical properties and deformation mechanisms of linearly graded porosity scaffolds for two different mathematically defined pore structures. Among TPMS-based scaffolds, P and D surfaces were subjected to gradient modeling to explore the mechanical responses for stretching and bending dominated deformations, respectively. Moreover, the results were compared to their corresponding uniform porosity structures. Mechanical properties were found to be by far greater for the stretching dominated structure (P-Surface). For bending dominated architecture (D-Surface), although there was no global fracture for uniform structures, graded structure showed a brittle fracture at 0.08 strain. A layer by layer deformation mechanism for stretching dominated structure was observed. For bending dominated scaffolds, deformation was accompanied by development of 45° shearing bands. Finite element simulations were also performed and the results showed a good agreement with the experimental observations.

Hepatitis C may enhance key amplifiers of psoriasis

BACKGROUND

Multiple studies have noted an association between hepatitis C and psoriasis, but it is not known whether psoriasis is a result of treatment modalities for hepatitis C or a result of hepatitis C alone.

OBJECTIVE

To examine the relationship between psoriasis and hepatitis C by measuring the expression of cathelicidin, TLR9 and IFNγ in psoriatic lesional and non-lesional skin in HCV-positive and negative psoriatic patients.

METHODS

Two 2 mm punch biopsies of lesional and non-lesional skin in 10 patients who were HCV-negative psoriatics and seven HCV-positive psoriatics were used to measure cathelicidin, TLR9 and IFNγ mRNA expression by quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR).

RESULTS

The mRNA levels of cathelicidin, TLR9 and IFNγ were significantly higher in both non-lesional and lesional skin of HCV-positive patients with psoriasis as compared to HCV-negative psoriatic patients. Additionally, the IFNγ level in lesional skin of HCV-positive psoriatic patients was higher than the IFNγ level seen in non-lesional skin of those same patients.

CONCLUSION

These findings suggest that HCV infection upregulates these inflammatory cytokines, possibly increasing susceptibility to developing psoriasis.

Conversion to resection of liver metastases from colorectal cancer with hepatic artery infusion of combined chemotherapy and systemic cetuximab in multicenter trial OPTILIV

BACKGROUND

Systemic chemotherapy typically converts previously unresectable liver metastases (LM) from colorectal cancer to curative intent resection in ∼15% of patients. This European multicenter phase II trial tested whether hepatic artery infusion (HAI) with triplet chemotherapy and systemic cetuximab could increase this rate to 30% in previously treated patients.

PATIENTS AND METHODS

Participants had unresectable LM from wt KRAS colorectal cancer. Main non-inclusion criteria were advanced extra hepatic disease, prior HAI and grade 3 neuropathy. Irinotecan (180 mg/m(2)), oxaliplatin (85 mg/m(2)) and 5-fluorouracil (2800 mg/m(2)) were delivered via an implanted HAI access port and combined with i.v. cetuximab (500 mg/m(2)) every 14 days. Multidisciplinary decisions to resect LM were taken after every three courses. The rate of macroscopic complete resections (R0 + R1) of LM, progression-free survival (PFS) and overall survival (OS) were computed according to intent to treat.

RESULTS

The patient population consisted of 42 men and 22 women, aged 33-76 years, with a median of 10 LM involving a median of six segments. Up to 3 extrahepatic lesions of <1 cm were found in 41% of the patients. A median of six courses was delivered. The primary end point was met, with R0-R1 hepatectomy for 19 of the 64 previously treated patients, 29.7% (95% confidence interval 18.5-40.9). Grade 3-4 neutropenia (42.6%), abdominal pain (26.2%), fatigue (18%) and diarrhea (16.4%) were frequent. Objective response rate was 40.6% (28.6-52.3). Median PFS and OS reached 9.3 (7.8-10.9) and 25.5 months (18.8-32.1) respectively. Those with R0-R1 hepatectomy had a median OS of 35.2 months (32.6-37.8), with 37.4% (23.6-51.2) alive at 4 years.

CONCLUSION

The coordination of liver-specific intensive chemotherapy and surgery had a high curative intent potential that deserves upfront randomized testing.

PROTOCOL NUMBERS

EUDRACT 2007-004632-24, NCT00852228.

Heat shock protein 70 mRNA expression and immune response of heat-stressed finishing broilers fed propolis (bee glue) supplementation

Abstract. This 2×2 factorial experiment investigated the efficacy of propolis (bee glue; BG) in ameliorating heat-stress-induced impairment of growth performance, the hematological profile, intestinal morphology, and biomarkers of heat stress in broilers. Two hundred and forty 21-day old Ross 308 male broiler chicks were allocated to four experimental treatments in six replicates of 10 birds each. The main factors were composed of diet (basal diet or addition of 3 g kg−1 of BG) and temperature (thermoneutral or heat stress). Broilers subjected to heat stress had reduced average daily gain (ADG) and average daily feed intake (ADFI); a higher heterophil level and heterophil-to-lymphocyte ratio, and a lower lymphocyte level; upregulated mRNA expression of 70 kDa heat shock protein (HSP70) levels in heart, kidney, and breast muscle; and shorter jejunal villus height, deeper crypt depth, and a lower ratio of villus-height-to-crypt-depth compared with those broilers raised in thermoneutral conditions. Supplemental BG increased ADG, jejunal villus height, and the villus-height-to-crypt-depth ratio and decreased the feed-to-gain ratio and creatine kinase and lactate dehydrogenase levels in breast muscle compared with the birds who received control diets. The inclusion of BG in diets significantly decreased the mRNA expression of HSP70 levels in heart, kidney, and breast muscle in birds subjected to heat challenge. These results indicate that the BG-supplemented diet was effective in partially ameliorating adverse effects in resistance to heat stress in broiler chickens.

Chemical Burn from Vinegar Following an Internet-based Protocol for Self-removal of Nevi

"Natural home remedies" for nevi removal found on the Internet can be ineffective, or worse, dangerous. Children and teens, in particular, may be more likely to attempt self-treatment in order to avoid discussing their concerns with their parents. Here, the authors report a case of an adolescent who presented with a chemical burn after following an Internet-based protocol for nevi removal using apple cider vinegar.

Review of dextromethorphan administration in 18 patients with subacute methotrexate central nervous system toxicity

BACKGROUND

The pathogenesis of methotrexate central nervous system toxicity is multifactorial, but it is likely related to central nervous system folate homeostasis. The use of folinate rescue has been described to decrease toxicity in patients who had received intrathecal methotrexate. It has also been described in previous studies that there is an elevated level of homocysteine in plasma and cerebrospinal fluid of patients who had received intrathecal methotrexate. Homocysteine is an N-methyl-D-aspartate receptor agonist. The use of dextromethorphan, noncompetitive N-methyl-D-aspartate receptor receptor antagonist, has been used in the treatment of sudden onset of neurological dysfunction associated with methotrexate toxicity. It remains unclear whether the dextromethorphan impacted the speed of recovery, and its use remains controversial. This study reviews the use of dextromethorphan in the setting of subacute methotrexate central nervous system toxicity.

METHODS

Charts of 18 patients who had sudden onset of neurological impairments after receiving methotrexate and were treated with dextromethorphan were reviewed.

RESULT

The use of dextromethorphan in most of our patients resulted in symptomatic improvement. In this patient population, earlier administration of dextromethorphan resulted in faster improvement of impairments and led to prevention of recurrence of seizure activity induced by methotrexate central nervous system toxicity.

CONCLUSIONS

Our study provides support for the use of dextromethorphan in patients with subacute methotrexate central nervous system toxicity.

General anesthesia in cesarean sections: a prospective review of 465 cesarean sections performed under general anesthesia

BACKGROUND

In many countries, neuraxial blocks comprise the majority of anesthetics given for cesarean section. In Iran, however general anesthesia for cesarean section is prevalent. In our institution, the rate of general anesthesia for cesarean section is 39%, providing an opportunity to collect data regarding airway management in the parturients. We report on the outcomes of a series of patients who received general anesthesia for cesarean section.

METHODS

A prospective observational study was conducted in two university hospitals, with approximately 5,500 deliveries annually. Demographics and airway characteristics were recorded. Eight potential risk factors for difficult intubation (short neck, obesity, facial edema, swollen tongue, receding mandible, and single, missing or protruding maxillary incisors) were analyzed. Then, laryngoscopic view, difficulty at intubation, and major complications were recorded.

RESULTS

Data were obtained from 465 patients. There was a significant correlation between higher Mallampati score and both higher laryngoscopic view graded on the Cormack-Lehane system (P < 0.001) and difficulty at intubation (P-Value = 0.05). Emergency cesarean section was not associated with difficult intubation (P = 0.67). Multivariate analysis showed that receding mandible was the only potential risk factor for difficult tracheal intubation (P < 0.001) and removed short neck or protruding maxillary incisor which initially was powered as a risk factor by univariate analysis. A grade 3 laryngoscopic view was obtained in 15 cases (3.2%). There was no case of grade 4 view. There was only one failed intubation (0.2%), and 9 cases of very difficult intubation (1.9%).

CONCLUSION

General anesthesia for cesarean section is safe with minimal risk.

'Being there' for women with metastatic breast cancer: a pan-European patient survey

BACKGROUND

Understanding their experiences of diagnosis is integral to improving the quality of care for women living with advanced/metastatic breast cancer.

METHODS

A survey, initiated in March 2011, was conducted in two stages. First, the views of 47 breast cancer-related patient groups in eight European countries were sought on standards of breast cancer care and unmet needs of patients. Findings were used to develop a patient-centric survey to capture personal experiences of advanced breast cancer to determine insights into the 'trade-off' between extending overall survival and side effects associated with its treatment. The second online survey was open to women with locally advanced or metastatic breast cancer, or their carers, and responders were recruited through local patient groups. Data were collected via anonymous local language questionnaires.

RESULTS

The online stage II survey received a total of 230 responses from 17 European countries: 94% of respondents had locally advanced or metastatic breast cancer and 6% were adult carers. Although the overall experience of care was generally good/excellent (77%), gaps were still perceived in terms of treatment choice and information provision. Treatment choice for patients was felt to be lacking by 32% of responders. In addition, 68% of those who responded would have liked more information about future medical treatments and research, with 57% wishing to receive this information from their oncologist. Two-thirds (66%) of women with advanced breast cancer, or their carers, believed life-extending treatment to be important so that they can spend more time with family and friends, and 67% said that the treatment was worthwhile, despite potential associated side effects.

CONCLUSION

These findings show a continuing need to provide women with advanced breast cancer with better information and emphasise the importance that these patients often place on prolonging survival.

Etanercept decreases the innate immune wounding response in psoriasis

Cathelicidin is increased when normal skin is injured and in psoriasis lesions where it has been suggested to play a pivotal role in inflammation through interactions with self-DNA and toll-like receptor 9 (TLR-9) in keratinocytes and plasmacytoid dendritic cells. Because of etanercept's success in treating psoriasis, we hypothesized that etanercept may suppress TLR-9 and cathelicidin induction. Examination of experimentally induced wounds of psoriatic lesional and non-lesional skin, and comparison with wounded normal skin, shows that the induction of cathelicidin and TLR-9 is greatly enhanced in lesional psoriatic skin. Six weeks of etanercept appears not to affect the baseline expression of cathelicidin or TLR-9, but does blunt the induction of cathelicidin in psoriasis with wounding. These findings support the role of cathelicidin in the enhancement of local inflammation in psoriasis and may partially explain one of the mechanisms enabling TNF-α inhibitors to successfully treat this disorder.

Induction and exacerbation of psoriasis with Interferon-alpha therapy for hepatitis C: a review and analysis of 36 cases

BACKGROUND

Interferon-alpha (IFN-α) therapy is used to treat hepatitis C infection. The exacerbation and occurrence of psoriasis in hepatitis C patients treated with IFN-α is increasingly recognized, but the distinct associated features, aetiology and management have not been reviewed.

OBJECTIVE

To review all published cases of hepatitis C patients who developed psoriasis while receiving IFN-α therapy.

METHODS

The review was conducted by searching the PubMed database using the keywords 'hepatitis C' AND 'psoriasis.' In addition, references to additional publications not indexed for PubMed were followed to obtain a complete record of published data.

RESULTS

We identified 32 publications describing 36 subjects who developed a psoriatic eruption while receiving IFN-α therapy for hepatitis C. Topical therapies were a commonly employed treatment modality, but led to resolution in only 30% of cases in which they were employed solely. Cessation of IFN-α therapy led to resolution in 93% of cases. Hundred per cent of those who developed psoriasis while on IFN-α therapy responded to systemic therapy and were able to continue the drug.

CONCLUSION

Further studies and analysis of IFN-α-induced lesions are necessary to clarify the role of IFN-α and the hepatitis C virus in the development of psoriatic lesions.

Photoletter to the editor: Linear atrophoderma of Moulin progressing slowly over 46 years

Linear atrophoderma of Moulin is a rare acquired disorder arising most commonly during childhood or adolescence, occurring equally in both sexes and characterized by hyperpigmented atrophoderma in a unilateral bandlike distribution along the lines of Blaschko. Since Moulin et al described the condition in 1992, only a few dozen cases have been reported. It has been postulated that linear atrophoderma of Moulin may be due to mosaicism.A 66-year-old man pre-sen-ted with a 46-year his-to-ry of evol-ving tan soft atro-phic con-fluent plaques in a striking-ly Blasch-koid dis-tri-bu-tion, in-vol-ving the left up-per back, shoulder, up-per arm, chest and flank. Ini-tial on-set, at age 20, con-sis-ted of a single mildly pru-ritic pink patch on the left back that was un-res-pon-sive to topical anti-fun-gals. Each new le-sion arose simi-larly as a pink pru-ritic patch, sub-se-quent-ly be-co-ming de-pressed, hy-per-pig-men-ted, and asym-pto-ma-tic over se-ve-ral years. Le-sions were never scaly, firm, or indu-rated. Punch biopsy speci-mens were obtained. The clinical and histo-patho-lo-gi-cal features con-firmed the diagnosis of linear atrophoderma of moulin.Our present case has the characteristic clinical and histopathological features of linear atrophoderma of Moulin, but is the first reported case with mild pruritus at the onset of each new lesion and progressing slowly over 46 years. The lack of any systemic symptoms or other complications in our patient reaffirms the benign nature of this skin disease.