Nodular type but not vitamin D levels increases the risk of second primary cancers in melanoma patients: An observational study of 663 patients

BACKGROUND

Vitamin D deficiency associates with the risk of developing many diseases, including cancer. At the molecular level, vitamin D appears to have an antineoplastic effect. However, the role of vitamin D deficiency in cancer pathogenesis remains unelucidated and numerous studies have resulted in discordant results. This study aimed to determine whether vitamin D deficiency during melanoma diagnosis increases the risk of developing non-cutaneous second primary cancers (SPC).

MATERIALS AND METHODS

A retrospective study on 663 patients diagnosed with melanoma between 1 January 2011 and 31 October 2022. The effect of each variable on the development of a subsequent non-cutaneous cancer was performed using Kaplan-Meier curves and differences were assessed by log-rank tests. Cox proportional hazard univariate and multivariate models were used to quantify the effect of each variable in the time to develop a non-cutaneous neoplasia.

RESULTS

Out of 663 patients, 34 developed a non-cutaneous SPC. There was no statistically significant association between vitamin D levels and non-cutaneous SPC development (log-rank, p=0.761). Age>60 years, stage III/IV, and nodular melanoma subtype were significantly associated with the development of a SPC. After multivariate analysis, only age>60 years (HR 3.4; HR CI 95%: 1.5-7.6) and nodular melanoma subtype (HR 2.2; HR CI 95%: 1.0-4.8) were included in the final model.

CONCLUSIONS

Our results suggest that vitamin D deficiency is not associated with an increased risk of developing non-cutaneous SPC in melanoma patients. However, age over 60 years and nodular melanoma subtype increase the risk for non-cutaneous SPC development.

Nodular Type but Not Vitamin D Levels Increases the Risk of Second Primary Cancers in Melanoma Patients: An Observational Study of 663 Patients

BACKGROUND

Vitamin D deficiency associates with the risk of developing many diseases, including cancer. At the molecular level, vitamin D appears to have an antineoplastic effect. However, the role of vitamin D deficiency in cancer pathogenesis remains unelucidated and numerous studies have resulted in discordant results. This study aimed to determine whether vitamin D deficiency during melanoma diagnosis increases the risk of developing non-cutaneous second primary cancers (SPC).

MATERIALS AND METHODS

A retrospective study on 663 patients diagnosed with melanoma between 1 January 2011 and 31 October 2022. The effect of each variable on the development of a subsequent non-cutaneous cancer was performed using Kaplan-Meier curves and differences were assessed by log-rank tests. Cox proportional hazard univariate and multivariate models were used to quantify the effect of each variable in the time to develop a non-cutaneous neoplasia.

RESULTS

Out of 663 patients, 34 developed a non-cutaneous SPC. There was no statistically significant association between vitamin D levels and non-cutaneous SPC development (log-rank, p=0.761). Age>60 years, stage III/IV, and nodular melanoma subtype were significantly associated with the development of a SPC. After multivariate analysis, only age>60 years (HR 3.4; HR CI 95%: 1.5-7.6) and nodular melanoma subtype (HR 2.2; HR CI 95%: 1.0-4.8) were included in the final model.

CONCLUSIONS

Our results suggest that vitamin D deficiency is not associated with an increased risk of developing non-cutaneous SPC in melanoma patients. However, age over 60 years and nodular melanoma subtype increase the risk for non-cutaneous SPC development.

PD-1 receptor outside the main paradigm: tumour-intrinsic role and clinical implications for checkpoint blockade

Blocking the inhibitory receptor PD-1 on antitumour T lymphocytes is the main rationale underlying the clinical successes of cancer immunotherapies with checkpoint inhibitor (CI) antibodies (Abs). Besides this main paradigm, there is recent evidence of unconventional and "ectopic" signalling pathways of PD-1, found to be expressed not only by lymphocytes but also by peculiar subsets of cancer cells. Several groups reported on the tumour-intrinsic role of PD-1 in multiple settings, including melanoma, hepatocellular, thyroid, lung, pancreatic and colorectal cancer. Its functional activity appears intriguing but is not yet conclusively clarified. The initial studies are, in fact, supporting either a pro-tumourigenic role involved in chemoresistance and disease relapse or, oppositely, tumour-suppressive functions. The implications connected to the therapeutic administration of PD-1 blocking Abs are, of course, potentially relevant, respectively inferring an anti-tumour activity contrasting PD-1+ tumourigenic cells or a pro-tumoural effect by tackling PD-1 tumour suppressive signalling. The progressive exploration and consideration of this new paradigm of tumour-intrinsic PD-1 signalling may improve the interpretation of the observed clinical effects by anti-PD-1 Abs, likely resulting from multiple cumulative activities, and might provide important bases for dedicated clinical studies that take into account such composite roles of PD-1.

Changes in CMR parameters and prediction of cardiac complications in thalassemia major: fibrosis tells us more than iron

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The MIOT project received “no-profit support” from industrial sponsorships (Chiesi Farmaceutici S.p.A. and ApoPharma Inc.).

Background

Cardiovascular magnetic Resonance (CMR) has dramatically changed the clinical practice and improved the prognosis in thalassemia major (TM).

Aim

This is the first study evaluating the predictive value of changes in CMR parameters (myocardial iron, function, and fibrosis) for cardiac complications in TM.

Methods

We followed prospectively 709 TM patients (374 females; 29.77 ± 8.53 years) consecutively enrolled in the Myocardial Iron Overload in Thalassemia (MIOT) Network who performed a baseline and a 1st follow up CMR scan after 18 months.  Myocardial iron overload (MIO) was measured by multislice multiecho T2* technique and atrial dimensions and biventricular function by cine images. Macroscopic myocardial fibrosis was detected by late gadolinium enhancement technique.

Risk classes were defined based on  the 4 patterns of MIO from worst to normal. For patients with baseline MIO (at least one segmental T2*<20 ms), improvement was defined as a transition to a better risk class, stabilization as no change in risk class, and worsening as a transition to a worse risk class. For patients without baseline MIO, the worsening was the transition to a worse risk class.

The percentage change was used for continuous variables. For biventricular ejection fractions, improvement was a %change > 10%, stabilization a %change between -10% and 10%, and worsening a %change<-10%. For biventricular volumes, LV mass index, and atrial areas, improvement was a % change<-10%, stabilization a % change between -10% and 10%, and worsening a % change > 10%.

Myocardial fibrosis was considered absent if not detected in any of the two CMRs and present if detected in at least one examination.

Results

During a mean follow-up of 89.4 ± 33.3 months, cardiac events were recorded in 50 (7.1%) patients: 24 (48%) episodes of heart failure, 24 (48%) arrhythmias (23 supraventricular and 1 hypokinetic), and 2 (4.0%) pulmonary hypertension.  Mean time from the 1st follow up CMR to the development of a cardiac complication was 75.31 ± 35.35 months.

In the univariate Cox regression analysis, cardiac iron cleareance and myocardial fibrosis were identified as univariate prognosticators (Table 1). In the multivariate analysis only myocardial fibrosis remained an independent predictor factor.

Conclusion

The presence of myocardial fibrosis at the baseline CMR or developed within 18 months emerges as the strongest long-term predictor for cardiac complications in TM. Our data demonstrate the importance in using the contrast medium for CMR scans in thalassemia patients.

The effect of extracellular acidosis on the behaviour of mesenchymal stem cells in vitro

The stem cell fraction of a cell population is finely tuned by stimuli from the external microenvironment. Among these stimuli, a decrease of extracellular pH (pHe) may occur in a variety of physiological and pathological conditions, including hypoxia and inflammation. In this study, by using bone marrow stem cells and dental pulp stem cells, we provided evidence that extracellular acidosis endows the maintenance of stemness in mesenchymal cells. Indeed, continuous exposure for 21 d to low pHe (6.5-6.8) conditions impaired the osteogenic differentiation of both cell types. Moreover, the exposure to low pHe, for 1 and up to 7 d, induced the expression of stemness-related genes and proteins, drove cells to reside in the quiescent G0 alert state and enhanced their ability to form floating spheres. The pre-conditioning with extracellular acidosis for 7 d did not affect the differentiation potential of dental pulp stem cells since, when the cells were cultured again at physiological pHe, their multilineage potential was almost unmodified. Our data provided evidence of the role of extracellular acidosis as a modulator of the stemness of mesenchymal cells. This condition is commonly found both in systemic and local bone conditions, hence underlining the relevance of this phenomenon for a better comprehension of bone healing and regeneration.

Association between markers of bone loss and urinary lithogenic risk factors in osteopenic postmenopausal women

In this study, we explored if urinary lithogenic risk parameters could have some application for monitoring bone health status. We recruited 20 women with postmenopausal osteopenia and a negative medical history for nephrolithiasis. Markers of lithogenic risk were evaluated on 24-h urine and fastingmorning urine. Serum levels of bone turnover markers (BTM) were measured in fasting-blood samples. We found that cross-linked telopeptide of type I collagen (CTX) was significantly correlated with 24-h calcium excretion. N-terminal propeptide of type I procollagen (PINP) correlated with 24-h excretion of potassium, calcium and citrate. CTX had considerably increased in patients with pH less than 5.5. Low citrate levels (less than 3.3 mmol/24 h) were associated with lower levels of CTX and PINP. Our findings suggest that a low-grade acidosis and some lithogenic risk factors are detectable in a proportion of patients with postmenopausal osteopenia. Further studies are necessary to confirm that this evaluation could be clinically relevant.

A consensus-based practical and daily guide for the treatment of acne patients

BACKGROUND

Many current guidelines provide detailed evidence-based recommendations for acne treatment.

OBJECTIVE

To create consensus-based, simple, easy-to-use algorithms for clinical acne treatment in daily office-based practice and to provide checklists to assist in determining why a patient may not have responded to treatment and what action to take.

METHODS

Existing treatment guidelines and consensus papers were reviewed. The information in them was extracted and simplified according to daily clinical practice needs using a consensus-based approach and based on the authors' clinical expertise.

RESULTS

As outcomes, separate simple algorithms are presented for the treatment of predominant comedonal, predominant papulopustular and nodular/conglobate acne. Patients with predominant comedonal acne should initially be treated with a topical retinoid, azelaic acid or salicylic acid. Fixed combination topicals are recommended for patients with predominant papulopustular acne with treatment tailored according to the severity of disease. Treatment recommendations for nodular/conglobate acne include oral isotretinoin or fixed combinations plus oral antibiotics in men, and these options may be supplemented with oral anti-androgenic hormonal therapy in women. Further decisions regarding treatment responses should be evaluated 8 weeks after treatment initiation in patients with predominant comedonal or papulopustular acne and 12 weeks after in those with nodular/conglobate acne. Maintenance therapy with a topical retinoid or azelaic acid should be commenced once a patient is clear or almost clear of their acne to prevent the disease from recurring. The principal explanations for lack of treatment response fall into 5 main categories: disease progression, non-drug-related reasons, drug-related reasons, poor adherence, and adverse events.

CONCLUSION

This practical guide provides dermatologists with treatment algorithms adapted to different clinical features of acne which are simple and easy to use in daily clinical practice. The checklists to establish the causes for a lack of treatment response and subsequent action to take will facilitate successful acne management.

Citrobacter koseri septicaemia in a holstein calf

A 4-day-old male Holstein calf with dull mentation, nystagmus and blindness was humanely destroyed and subject to necropsy examination. Gross lesions included severe suppurative meningitis characterized by diffuse cloudy thickening of the meninges, bilateral hypopyon and fibrinosuppurative polyarthritis affecting the hocks. Citrobacter koseri was isolated from the meninges, ocular fluid, synovial fluid, spleen and small intestine. Microscopically, there was neutrophilic and histiocytic meningitis with intralesional bacilli, endophthalmitis, neutrophilic splenitis and multiple renal microabscesses. Failure of passive transfer of colostrum was confirmed. This appears to be the first characterization of septicaemia in a calf caused by C. koseri, with lesions comparable with those described in human neonates.

Impact of environmental changes and human-related factors on the potential malaria vector, Anopheles labranchiae (Diptera: Culicidae), in Maremma, Central Italy

The Maremma Plain (central Italy) was hyper-endemic for malaria until the mid-20th century, when a national campaign for malaria elimination drastically reduced the presence of the main vector Anopheles labranchiae Falleroni. However, the introduction of rice cultivation over 30 yr ago has led to an increase in the An. labranchiae population and concern over possible malaria reemergence. We studied the impact of anthropogenic environmental changes on the abundance and distribution of An. labranchiae in Maremma, focusing on rice fields, the main breeding sites. Adults and larvae were collected in three main areas with diverse ecological characteristics. Data were collected on human activity, land use, and seasonal climatic and demographic variations. We also interviewed residents and tourists regarding their knowledge of malaria. Our findings showed that the most important environmental changes have occurred along the coast; An. labranchiae foci are present throughout the area, with massive reproduction strictly related to rice cultivation in coastal areas. Although the abundance of this species has drastically decreased over the past 30 yr, it remains high and, together with climatic conditions and the potential introduction of gametocyte carriers, it may represent a threat for the occurrence of autochthonous malaria cases. Our findings suggest the need for the continuous monitoring of An. labranchiae in the study area. In addition to entomological surveillance, more detailed knowledge of human-induced environmental changes is needed, so as to have a more complete database that can be used for vector-control plans and for properly managing emergencies related to autochthonous introduced cases.

Bayesian compressive optical imaging within the Rytov approximation

Within the range of validity of the Rytov approximation (RA), an innovative Bayesian compressive sensing (BCS) inverse scattering technique is developed. Potentialities and limitations of the BCS-RA method are validated through numerical experiments and representative results are discussed.

The prevalence of acne in the north of Portugal

BACKGROUND

Acne is a disease that affects almost all teenagers (60-90%), and it is the pathology exhibiting the highest morbidity in the 10-24 year-olds age group. There are no consistent data at national level by which we can evaluate the preponderance of this pathology in the Portuguese population.

OBJECTIVE

To estimate the prevalence of acne in teenage school students (10-12 year-olds).

STUDY DESIGN

A study was carried out involving all 8 regions in the north of Portugal. One school per region was selected at random.

RESULTS

As expected, the figure we obtained for the prevalence of this pathology was high (82.4%) with males being the most affected. Nevertheless, only 44% of the affected treated their acne, although the face is the part of the body most affected. In the females high androgenization (which is manifested by the presence of hair on the upper lip and on the side of the face) doubles the median of the degree of acne registered. Regional asymmetry was found in relation to information about the disorder. The degrees of acne are higher in schools in the interior. In the more rural areas, the pharmacist still plays an important role in prescribing treatment.

CONCLUSION

As a rule, individuals are correctly informed about acne, confirming that the search for treatment and awareness of its value are generally helping to gradually eliminate some of the stigmas from the past.

Lymphocele After Renal Transplantation: The Influence of the Immunosuppressive Therapy

Lymphocele is a complication of renal transplantation, representing a lymphatic collection around the grafted kidney. The use of the immunosuppressive agent sirolimus (SRL) has been associated with a significant increase in lymphocele formation. This complication has been related to the antiproliferative activity of SRL, which delays surgical wound repair and closure of injured lymphatic vessels. The aim of this study was to relate the incidence of lymphocele with immunosuppression among 158 renal transplant patients operated with routine closure of all the visible lymphatic vessels around the iliac vessels and at the renal hilum. The incidence of lymphocele was not significantly different among the various immunosuppressive regimens.

Cutaneous manifestations of familial amyloidotic polyneuropathy

Familial amyloidotic polyneuropathy is an autosomal dominant amyloidosis, characterized by the systemic deposition of amyloid with a particular involvement of the peripheral nerves. The disease generally manifests as a severe sensory, motor and autonomic neuropathy. Cardiomyopathy, nephropathy, vitreous opacities and carpal tunnel syndrome may occur in a variable association with the neuropathy. Trophic dermatological lesions are frequent in the more advanced stages of the disease. We examined the skin of 142 patients. The cutaneous manifestations more frequently observed were: xerosis (81.6%), seborrheic dermatitis (21.8%), traumatic and burn lesions (19.7%), acne (18.3%), neurotrophic ulcers (14%) and onychomycosis (10.5%). Among the hepatic transplanted patients (31%), seborrheic dermatitis and acne were the most frequent diagnoses.

Plasma cell cheilitis

Plasma cell cheilitis is a rare inflammatory disorder of the lip with a characteristic band-like infiltrate of plasma cells in the upper dermis. Differential diagnosis should consider allergic/irritant contact cheilitis, candidiasis, syphilis, Queyrat's erythroplasia, granulomatous cheilitis, plasmoacanthoma, plasmacytoma, squamous cell carcinoma and exfoliative or factitious cheilitis. We observed plasma cell cheilitis in a 60-year-old Caucasian female who had a partial response to topical steroids and oral griseofulvin.

[The activation of the phosphotyrosine phosphatase eta is responsible for the somatostatin inhibition of PCCl3 thyroid cell proliferation]

BACKGROUND

This study was aimed to identify possible intracellular effectors of the somatostatin (SST) antiproliferative activity, in PCCl3 thyroid cells.

METHODS

To prove the involvement of r-PTPeta in SST's effect, we studied th proliferative activity of subclones of PCCl3 cells that do or do not express this PTP.

RESULTS

SST inhibited PCCl3 TSH+insulin-dependent cell proliferation through the induction of a phosphotyrosine phosphatase (PTP) activity, detected using the synthetic substrate pNPP (+150%, p<0.01). Conversely, PCCl3 cells stably expressing the v-mos oncogene (PCmos) were completely insensitive to SST antiproliferative effects due to the incapability of SST to increase PTP activity, that correlated with the abolishment of the expression of the receptor-like PTP, r-PTPeta. In the cells in which r-PTPeta was transfected (PCmos/ PTPeta) SST inhibited cell proliferation showing a dose-dependence similar to that observed in PCCl3 cells. Conversely, the transfection of a catalytically inactive mutant of r-PTPeta did not restore the responsivity to SST. Also in PCmos/PTPeta cells SST, treatment increased membrane PTP activity.

CONCLUSIONS

SST inhibition of PCC13 cell proliferation requires the activation of r-PTPeta.

The activation of the phosphotyrosine phosphatase eta (r-PTP eta) is responsible for the somatostatin inhibition of PC Cl3 thyroid cell proliferation

The aim of this study was the characterization of the intracellular effectors of the antiproliferative activity of somatostatin in PC Cl3 thyroid cells. Somatostatin inhibited PC Cl3 cell proliferation through the activation of a membrane phosphotyrosine phosphatase. Conversely, PC Cl3 cells stably expressing the v-mos oncogene (PC mos) were completely insensitive to the somatostatin antiproliferative effects since somatostatin was unable to stimulate a phosphotyrosine phosphatase activity. In PC mos cells basal phosphotyrosine phosphatase activity was also reduced, suggesting that the expression of a specific phosphotyrosine phosphatase was impaired in these transformed cells. We suggested that this phosphotyrosine phosphatase could be r-PTP eta whose expression was abolished in the PC mos cells. To directly prove the involvement of r-PTP eta in somatostatin's effect, we stably transfected this phosphatase in PC mos cells. This new cell line (PC mos/PTP eta) recovered somatostatin's ability to inhibit cell proliferation, showing dose-dependence and time course similar to those observed in PC Cl3 cells. Conversely, the transfection of a catalytically inactive mutant of r-PTP eta did not restore the antiproliferative effects of somatostatin. PC mos/PTP eta cells showed a high basal phosphotyrosine phosphatase activity which, similarly to PC Cl3 cells, was further increased after somatostatin treatment. The specificity of the role of r-PTP eta in somatostatin receptor signal transduction was demonstrated by measuring its specific activity after somatostatin treatment in an immunocomplex assay. Somatostatin highly increased r-PTP eta activity in PCCl3 and PC mos/PTP eta (+300%, P < 0.01) but not in PCmos cells. Conversely, no differences in somatostatin-stimulated SHP-2 activity, (approximately +50%, P < 0.05), were observed among all the cell lines. The activation of r-PTP eta by somatostatin caused, acting downstream of MAPK kinase, an inhibition of insulin-induced ERK1/2 activation with the subsequent blockade of the phosphorylation, ubiquitination, and proteasome degradation of the cyclin-dependent kinase inhibitor p27(kip1). Ultimately, high levels of p27(kip1) lead to cell proliferation arrest. In conclusion, somatostatin inhibition of PC Cl3 cell proliferation requires the activation of r-PTP eta which, through the inhibition of MAPK activity, causes the stabilization of the cell cycle inhibitor p27(kip1).

Cutaneous necrobiotic xanthogranuloma (NXG)--successfully treated with low dose chlorambucil

We report a case of necrobiotic xanthogranuloma in a 51 year-old white male patient presenting with a 6-year history of multiple indurated violaceous nodules and plaques involving the eyelids, trunk and extremities. He had an associated paraproteinemia (Ig G lambda), elevated sedimentation rate, cryoglobulinemia and hypocomplementemia. No extracutaneous involvement was detected. He was successfully treated with chlorambucil (2 mg/d for 7 months), leading to disappearance of all skin lesions.

Acral necrosis by Stenotrophomonas maltophilia

BACKGROUND

Stenotrophomonas maltophilia (SM) has been considered a nosocomial pathogen. Nevertheless, community acquired infection may occur more frequently than usually recognized.

CASE

We describe distal necrosis of the fingers by SM in a farmer, contracted in the community and successfully treated with a combination of cotrimoxazole and ciprofloxacin. The patient was diagnosed with chronic lymphocytic leukaemia 6 months later.

CONCLUSIONS

This unusual presentation shows that infection with SM should be included in the differential diagnosis of the skin and soft tissue infection, even in apparently healthy patients.

Prediction of electromagnetic field distributions inside biological bodies by using an inverse scattering procedure based on a statistical cooling algorithm

This paper presents an inverse scattering procedure based on a statistical cooling algorithm to predict the electromagnetic field inside a biological body. By knowing only the scattered electric field distribution in a set of observation points external to the biological model, this method seems to be able to predict the electromagnetic field distributions in the investigation domain, minimizing a suitable cost function. To this end, a numerical statistical procedure is used, which allows to treat functions with a large number of unknowns in an efficient manner and to exploit the so called a priori knowledge in the reconstruction process. Some preliminary results are reported, concerning simplified biological geometries, which clearly show the capabilities and effectiveness, and also the current limitations of the proposed approach. Finally, further advances for the proposed imaging technique are indicated and discussed.

[Prevalence of cutaneous lesions in Freixo de Espada à Cinta]

Incidence or prevalence studies on cutaneous lesions in general populations are not available. The community observed by the authors (Freixo de Espada à Cinta, North-Eastern Portugal) is relatively closed. A pre-tested questionnaire for socio-demographic and clinical information was used and a physical observation was conducted in January and February 1994 by the Dermatology Team of Santo António General Hospital, Oporto. The analysis was supported by independent tests (Pearson and Fisher chi 2, Student-t, Mann-Whitney and Kruskall-Wallis). The Spearman correlation coefficient was also used. The results indicated that 51.9% of 1000 subjects analysed were in phototype III. Concerning specific pathologies, the following percentages were observed: melanocytic nevi 81.2; hemangiomas 26.5; androgenetic alopecia 20.5; deshydrotic eczema 12.7; seborrheic keratosis 11; solar keratosis 9.6; acne vulgaris 9.5; seborrheic dermatitis 6.9; superficial mycosis 6.4; other dermatitis 5.5; vascular spiders 4.4; vulgar psoriasis 1.9; vulgar warts 1.5; pediculosis and scabiosis 1.2.; herpes simplex 0.9; impetigo 0.7; tumours (neoplasias) 0.7; dysplastic nevi 0.6; urticaria 0.3. More than nine nevi were counted in 50% of the subjects observed. A difference was observed (p < 0.05) concerning the presence of nevi, mycosis, hemangiomas, non-specific dermatitis, vascular spider and solar keratosis according to sex. The females had more nevi in number than males (Mann-Whitney, p = 0.03). According to age there was a difference concerning the presence of nevi, superficial mycosis, deshydrotic eczema, seborrheic dermatitis, acne, psoriasis, tumours, hemangiomas, non-specific dermatitis, vascular spider, solar keratosis (with linear augmentation by age) and seborrheic keratosis. Nevi increased with ageing (Rs = 0.10 p < 0.001) and a greater number were observed in age groups 0-9 and 60 or more years. Acne was observed in 9.4% of the females and 9.7% of the males, 46.2% in the 15-29 year-old age group. This study indicated that the population had a mean of nine nevi. Psoriasis was similar to that mentioned in other studies: about 1% in the United States of America. Atopic dermatitis (5.5%) is below the values for the northern population (> = 15%), but above that indicated for the English and American population. Nevertheless, the values of the present study were higher than those in the latter populations, when children until seven years old were considered. The Freixo de Espada à Cinta population above 60 years had solar keratosis in 30.6%, a value three times higher than the previous decade (10.9%); reference values were not found. Contrary to the literature, an association was not established between phototype and solar keratosis. Cutaneous tumours were observed in 0.7% of the cases.

Guess what! Porokeratosis of Mibelli

A 72-year-old man had noticed, in his early forties, the appearance of well-defined papulous hyperkeratotic lesions, with increasing growth, located on both sides of his feet. After twenty-five years he consulted a dermatologist for the first time. Physical examination showed annular papules and rose-coloured plaques with atrophic centres, some of them hypopigmented, with higher and irregular borders, separated from the surrounding skin by longitudinal and well-defined furrows. The lesions presented variable sizes and shapes, some of them punctate, involving exclusively and in a bilateral form, both sides, back and sole of the feet (Figs. 1 and 2). The patient did not report any subjective symptoms. He was immunocompetent and did not remember that any relative had the same disease, nor had he been subjected to radiation treatment.

Hemoglobin switching in unicellular erythroid culture of sibling erythroid burst-forming units: kit ligand induces a dose-dependent fetal hemoglobin reactivation potentiated by sodium butyrate

Mechanisms underlying fetal hemoglobin (HbF) reactivation in adult life have not been elucidated; particularly, the role of growth factors (GFs) is controversial. Interestingly, histone deacetylase (HD) inhibitors (sodium butyrate, NaB, trichostatin A, TSA) reactivate HbF. We developed a novel model system to investigate HbF reactivation: (1) single hematopoietic progenitor cells (HPCs) were seeded in serum-free unilineage erythroid culture; (2) the 4 daughter cells (erythroid burst-forming units, [BFU-Es]), endowed with equivalent proliferation/differentiation and HbF synthesis potential, were seeded in 4 unicellular erythroid cultures differentially treated with graded dosages of GFs and/or HD inhibitors; and (3) HbF levels were evaluated in terminal erythroblasts by assay of F cells and gamma-globin content (control levels, 2.4% and 1.8%, respectively, were close to physiologic values). HbF was moderately enhanced by interleukin-3 (IL-3) and granulocyte-macrophage colony-stimulating factor treatment (up to 5%-8% gamma-globin content), while sharply reactivated in a dose-dependent fashion by c-kit ligand (KL) and NaB (20%-23%). The stimulatory effects of KL on HbF production and erythroid cell proliferation were strictly correlated. A striking increase of HbF was induced by combined addition of KL and NaB or TSA (40%-43%). This positive interaction is seemingly mediated via different mechanisms: NaB and TSA may modify the chromatin structure of the beta-globin gene cluster; KL may activate the gamma-globin promoter via up-modulation of tal-1 and possibly FLKF transcription factors. These studies indicate that KL plays a key role in HbF reactivation in adult life. Furthermore, combined KL and NaB administration may be considered for sickle cell anemia and beta-thalassemia therapy.

Hydroxyurea therapy in paraparesis and cauda equina syndrome due to extramedullary haematopoiesis in thalassaemia: improvement of clinical and haematological parameters

Patients with beta-globin disorders show amelioration of clinical condition by sustained synthesis of fetal haemoglobin in adult life. We report data on a patient with beta(o)-thalassaemia genotype and thalassaemia intermedia clinical phenotype. He received therapy with hydroxyurea (20 mg/kg/d) because of the presence of extramedullary masses causing paraparesis, neurogenic bladder and impotence. During therapy, the patient showed an improved clinical picture and a significant increase in total Hb (from 71.8 to 103.2 g/L) and a gamma/alpha globin synthetic ratio (from 0.39 to 0.68). The myelosuppressive effect of hydroxyurea was revealed by a decrease in CFU-GEMM, BFU-E, and CFU-GM. Therefore hydroxyurea can be effective in the treatment of patients with extramedullary haematopoiesis (EMH) who are not transfusion-dependent and cannot be treated with radiotherapy.

Two recent cases of tertiary syphilis

Tertiary syphilis is now a rare disease in Europe, mainly as a result of occasional antibiotherapy for concomitant infections. However early syphilis is rising in USA and Germany, and it is necessary to maintain an high level of knowledge and suspicion to achieve a diagnosis in the tertiary stage of the disease. In this report two patients with benign tertiary syphilis are described. The first one is a 55-year-old female with erythemato-violaceous annular scaling plaques on the right buttock and scapula and on both thighs, which had a negative and then a low VDRL titer. The second case is a 33-year-old mentally handicapped female with erythematous plaques, with psoriasiform scaling in the trunk and well defined crusted ulcers on the face, which also had negative VDRL. Biopsy of the skin lesions revealed plasmocytic infiltrate with endothelial swelling without granulomas and with negative silver stains in both patients. The investigation for cardiovascular and neurological involvement was negative in both patients. Diagnosis of tertiary syphilis can be difficult as clinical pictures can be misleading, similar to other granulomatous diseases, and serological titers can be low or negative. We recall the necessity of ruling out neurological and cardiac involvement in this stage of syphilis. These cases are reported as a reminder of the possibility of syphilis, so that new cases are not misdiagnosed and mistreated as other diseases.

Two recent cases of tertiary syphilis

Tertiary syphilis is now a rare disease in Europe, mainly as a result of occasional antibiotherapy for concomitant infections. However early syphilis is rising in USA and Germany, and it is necessary to maintain an high level of knowledge and suspicion to achieve a diagnosis in the tertiary stage of the disease. In this report two patients with benign tertiary syphilis are described. The first one is a 55-year-old female with erythemato-violaceous annular scaling plaques on the right buttock and scapula and on both thighs, which had a negative and then a low VDRL titer. The second case is a 33-year-old mentally handicapped female with erythematous plaques, with psoriasiform scaling in the trunk and well defined crusted ulcers on the face, which also had negative VDRL. Biopsy of the skin lesions revealed plasmocytic infiltrate with endothelial swelling without granulomas and with negative silver stains in both patients. The investigation for cardiovascular and neurological involvement was negative in both patients. Diagnosis of tertiary syphilis can be difficult as clinical pictures can be misleading, similar to other granulomatous diseases, and serological titers can be low or negative. We recall the necessity of ruling out neurological and cardiac involvement in this stage of syphilis. These cases are reported as a reminder of the possibility of syphilis, so that new cases are not misdiagnosed and mistreated as other diseases.

Immediate and delayed hypersensitivity to mite antigens in atopic dermatitis

Atopic dermatitis (AD) is a common disorder and appears to be on the increase, especially among children. It was thought at first to be a manifestation of immediate hypersensitivity, but it is now known that delayed hypersensitivity also plays an important role. Sensitivity to mite antigens is found in 20% to 60% of patients when immediate hypersensitivity is evaluated by the detection of specific IgE antibodies and prick tests, and in 30% to 50% of patients when delayed hypersensitivity is studied by patch testing. A prospective randomized study was carried out in the pediatric dermatology clinic on a sample of 51 children under 15 years of age. A prevalence of immediate and delayed hypersensitivity to mites, like that described for other populations, was found. It was further found that there was a positive association, not described in the literature, between the younger age groups and delayed hypersensitivity to mite antigens, while the opposite was true for immediate hypersensitivity. We believe that patch tests with airborne allergens, specifically mites, should be part of the protocol for assessing children with AD, particularly in the younger age groups.

[Photosensitivity induced by piroxicam]

In Portugal, piroxicam is one of the most prescribed non-steroidal anti-inflammatory agents (NSAIDs) and is frequently associated to photosensitivity skin reactions, well known by all dermatologists. The authors review the physiopathology and clinical patterns of this adverse drug reaction. Importance is given to the high prevalence of thimerosal sensitisation in our country, a marker of piroxicam photosensitivity. The authors propose that piroxicam prescription should be avoided in Portugal, as this drug can be substituted by any other NSAID, without marked photosensitivity.

[Scleredema, acanthosis nigricans and IgA/Kappa multiple myeloma]

BACKGROUND

Scleredema is an uncommon disease of unknown origin. Characteristic thick skin with symmetrical diffuse induration develops. The infiltration begins on the face and neck then extends to the root of the upper limbs and trunk. There are three clinical types of scleredema. The first is preceded by an upper airway infection and progresses rapidly before regressing spontaneously within a few months. The second type is associated with chronic diabetes. The third type is associated with monoclonal gammapathy, rarely of myelomatous type, and develops insidiously. Acanthosis nigricans can be a paraneoplastic syndrome, often associated with a gastrointestinal cancer. Few cases associating scleredema and acanathosis nigricans have been reported.

CASE REPORT

A 56-year old woman had developed scleredema over the last 6 years when acanthosis nigricans appeared together with IgA kappa multiple myeloma. Treatment with melphalan and prednisolone was effective against the myeloma as well as the scleredema and acanthosis nigricans.

DISCUSSION

Only five cases of associated scleredema and multiple myeloma have been reported, four with kappa IgG myeloma and one with IgA myeloma. An association between acanthosis nigricans and sclerederma could be coincidental although the fact that the different manifestations regressed together after the myeloma treatment would suggest some relationship between these three diseases.

[Skin cancer]

The authors, using the Cancer Registry data of S. Antonio General Hospital in Oporto, selected the cancer cases from 1981 to 1993. Distribution according to age, sex, topography and morphology is presented. Seven point nine percent of the 12,124 cases mentioned in the Registry were skin cancers (n = 883). They were mostly on the face (56.8%), trunk (11.7%) and scalp and neck (7.7%). As for the type of tumour, 472 basaliomas, 231 squamous cell carcinomas and 63 melanomas were recorded. One may conclude that basaliomas and squamous cell cancers arise at a later age than melanomas; melanomas are more frequent on the lower limbs and on the trunk; squamous cell carcinomas are more frequent on the face and lips. Basalioma is more frequent on the face. These results are in accordance with those published internationally.

Childhood cutaneous mucinosis

A case of childhood cutaneous mucinosis is described. This is a clinical condition that is rarely seen and has only recently been included in the group of primary mucinosis.