Insights into proton pump inhibitor-induced photosensitivity: An observational study in a tertiary photobiology service

BACKGROUND

Proton pump inhibitors (PPIs) are extensively prescribed but may cause photosensitivity and drug-induced lupus erythematosus (DILE), which can be overlooked as the drug may have been taken for years prior to presentation.

METHODS

We reviewed the clinical and investigation findings of patients diagnosed with PPI-induced photosensitivity, diagnosed through the Scottish Photobiology Service.

RESULTS

We report 11 patients with median age of onset 61-years and mean duration of PPI ingestion of 5-years [DILE (n = 6), phototoxicity (n = 3) and drug-induced solar urticaria through a lupus mechanism (n = 2)]. Five had Anti-Ro antibodies (three also ANA positive). Predominantly UVA and visible light photosensitivity was observed on phototesting.

DISCUSSION

PPIs are a reversible cause of photosensitivity and DILE. Time to onset from drug initiation to symptoms can be prolonged, so clinicians should have a high index of suspicion in those taking PPIs. Most are diagnosed through clinical assessment and lupus serology, with phototesting indicated if there is diagnostic uncertainty.

A rapidly expanding nodule on the lower leg

We present a case of a 34-year-old man who developed a lesion over his posterior calf. We discuss the clinical and histopathological features, as well as relevant immunohistochemical markers.

A newly growing asymptomatic facial lesion

A 23-year-old man presenting with a 1-year history of a lesion of the right cheek. We highlight this case for awareness as this tumour may mimic other benign lesions, such as pilomatrixoma or benign cysts, as it does not have any uniquely identifying clinical or dermoscopic features. Additionally, it is of concern as malignant transformation can occur and therefore surgery should be considered as both for diagnostic and therapeutic benefit.

Gender-based incidence, recovery period, and mortality rate of COVID-19 among the population of district Attock, Pakistan

COVID-19 is reported as an extremely contagious disease with common symptoms of fever, dry cough, sore throat, and tiredness. The published literature on incidence and gender-wise prevalence of COVID-19 is scarce in Pakistan. Therefore, the present study was designed to compare the distribution, incubation period and mortality rate of COVID-19 among the male and female population of district Attock. The data were collected between 01 April 2020 and 07 December 2020 from the population of district Attock, Pakistan. A total of 22,962 individuals were screened and 843 were found positive for RT-qPCR for SARS-CoV-2. The confirmed positive cases were monitored carefully. Among the positive cases, the incidence of COVID-19 was 61.7% among males and 38.2% among females. The average recovery period of males was 18.89±7.75 days and females were 19±8.40 days from SARS-CoV-2. The overall mortality rate was 8.06%. The death rate of male patients was significantly higher (P<0.05) compared to female patients. Also, the mortality rate was higher (P<0.05) in male patients of 40-60 years of age compared to female patients of the same age group. Moreover, the mortality rate significantly increased (P<0.05) with the increase of age irrespective of gender. In conclusion, the incidence and mortality rate of COVID-19 is higher in males compared to the female population. Moreover, irrespective of gender the mortality rate was significantly lower among patients aged <40 years.

Decision-making in dermatologic surgery

Good clinical decision-making is important in dermatologic surgery. Experience and knowledge help considerably, but take time to acquire. However, how the clinician thinks is also a significant contributory factor. How we think is influenced by many factors, including our beliefs, prejudices, confidence and variables like how we are feeling at that moment physically and emotionally. Thought process can be either fast and subconscious or slow and analytical. Fast thinking contributes to the majority of decision-making and is especially prone to a range of biases which may contribute to suboptimal clinical outcomes. We wish to highlight and illustrate common biases in thinking encountered by the dermatologic surgeon.

Evaluation of economic loss caused by Indian crested porcupine (Hystrix indica) in agricultural land of district Muzaffarabad, Azad Jammu and Kashmir, Pakistan

The Indian crested porcupine (Hystrix indica) is a vertebrate pest of agricultural lands and forest. The study was aimed to report the damage to local crops by the Indian crested porcupine (Hystrix indica) in the Muzaffarabad District. A survey was conducted to identify the porcupine-affected areas and assess the crop damage to the local farmers in district Muzaffarabad Azad Jammu and Kashmir (AJK) from May 2017 to October 2017. Around 19 villages were surveyed, and a sum of 191 semi-structured questionnaires was distributed among farmers. Crop damage was found highest in village Dhanni where a porcupine destroyed 175 Kg/Kanal of the crops. Regarding the total magnitude of crop loss, village Danna and Koomi kot were the most affected areas. More than half (51.8%) of the respondents in the study area suffered the economic loss within the range of 101-200$, and (29.8%) of the people suffered losses in the range of 201-300$ annually. Among all crops, maize (Zea mays) was found to be the most damaged crop ranging between 1-300 Kg annually. In the study area, porcupine also inflicted a lot of damages to some important vegetables, including spinach (Spinacia oleracea), potato (Solanum tuberosum) and onion (Allium cepa). It was estimated that, on average, 511Kg of vegetables are destroyed by porcupine every year in the agricultural land of Muzaffarabad. It was concluded that the Indian crested porcupine has a devastating effect on agriculture which is an important source of income and food for the local community. Developing an effective pest control strategy with the help of the local government and the Wildlife department could help the farmers to overcome this problem.

A comparative study to evaluate the effects of antibiotics, plant extracts and fluoride-based toothpaste on the oral pathogens isolated from patients with gum diseases in Pakistan

Oral diseases caused by various microorganisms are common around the world. Scientific research has now been focusing on novel medicines to overcome bacterial resistance and antibiotics side effects; therefore, the current study was designed to assess the efficacy of certain antibiotics, toothpaste, and medicinal plant extracts (Ajuga bracteosa and Curcuma longa) versus the bacterial pathogens isolated from the human oral cavity. A total of 130 samples were collected from Khyber Teaching Hospital Peshawar, Pakistan, among those 27 species isolated, and eight bacterial species were identified from the samples. Among all the bacterial species, Staphylococcus aureus (29.62%) and Proteus mirabilis (22.2%) were found to be more prevalent oral pathogens. In comparison, the least pervasive microbes were Proteus vulgaris, Shigella sonnei, Escherichia coli and Aeromonas hydrophila. The study also suggested that dental problems were more prevalent in males (41-50 years of age) than females. Among the eight antibiotics used in the study, the most promising results were shown by Foxicillin against A. hydrophila. The survey of TP1 revealed that it showed more potent antagonist activity against Proteus vulgaris as compared TP2 and TP3 that might be due to the high content of fluoride. The Curcuma longa showed more significant activity than Ajuga bracteosa (Stem, leaves and root) extracts. The data obtained through this study revealed that antibiotics were more effective for oral bacterial pathogens than toothpaste and plant extracts which showed moderate and low activity, respectively. Therefore, it is suggested that the active compounds in individual medicinal plants like Curcuma longa and Ajuga bracteosa could replace the antibiotics when used in daily routine as tooth cleansers or mouth rinses.

A new approach to actinic folliculitis: prophylactic narrowband ultraviolet B phototherapy

BACKGROUND

We have observed an increasing number of patients referred to the Scottish Photobiology Service (SPS), who were later diagnosed with actinic folliculitis (AF) and had positive phototesting results. Treatment options for AF are limited, with only a few reports in the literature. The use of prophylactic narrowband ultraviolet B (NB-UVB) phototherapy for AF has not previously been described, and we report on this for the first time.

AIM

To analyse the clinical characteristics, phototesting results and responses to treatment for patients with AF diagnosed by the SPS.

METHODS

We undertook a retrospective review over 10 years of all case notes of patients who were assessed and diagnosed with AF through the SPS, based at the Photobiology Unit, Dundee, UK.

RESULTS

All 10 patients were women. Mean age of onset was 25 years and mean time to referral for investigation was 7 years. The commonest site involved was the face, with the main clinical feature being monomorphic pustules appearing after sunlight exposure. The eruption could be provoked with iterative doses of broadband UVA irradiation in five patients. All patients were offered photoprotective advice and prophylactic NB-UVB phototherapy. Five patients proceeded with phototherapy; four of these completed the desensitization course and all four reported either a delay in symptom onset or total prevention of rash induction, with complete efficacy of desensitization maintained for 3 years in one patient.

CONCLUSION

We demonstrate the successful use of UVA provocation testing as a diagnostic tool in AF. Additionally, we recommend the use of prophylactic NB-UVB phototherapy in AF as an effective and well-tolerated approach.

Effect of cardiac resynchronization therapy on septal perfusion and septal thickening: Association with left ventricular function, reverse remodelling and dyssynchrony

BACKGROUND

We evaluated the effect of cardiac resynchronization therapy (CRT) on septal perfusion and thickening at 6 months post implantation assessed on Tc99m-MIBI Gated myocardial perfusion SPECT (GMPS).We also studied the association of change in septal perfusion and thickening with primary outcome defined as at least one [improvement in ≥1NYHA class, left ventricular ejection fraction (LVEF) by ≥ 5%, reduction of end-systolic volume (ESV) by ≥ 15%, and improvement ≥ 5 points in Minnesota living with heart failure questionnaire (MLHFQ)].

METHOD

One hundred and five patients underwent clinical and GMPS evaluation before and at 6 months post CRT.

RESULT

Post CRT there was significant improvement in mean normalized septal perfusion uptake and in septal thickening (P value = 0.001, both). There was no significant relation between improvement in septal perfusion and primary outcome. However, improvement in septal thickening was statistically significant with favorable primary outcome (P = 0.001).There was no significant correlation between improvement of septal perfusion and improvement in LVEF, reduction in End diastolic volume (EDV), ESV, and Left ventricular Dyssynchrony (LVD). But, there was significant correlation between improvement of septal thickening and these parameters.

CONCLUSION

Improvement in septal thickening was associated with reverse remodeling, improvement in LVEF, and reduction of LVD.

Correction to: Current concept in upright spinal MRI

Unfortunately, the legend of Fig. 5 was incorrectly published in original publication. The corrected legend is given below.

Comparative quantitative assessment of global small bowel motility using magnetic resonance imaging in chronic intestinal pseudo-obstruction and healthy controls

BACKGROUND

Chronic intestinal pseudo-obstruction (CIPO) is characterized by dilatation of the bowel lumen and abnormal motility. In this study, we aimed to quantify small bowel dysmotility in CIPO using a validated pan-intestinal motility assessment technique based on motion capture magnetic resonance imaging (MRI) compared to normal controls. In addition, we explored if motility responses of CIPO patients to neostigmine challenge differed from healthy volunteers.

METHODS

Twenty healthy volunteers (mean age 28, range 22-48) and 11 CIPO patients (mean age 47, range 19-90) underwent MRI enterography to capture global small bowel motility. Eleven controls and seven CIPO patients further underwent a randomized placebo-controlled crossover study of either intravenous neostigmine (0.5 mg) or saline with motility MRI repeated at a mean of 3 weeks. Motility was quantified in regions of interest placed to encompass the whole small bowel volume using a validated, postprocessing technique to give a global motility index in arbitrary units (AU). Baseline and stimulated motility was compared using Wilcoxon rank-sum paired T-tests.

KEY RESULTS

Baseline global small bowel motility was significantly lower in CIPO patients compared to controls (mean 0.25 AU vs 0.35 AU, p < 0.001). Motility in both groups increased significantly after neostigmine (0.06 AU increase, p = 0.016 in CIPO and 0.06 AU increase, p = 0.002 in controls). Three patients with scleroderma had a reduced response to neostigmine.

CONCLUSIONS & INFERENCES

Global small bowel motility in CIPO patients is significantly lower than controls and response to the pro-kinetic agent neostigmine may differ according to disease phenotype. Software-quantified bowel motility using cine MRI has potential as a future tool to investigate enteric dysmotility.

Sodium salicylate reduces the level of GABAB receptors in the rat's inferior colliculus

Previous studies have indicated that sodium salicylate (SS) can cause hearing abnormalities through affecting the central auditory system. In order to understand central effects of the drug, we examined how a single intraperitoneal injection of the drug changed the level of subunits of the type-B γ-aminobutyric acid receptor (GABAB receptor) in the rat's inferior colliculus (IC). Immunohistochemical and western blotting experiments were conducted three hours following a drug injection, as previous studies indicated that a tinnitus-like behavior could be reliably induced in rats within this time period. Results revealed that both subunits of the receptor, GABABR1 and GABABR2, reduced their level over the entire area of the IC. Such a reduction was observed in both cell body and neuropil regions. In contrast, no changes were observed in other brain structures such as the cerebellum. Thus, a coincidence existed between a structure-specific reduction in the level of GABAB receptor subunits in the IC and the presence of a tinnitus-like behavior. This coincidence likely suggests that a reduction in the level of GABAB receptor subunits was involved in the generation of a tinnitus-like behavior and/or used by the nervous system to restore normal hearing following application of SS.

Diabetes and onset of natural menopause: results from the European Prospective Investigation into Cancer and Nutrition

STUDY QUESTION

Do women who have diabetes before menopause have their menopause at an earlier age compared with women without diabetes?

SUMMARY ANSWER

Although there was no overall association between diabetes and age at menopause, our study suggests that early-onset diabetes may accelerate menopause.

WHAT IS KNOWN ALREADY

Today, more women of childbearing age are being diagnosed with diabetes, but little is known about the impact of diabetes on reproductive health.

STUDY DESIGN, SIZE, DURATION

We investigated the impact of diabetes on age at natural menopause (ANM) in 258 898 women from the European Prospective Investigation into Cancer and Nutrition (EPIC), enrolled between 1992 and 2000.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Determinant and outcome information was obtained through questionnaires. Time-dependent Cox regression analyses were used to estimate the associations of diabetes and age at diabetes diagnosis with ANM, stratified by center and adjusted for age, smoking, reproductive and diabetes risk factors and with age from birth to menopause or censoring as the underlying time scale.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, no association between diabetes and ANM was found (hazard ratio (HR) = 0.94; 95% confidence interval (CI) 0.89-1.01). However, women with diabetes before the age of 20 years had an earlier menopause (10-20 years: HR = 1.43; 95% CI 1.02-2.01, <10 years: HR = 1.59; 95% CI 1.03-2.43) compared with non-diabetic women, whereas women with diabetes at age 50 years and older had a later menopause (HR = 0.81; 95% CI 0.70-0.95). None of the other age groups were associated with ANM.

LIMITATIONS, REASONS FOR CAUTION

Strengths of the study include the large sample size and the broad set of potential confounders measured. However, results may have been underestimated due to survival bias. We cannot be sure about the sequence of the events in women with a late age at diabetes, as both events then occur in a short period. We could not distinguish between type 1 and type 2 diabetes.

WIDER IMPLICATIONS OF THE FINDINGS

Based on the literature, an accelerating effect of early-onset diabetes on ANM might be plausible. A delaying effect of late-onset diabetes on ANM has not been reported before, and is not in agreement with recent studies suggesting the opposite association.

STUDY FUNDING/COMPETING INTERESTS

The coordination of EPIC is financially supported by the European Commission (DG-SANCO) and the International Agency for Research on Cancer. The national cohorts are supported by Danish Cancer Society (Denmark); Ligue Contre le Cancer, Institut Gustave Roussy, Mutuelle Générale de l'Education Nationale, Institut National de la Santé et de la Recherche Médicale (INSERM) (France); German Cancer Aid, German Cancer Research Center (DKFZ) and Federal Ministry of Education and Research (BMMF) (Germany); Ministry of Health and Social Solidarity, Stavros Niarchos Foundation and Hellenic Health Foundation (Greece); Italian Association for Research on Cancer (AIRC) and National Research Council (Italy); Dutch Ministry of Public Health, Welfare and Sports (VWS), Netherlands Cancer Registry (NKR), LK Research Funds, Dutch Prevention Funds, Dutch ZON (Zorg Onderzoek Nederland), World Cancer Research Fund (WCRF), Statistics Netherlands (The Netherlands); ERC-2009-AdG 232997 and Nordforsk, Nordic Centre of Excellence programme on Food, Nutrition and Health (Norway); Health Research Fund (FIS), Regional Governments of Andalucía, Asturias, Basque Country, Murcia (no. 6236) and Navarra, ISCIII RETIC (RD06/0020) (Spain); Swedish Cancer Society, Swedish Scientific Council and Regional Government of Skåne and Västerbotten (Sweden); Cancer Research UK, Medical Research Council, Stroke Association, British Heart Foundation, Department of Health, Food Standards Agency, and Wellcome Trust (UK). None of the authors reported a conflict of interest.

Personal professional indemnity and contractual issues for trainees in obstetrics and gynaecology

Over the last few decades, more healthcare professionals have faced investigation into complaints about medical care and healthcare outcomes (Department of Health 2003). With increasing medical negligence cases being brought against doctors, it is time to carefully consider the implications of such actions to ensure appropriate safeguards (Ferner and McDowell 2006). At a time when the culture of 'no win, no fee' is rampant, the jobbing frontline doctor is on the back-foot trying to untangle the legalities of a malpractice claim (Ferner and McDowell 2006). Reassuringly, the numbers of doctors referred to the GMC or having to face legal procedures or claims for compensation are still very small (National Audit Office 2001). An essential issue for all doctors is having appropriate indemnity cover in the event that their practice is challenged. The opt-out for the European Working Time Regulations (EWTR) has caused further confusion as to what is covered for junior doctors by individual indemnity policies and the employer's liability scheme. Recently, the RCOG Trainees committee and the BMA Junior Doctors Association issued a joint advice regarding this issue (RCOG 2010). In this paper, we consider the differences in cover provided by the employer's liability scheme, individual professional indemnity schemes and the role of professional bodies. We also seek to clarify the understanding of these surrounding EWTR and the voluntary opt-out clause and provide up-to-date information on medico-legal issues and protection schemes regarding legal liabilities.

Tumour-related factors and prognosis in breast cancer detected by screening

BACKGROUND

Breast cancer detected by screening has an unexplained prognostic advantage beyond stage shift compared with cancers detected clinically. The aim was to investigate biological factors in invasive breast cancer, with reference to mode of detection and rate of death from breast cancer.

METHODS

Histology, oestrogen receptor α and β, progesterone receptor, human epidermal growth factor receptor (HER) 2, cyclin D1, p27, Ki-67 and perinodal growth were analysed in 466 tumours from a prospective cohort, the Malmö Diet and Cancer Study. Using logistic regression, odds ratios were calculated to investigate the relationship between tumour characteristics and mode of detection. The same tumour factors were analysed in relation to standard prognostic features. Death from breast cancer was analysed using Cox regression with adjustments for standard tumour factors; differences following adjustment were analysed by means of Freedman statistics.

RESULTS

None of the biological tumour characteristics varied with mode of detection of breast cancer. After adjustment for age, tumour size, axillary lymph node involvement (ALNI) and grade, women with cancer detected clinically had an increased risk of death from breast cancer (hazard ratio 2·48, 95 per cent confidence interval 1·34 to 4·59), corresponding to a 37·2 per cent difference compared with the unadjusted model. Additional adjustment for biological tumour factors studied caused only minor changes.

CONCLUSION

None of the biological tumour markers investigated explained the improved prognosis in breast cancer detected by screening. None of the factors was related to ALNI, suggesting that other mechanisms may be responsible for tumour spread.

Combined effect of low-penetrant SNPs on breast cancer risk

BACKGROUND

Although many low-penetrant genetic risk factors for breast cancer have been discovered, knowledge about the effect of multiple risk alleles is limited, especially in women <50 years. We therefore investigated the association between multiple risk alleles and breast cancer risk as well as individual effects according to age-approximated pre- and post-menopausal status.

METHODS

Ten previously described breast cancer-associated single-nucleotide polymorphisms (SNPs) were analysed in a joint European biobank-based study comprising 3584 breast cancer cases and 5063 cancer-free controls. Genotyping was performed using MALDI-TOF mass spectrometry, and odds ratios were estimated using logistic regression.

RESULTS

Significant associations with breast cancer were confirmed for 7 of the 10 SNPs. Analysis of the joint effect of the original 10 as well as the statistically significant 7 SNPs (rs2981582, rs3803662, rs889312, rs13387042, rs13281615, rs3817198 and rs981782) found a highly significant trend for increasing breast cancer risk with increasing number of risk alleles (P-trend 5.6 × 10(-20) and 1.5 × 10(-25), respectively). Odds ratio for breast cancer of 1.84 (95% confidence interval (CI): 1.59-2.14; 10 SNPs) and 2.12 (95% CI: 1.80-2.50; 7 SNPs) was seen for the maximum vs the minimum number of risk alleles. Additionally, one of the examined SNPs (rs981782 in HCN1) had a protective effect that was significantly stronger in premenopausal women (P-value: 7.9 × 10(-4)).

CONCLUSION

The strongly increasing risk seen when combining many low-penetrant risk alleles supports the polygenic inheritance model of breast cancer.

Non-caseating granulomas in patients after the diagnosis of cancer: clinical characteristics and outcome

BACKGROUND

The association between cancer and non-caseating granulomas is controversial. The aim of this study is to describe the clinical characteristics and outcome of a cohort of patients found to have non-caseating granulomas following the diagnosis of cancer.

METHODS

Retrospective review of medical records.

RESULTS

There were 30 patients with non-caseating granulomas following the diagnosis of cancer. There were 21 females and 14 patients were African Americans. Breast, lung, and head and neck cancers were the most common malignancies. The time between the diagnosis of cancer and non-caseating granulomas was a mean of 27.6 months (range 3 to 245 months). New mediastinal lymphadenopathy were present in 29 patients and pulmonary infiltrates or nodules were detected in 15 patients. All patients who underwent FDG-PET scan (n=18) had FDG avid findings with a mean SUV of 6.8 (range 2.8-19.4). Non-caseating granulomas were diagnosed by mediastinoscopy (12 patients), EBUS-FNA (6 patients), surgical thoracic biopsy (3 patients), transbronchial biopsy (2 patients), and other biopsies (7 patients). Patients were followed for a mean of 32.7 months (range 6-98 months) and 3 patients developed recurrence of the primary cancer.

CONCLUSION

Non-caseating granulomas should be considered in patients with cancer who develop lymphadenopathy or pulmonary nodules. Recurrence of cancer should not always be assumed, and tissue diagnosis is essential.

Aberrant pathway in an anomaly: pre-excitation syndrome in association with coronary sinus aneurysm

Congenital coronary sinus anomalies are unusual and they rarely coexist with accessory atrio-ventricular pathways. These anomalies are generally symptomatic; however they can cause difficulty in mapping. The association between accessory pathway and coronary sinus anomalies may suggest an embryological link. Here, we report on a male patient with an accessory conducting pathway in the coronary sinus, leading to Wolff-Parkinson-White (WPW) syndrome.

Change in hepatitis C virus clades: a cross-sectional study of chronic HCV patients in Pakistan from 2000-2010

The changing pattern in hepatitis C virus (HCV) clades overtime is not well known in Pakistan. To find out the changing pattern of different HCV clades over time in this country 22,125 patients were genotyped and tracked for a period of 11 years (2000-2010). A changing pattern in HCV clades was seen in this region during the study period. Sub-clade 3a remained the dominant sub-clade circulating in different areas of the country in the study era. HCV sub-clade 3a demonstrated significantly high correlation with time (p < 0.05) whereas undetermined clades were seen with statistically non-significant correlation with time (years). All the other clades showed negative correlation with time. In general a significant decline was observed in the percentages of HCV clades 2, 4, 5 and 6 (p < 0.001). Among sub-clades, HCV 1a, 2c, 2b and 3b significantly decreased overtime (p < 0.05), while an increase has been observed for HCV 3a sub-clade and mixed clades (p <0.001). The ratio of undetermined clades remained constant over the study period. In conclusion, a changing pattern of HCV clades was observed over the 11-year study period, and this changed pattern might have direct impact on HCV disease outcome.