Immunologic and nonimmunologic sclerodermal skin conditions - review.

Scleroderma-like cutaneous lesions have been found in many pathological conditions and they have the clinical appearance of sclerotic or scleroatrophic lesions. Affected skin biopsies described histopathological changes similar to those of scleroderma located strictly on the skin or those of systemic sclerosis. These skin lesions can be found in inflammatory diseases with autoimmune substrate (generalized morphea, chronic graft versus host disease, eosinophilic fasciitis), tissue storage diseases (scleredema, scleromyxedema, nephrogenyc systemic fibrosis, systemic amyloidosis), metabolic diseases (porphyrya cutanea tarda, phenylketonuria, hypothyroidism, scleredema diabeticorum), progeroid syndromes. Given the multiple etiologies of sclerodermal lesions, a correct differential diagnosis is necessary to establish the appropriate treatment.

The Influence of Living in Rural Areas on the Evolution and Management of Pediatric Ovarian Cystic Lesions: A Retrospective Study on a Cohort from South Eastern Romania.

Background: The incidence of ovarian cystic lesions (OCLs) in pediatric patients has been increasing in recent years. An early diagnosis is mandatory for a favourable prognosis but it depends on the primary medical care services and on the socioeconomic status of the patient. The present study aims at assessing the prevalence and the age-specific frequencies of pediatric OCLs, as well as identifying disparities between subjects in the urban and the rural areas, in order to explore the extent to which OCLs occurrence, diagnosis, evolution and treatment differ in the case of patients living in rural areas. Methods: A 3-year retrospective study was conducted between 2017 and 2019. All the female patients aged between 0 and 18 with OCLs ≥10 mm (N = 488), diagnosed and treated at "Sf.Ioan" Clinical Emergency Hospital for Children in Galati were included in the study. The Chi2 test was used for comparing the distributions of frequencies, and the t-Student test was used for comparing the means of any two normally distributed variables. The statistical significance threshold (p) was set at 0.05. Results: The prevalence of OCLs ≥10 mm was 14.85%, 47.13% of the subjects originating in rural area (p = 0.62). Different from the urban areas, the rural ones are characterised by a lower proportion of patients with BMI ≥25 (p = 0.002), larger OCLs mean size (p = 0.278), a more frequent complex aspect on ultrasonography (p = 0.01), and a smaller number of general physician referrals (p = 0.005). Moreover, a higher proportion of rural patients were intraoperatively diagnosed with OCLs (p = 0.044), had complicated OCLs (p = 0.012) and had their OCLs surgically treated OCLs (p < 0.01). Conclusion: Taking into consideration the socio-economic situation of south eastern Romania, patients living in rural areas have proven exposed to a higher risk of presenting with larger, complex and complicated OCLs, which most often require surgical treatment.

Clinical, Imaging, Histological and Surgical Aspects Regarding Giant Paraovarian Cysts: A Systematic Review.

Paraovarian cysts (POCs) develop within the broad ligament of the uterus. POCs are considered to be giant when the threshold of 150 mm is exceeded. Clinical signs and symptoms occur as a consequence of the pressure effect on adjacent organs or due to complications. Abdominal ultrasonography, computed tomography or magnetic resonance imaging are useful imaging tools, but most often the exact origin of such voluminous cysts is revealed only by surgical exploration. The review aims to appraise and update the diagnostic, the histological aspects and the treatment of the giant POCs in rare cases. We carried out a systematic search in Medline-PubMed, Google Scholar and ResearchGate electronic databases. Twenty-seven papers fulfilling the selection criteria were included in the review. The data extracted included information about first author, year of publication, country, patient age, size and side of the POCs, symptoms, tumoral markers, imaging methods, preoperative diagnosis, surgical management and histopathological findings. Although not very numerous, all the studies highlighted the low incidence of giant POCs, the impossibility of establishing the origin of the cystic mass by clinical and imaging methods even with advanced technical tools and the low risk of torsion (11.1%). Despite the recognized benign nature of POCs, we found an unexpected high percent (25.9%) of borderline giant POCs. Surgical excision is the only treatment option. Ovarian-sparing surgery was performed in 85.1% of the cases, and minimally invasive techniques were applied in only 42.9% of the patients, which demonstrates the need of a high-level laparoscopic expertise. Knowledge of this pathology, its recognition as a possible etiology of an abdominopelvic cyst, and a higher awareness of the possibility of a borderline histology in giant POCs are required for the proper management of these particular cases.

An Unusual Case of Meckel Diverticulitis Misdiagnosed as an Infected Urachal Cyst.

Introduction: Meckel's diverticulum (MD), a remnant of the omphaloenteric duct, is among the most frequent intestinal malformations. Another embryonic vestige is the urachus, which obliterates, becoming the median umbilical ligament; the failure of this process can lead to a urachal cyst formation. We present a case of Meckel diverticulitis misdiagnosed as an infected urachal cyst. Presentation of case: A 16-year-old girl presented with hypogastric pain, fever and vomiting. She had undergone an appendectomy 6 years prior and no digestive malformation had been documented. In the last 2 years, she had 3 events of urinary tract infections with Escherichia coli, and anabdominal ultrasound discovered a 28/21 mm hypoechogenic preperitoneal round tumor, anterosuperior to the bladder. We established the diagnosis of an infected urachal cyst, confirmed later by magnetic resonance imaging. Intraoperative, we found MD with necrotic diverticulitis attached to the bladder dome. Discussions: Meckel's diverticulum and urachal cyst (UC) are embryonic remnants. Both conditions are usually asymptomatic, being incidentally discovered during imaging or surgery performed for other abdominal pathology. Imaging diagnosis is accurate for UC, but for MD they are low sensitivity and specificity. For UC treatment, there is a tendency to follow an algorithm related to age and symptoms, but there is no general consensus on whether to perform a routine resection of incidentally discovered MD. Conclusion: Preoperatory diagnosis of MD represents a challenge. We want to emphasize the necessity of a thorough inspection of the small bowel during all abdominal surgical interventions and MD surgical excision regardless of its macroscopic appearance. These two actions seem to be the best prophylaxis measures for MD complications and consequently to avoid emergency surgery, in which case more extensive surgical procedures on an unstable patient may be needed.

Multifactorial expression of IL-6 with update on COVID-19 and the therapeutic strategies of its blockade (Review).

Interleukin 6 (IL-6), a cytokine produced by various cells of the human body (macrophages, lymphocytes, astrocytes, ischemic myocytes, endothelial cells) has both pro-inflammatory and anti-inflammatory properties, being a key component in regulating various physiologic and pathological processes. The structure of this molecule and the receptor system it possesses are important due to the different activities that IL-6 can exert; through trans-signaling pro-inflammatory activities are mediated, while through classic signaling, IL-6 is responsible for anti-inflammatory and regenerative activities. IL-6 signaling is involved in coronary artery disease and the global COVID-19 pandemic. This proatherogenic cytokine reaches elevated serum levels in the cytokine storm generated by SARS-CoV-2, and is also associated with smoking or obesity-classic cardiovascular risk factors which promote inflammatory states. IL-6 levels are proportionally correlated with dyslipidemia, hypertension and glucose dysregulation, and they are associated with poor outcomes in patients with unstable angina or acute myocardial infarction. IL-6 targeting for treatment development (not only) in cardiovascular disease and COVID-19 is still a matter of ongoing research, although tocilizumab has proven to be effective in reducing the proatherogenic effects of IL-6 and is suggested to improve COVID-19 patient survival.

Influence of phytochemicals in induced psoriasis (Review).

Cytokines involved in pathogenesis of psoriasis such as interleukins (IL-1ß, IL-6, IL-17, IL-22, IL-23), interferon-α, tumor necrosis factor-α and interferon-γ can also become therapeutic targets. Research currently uses murine models of imiquimod-induced psoriatic-type dermatitis in order to analyze potentially helpful phytotherapeutics for psoriasis treatment: Curcuma longa, Aloe vera, Nigella sativa, Rubia cordifolia, Smilax china, Thespesia populnea, Wrightia tinctoria, Scutellaria baicalensis, Cassia tora, Pongamia pinnata and various Chinese herbal formulas. Psoriasis is a chronic inflammatory disease with complex pathogenic mechanisms that yield abnormal immune responses with clinical and morphological echoes (erythematous, scaly plaques with a histopathological basis made up of alterations i.e. keratinocyte aberrant proliferation, parakeratosis or chronic inflammation). The current therapeutic approach has only been able to manage the disease, without ensuring a certified treatment, thus giving rise to the need for better medications. This novel therapeutic approach has shown promising results in preclinical studies, giving hope for future phytochemical animal-based studies.

Metamizole for Postoperative Pain in Pediatric Patients Undergoing Subarachnoid Anesthesia.

BACKGROUND: Efficient postoperative pain management, which is aimed at decreasing the risk of complications and drug-induced side effects, without affecting the quality of analgesia, is part of today's concept of enhanced recovery after surgery, that is, fast-track surgery. STUDY QUESTION: The objective of this study was to determine whether effective management of acute postoperative pain was possible without opioids, while avoiding complications, drug-induced side effects, and suboptimal treatment. Introduction of metamizole, which has regained popularity, into a multimodal analgesia regimen was used, as opioids are not routinely administered. STUDY DESIGN: The study was prospective, observational, unrandomized, and without the control group. MEASURES AND OUTCOMES: This study was performed in a pediatric hospital with 300 beds and an average of 1700 annual surgical interventions. The study group comprised 378 patients aged 1-17 years, undergoing lower abdominal or limb surgery between June 2016 and June 2017. Children underwent subarachnoid anesthesia combined with intravenous sedation and received not routinely but on demand postoperative opioid analgesia. The pain was self-assessed by the pediatric patient or was assessed by the nurse using pain scores. RESULTS: Metamizole proved to be safe, efficient, and very well tolerated by children. Multimodal analgesia using acetaminophen, nonsteroidal anti-inflammatory drug with metamizole for the treatment of moderate to severe pain in children undergoing surgery, required a single opioid dose in 292 patients (77.24%) of the 378 in this study. CONCLUSIONS: In pediatric patients undergoing surgery, subarachnoid anesthesia combined with intravenous sedation, multimodal analgesia that includes metamizole, and nonpharmacological complementary therapies in pain management enable avoidance or reduction of opioids to a single dose, without undertreatment. There is also a minimum of anesthesia, accelerated children's recovery and a rapid return to presurgical levels of function.

Case series of an alternative therapy for generalised lichen planus: Four case studies.

Lichen planus (LP) is an idiopathic, cell-mediated immune disorder, accompanied by itching. Spontaneous remission occurs. Topical and systemic therapies are utilised. Four cases of generalized LP with and without mucosal involvement treated homeopathically are presented. Case 1: A 48-year-old female presented with a 7-month history of generalized itchy rash, which had been diagnosed as LP, treated unsuccessfully with topical steroids and removal of dental fillings. Examination revealed violaceous papules on upper and lower limbs, oral mucosal lesions and an irregular, erythematous, blanching, macular rash on the chest. She received homeopathic Ignatia amara at medication dilution factor (MK) potency, weekly dose and went into remission at 3 months. Patient remains in remission. Case 2: A 65-year-old female presented with a 27-year history of generalized, LP, which had been unresponsive to topical steroids. Examination showed generalized, violaceous papules, with no mucosal involvement. She received homeopathic Aurum metallicum, MK potency, weekly, and went into remission. She relapsed at 8 months after onset of therapy, following a very stressful incident, but gained remission again with Aurum metallicum after 1 month of therapy. She remains in remission. Case 3: A 38-year-old male presented with a 21-year history of generalized LP. Medical history was significant for hepatitis B and asthma. Topical steroid therapy was only partially successful. Examination revealed generalized, violaceous papules, with oral and genital involvement. He received homeopathic Lycopodium at MK potency, weekly, and remitted by 2 months. He remains in remission. Case 4: A 41-year-old male presented with a 12-year history of generalized hypertrophic LP, which had responded partially to topical steroids and ultraviolet A therapy. Medical history was significant for reduced sense of smell. Examination revealed generalized, violaceous, hypertrophic papules and nodules. He received homeopathic Carcinosinum at MK potency and remitted at 6-months. In its long-standing, generalized form, with mucosal involvement, LP may respond to individualized homeopathy. More research may clarify homeopathy's place in LP therapy.

Immunologic adverse reactions of ß-blockers and the skin.

ß-Blockers are a widely utilised class of medication. They have been in use for a variety of systemic disorders including hypertension, heart failure and intention tremors. Their use in dermatology has garnered growing interest with the discovery of their therapeutic effects in the treatment of haemangiomas, their potential positive effects in wound healing, Kaposi sarcoma, melanoma and pyogenic granuloma, and, more recently, pemphigus. Since ß-blockers are deployed in a variety of disorders, which have cutaneous co-morbidities such as psoriasis, their pertinence to dermatologists cannot be overstated. Likewise, ß-blockers, like any other drug category, carry risks of side effects, some of which are dermatologic. These include triggering and exacerbation of psoriasis, psoriatic and rheumatoid arthritis, anaphylaxis, contact dermatitis, occupational contact dermatitis, Raynaud's disease, alopecia, lichen planus-like drug eruption, hyperhydrosis and vitiligo. While recent articles have focussed on the positive uses of ß-blockers, it may also be wise to call our attention to the potential dermatologic adverse effects that may follow ß-blocker use, as well as possible therapeutic approaches to these. This short review will focus on those dermatoses resulting from ß-blocker use, which have an immunologic basis.