Comorbid Conditions in a Cohort of Inpatients with SARS-CoV-2 and their Association with In-Hospital Mortality During the Early Phases of the Pandemic.

Introduction: Studies determined that age and associated comorbidities are associated with worse outcomes for COVID-19 patients. The aim of the present study is to examine previous electronic health records of SARS-CoV-2 patients to identify which chronic conditions are associated with in-hospital mortality in a nationally representative sample. Materials and Methods: The actual study is a cross-sectional analysis of SARS-CoV-2 infected patients who were treated in repurposed hospitals. The study includes a cohort of patients treated from 06-11-2020 to 15-03-2021 for COVID-19 associated pneumonia. To examine the presence of comorbidities, electronic health records were examined and analyzed. Results: A total of 1486 in-patients were treated in the specified period, out of which 1237 met the criteria for case. The median age of the sample was 65 years. The overall in-hospital mortality in the sample was 25.5%, while the median length of stay was 11 days. From whole sample, 16.0% of the patients did not have established diagnoses in their electronic records, while the most prevalent coexisting condition was arterial hypertension (62.7%), followed by diabetes mellitus (27.3%). The factors of age, male gender, and the number of diagnoses showed a statistically significant increase in odds ratio (OR) for in-hospital mortality. The presence of chronic kidney injury was associated with the highest increase of OR (by 3.37) for in-hospital mortality in our sample. Conclusion: The study reaffirms the findings that age, male gender, and the presence of comorbidities are associated with in-hospital mortality in COVID-19 treated and unvaccinated patients. Our study suggests that chronic kidney injury showed strongest association with the outcome, when adjusted for age, gender, and coexisting comorbidities.

Adult-onset Still's disease as a cutaneous marker of systemic disease.

Adult-onset Still's disease (AOSD) is a rare, systemic, inflammatory disorder characterized by spiking fevers, an evanescent eruption, arthritis, and multiorgan involvement. The disease has been recently classified as a polygenic autoinflammatory disorder at the "crossroads" of autoinflammatory and autoimmune diseases. The highly characteristic salmon-colored eruption is a cutaneous manifestation of a generalized inflammatory reaction and an important diagnostic criterion. In addition to the evanescent eruption, there are atypical persistent papules and plaques in many patients with AOSD. Emerging data suggest that AOSD with this typical evanescent eruption has a different clinicopathologic presentation and clinical course than AODS with atypical cutaneous manifestations. It appears that there are two subtypes of AOSD with different immunologic profiles, including (1) a systemic disease with high fever, organ involvement, and elevated levels of ferritin, and (2) a chronic disease course with arthritis as the predominant finding. These observations provide novel insight into the disease pathogenesis, suggesting that the underlying mechanisms might differ between these two forms, partially explaining the reported differences in drug response. Recent advances in the understanding of AOSD are summarized with a focus on the spectrum of cutaneous manifestations and its relationship to systemic inflammation.

Hydroxyurea Associated Cutaneous Lesions: A Case Report.

BACKGROUND: Hydroxyurea (HU) is an antimetabolite agent that interferes with the S-phase of cellular replication and inhibits DNA synthesis, with little or no effect on RNA or protein synthesis. It is used in the treatment of many myeloproliferative disorders (MD) and is particularly a first line treatment drug for intermediate to high-risk essential thrombocythemia. Although safe and very well tolerated by the patients suffering from MD, there have been numerous reports of a broad palette of cutaneous side effects associated with prolonged intake of the medication. These may include classical symptoms such as xerosis, diffuse hyperpigmentation, brown-nail discolouration, stomatitis and scaling of the face, hands, and feet or more serious side effects such as actinic keratosis lesions, leg ulcers and multiple skin carcinomas. CASE REPORT: We report a case of a 52-year-old man, on long-term therapy with HU for essential thrombocytosis, with several concurrent skin lesions. Despite the perennial use of HU, the cutaneous changes were neglected. The local dermatological examination revealed oval perimalleolar ulcer on the right leg, with dimensions 6 x 4 cm, clearly demarcated from the surroundings with regular margins, periulcerous erythema, with very deep and highly fibrinous bed of the ulcer, positive for bacterial infection. The ulcer was treated with topical wound therapy with alginate and parenteral antibiotics. The extended dermatological screening also showed two nummular lesions in the right brachial region, presenting as erythematous papules with sharp margins from the surrounding skin, gritty desquamation and dotted hyperpigmentations inside the lesion. Further dermoscopy and biopsy investigations confirmed a diagnosis of basal cell carcinoma. Nasal actinic keratosis was also noted. The patient was advised for discontinuing or substituting the HU therapy. CONCLUSION: We present this case to draw attention to the various cutaneous side effects that occur with perennial HU use and suggest an obligatory reference to a dermatological consult.

Complementary and integrative therapies for psoriasis: Looking forward.

Despite the great advances in our understanding of disease pathogenesis and a rich variety of therapeutic options, including the availability of newer biologic agents, there is still no cure for psoriasis. Based on low levels of satisfaction in the treatment they receive and their overall care, it is not surprising that a substantial part of patients turn to complementary and alternative therapies. Integrative medicine is an exciting new approach to health care. The dermatologist should recognize this growing trend and become familiar with the current literature on integrative therapies for psoriasis. Several complementary therapies, those that have been found to be safe and effective, can be recommended as part of an integrative treatment plan.

Topical Imiquimod 5% as a Treatment Option in Solitary Facial Keratoacanthoma.

BACKGROUND: Keratoacanthoma (KA) is a rapidly growing epithelial tumour with histopathologic and clinical features similar to squamous cell carcinoma (SCC) and a certain tendency toward spontaneous regression. CASE PRESENTATION: This article presents a unique and rare case of keratoacanthoma arising from the upper lip of a young male patient. These two features are in contrast to most of the reported cases in elder male individuals and on the lower lip. Relevant management protocol of the case has also been discussed. CONCLUSION: The article emphasises the significance of discerning such lesions from squamous cell carcinoma thus carrying diagnostic and therapeutic implications. However, in case of the dilemma it is prudent to assume that the lesion is SCC unless proved otherwise clinically and histologically.

Onychomadesis Following Cutaneous Vasculitis.

Beau lines are transverse, band-like depressions extending from one lateral edge of the nail to the other and affecting all nails at corresponding levels (1). Onychomadesis is considered an extreme form of Beau line with subsequent separation of the proximal nail plate from the nail bed. Both fall along a spectrum of nail plate abnormalities that occur secondary to temporary nail matrix arrest (NMA). Various systemic and dermatologic conditions have been reported in association with onychomadesis (2-7) (Table 1). Nail changes can affect all or some of the nails and both the fingernails and toenails; however, fingernails are more frequently affected. The severity of the nail changes varies depending on the underlying cause, its duration, and environmental factors (8). We present a case of onychomadesis following cutaneous leukocytoclastic vasculitis (CLCV). A 61-year-old woman presented to the Dermatology Clinic complaining of a purpuric rash that began on her lower extremities and rapidly progressed to her abdomen and upper extremities over the previous five days. Her medical history was remarkable for hypertension and diet-controlled diabetes mellitus. Her medications included enalapril, which she had been taking for the past four years. On three consecutive days before the skin eruption, the patient took oral diclofenac sodium for hip pain. A clinical examination revealed non-blanching petechial rash on the legs, abdomen, and upper limbs up to the elbow (Figure 1, A) with leukocytoclastic vasculitis on biopsy (Figure 1, B). Direct immunofluorescence was negative. Laboratory investigations revealed a white blood cell count of 14.5 × 109/L with a normal differential count, and a platelet count of 380 × 109/L. Westergren erythrocyte sedimentation rate was 65 mm/1st h, and C reactive protein was at 8.5 mg/dL. Antinuclear antibodies, rheumatoid factor, immune complexes, and cryoglobulinemia were negative, as were B and C hepatitis virus serological tests. Her renal, cardiac, pulmonary, and abdominal exams were normal. Diclofenac was discontinued due to a clinical suspicion of drug-induced cutaneous vasculitis. The rash resolved in 2 weeks without treatment, leaving post-inflammatory hyperpigmentation. Four weeks later, she presented with painless, palpable grooves on all 10 fingernails (Figure 2). The grooves were 3 to 4 mm in width, at a similar distance from the proximal nail fold. There were no signs of periungual inflammation. The patient denied any recent history of trauma, unusual activities, or chemical exposure. Routine serum biochemistry and hematology results were normal. Repeated potassium hydroxide preparations and fungal cultures of the nail clippings were negative. A diagnosis of Beau lines and onychomadesis was made. Nail changes were tolerable and did not require any specific treatment. During the follow up, the Beau lines advanced with the linear growth of the nails and disappeared (Figure 3 and 4). Four fingernails developed complete nail shedding (onychomadesis). No toenail alterations were observed in this period. A complete recovery of the nail plate surface was observed after 4 months. The nail matrix epithelium is formed by highly proliferating cells that differentiate and keratinize to produce the nail plate. The nail matrix epithelium is very susceptible to toxic noxae, and acute damage results in a defective nail plate formation. Nail matrix arrest is a term used to describe a temporary inhibition of the nail matrix proliferation that can present as Beau lines and onychomadesis (8). The width of Beau lines relates to the duration of the etiological agent. As the nail adheres firmly to the nail bed, the onychomadesis remains latent for several weeks before leading to temporary shedding (8,9). There are several proposed etiological mechanisms for NMA. NMA associated with fever, severe infection, and major medical illnesses can be explained by an inflammation of the matrix, periungual tissues, or digital blood vessels (8); chemotherapy agents temporary inhibit the mitotic activity in nail matrix (10); the detection of Coxackie virus in the shedding nail particle, following hand, foot, and mouth disease, suggests that the viral replication itself may directly damage the nail matrix (11). However, as nail changes are not unique, it may be difficult to incriminate a single etiological agent. Our patient presented with an onset of Beau lines seven weeks after the initial CLCV lesions, which suggests that vasculitis might have acted as a trigger for NMA. As the fingers were not affected by CLCV, an indirect effect of vasculitis is more plausible. Leukocytoclastic vasculitis is a small-vessel inflammatory disease mediated by a deposition of immune complexes. Thus, the circulating immune complexes may be involved in the damage of nail bed microvasculature. Considering that the patient had been receiving enalapril and diclofenac, it is less likely that those drugs were involved in the pathogenesis of NMA. Enalapril was continued, and the nail changes were resolved while patient was still on enalapril. Furthermore, diclofenac is a widely prescribed drug and its association with NMA is yet to be described in literature. We described a patient who developed Beau lines and onychomadesis following cutaneous leukocytoclastic vasculitis. This clinical observation can expand the spectrum of possible causes of nail matrix arrest.

Eosinophilic ulcer of the oral mucosa: report of a case with multiple synchronous lesions.

Eosinophilic ulcer of the oral mucosa is considered to be a benign, reactive, and self-limiting lesion, with unclear pathogenesis, manifesting as a rapidly developing solitary ulcer. We report the case of a 52-year-old man who presented with 4 synchronous ulcerations of the tongue. Histopathological examination showed polymorphic inflammatory infiltrate, rich in eosinophils, involving the superficial mucosa and the deeper muscle layer. Immunohistochemical analysis revealed single CD30 cells scattered within an inflammatory infiltrate. All the lesions began to regress spontaneously within 1 week after biopsy. A 4-year follow-up showed no recurrence.

Complementary and alternative medicine use among patients with psoriasis.

Despite the growing attention on safety and efficacy of conventional treatments, there is little information available on complementary and alternative medicine (CAM) used in psoriasis. In order to collect comprehensive information on CAM use, we conducted a face-to-face interview with 122 patients with psoriasis. All unconventional treatments for psoriasis used in the last 12 months were recorded. Fifty-seven patients (46.7%) used one of the CAM methods in the previous year, including topical and systemic antipsoriatics, dietary supplements, and diet. Forty-one different nonconventional topical treatments were used. Seven patients (5.7%) took nonconventional systemic medication, and 15.5% used dietary supplements. There were three patients who reported current adherence to a diet as treatment of psoriasis. Clinicians are often not informed that their patients are using complementary therapies. CAM may offer benefits as well as risks to patients with psoriasis. It is important to remind patient to report all ongoing and past topical and systemic treatments. The use of medications with unknown composition, efficiency, and safety should be discouraged.

The role of nitric oxide in the pathogenesis of venous ulcers.

Chronic venous insufficiency frequently leads to ulceration. The exact pathophysiological mechanisms underlying the development of venous ulceration remain to be elucidated. One major etiological factor of the trophic changes is the phenomenon of leukocyte trapping. The aim of the study was to review the pathophysiological events culminating in venous ulceration, focusing primarily on the role of alterations in nitric oxide (NO) production. We establish the hypothesis that venous stasis in the microcirculation reduces the rate of shear stress on the endothelial cells, effectively resulting in a decrease in cellular levels of NO, a key event of enhanced adhesion molecule expression and subsequent massive neutrophil activation. A similar series of events is proposed to explain the ischemic-reperfusion tissue injury. Inducible NO (iNO) produced by the inflammatory cells causes free radical injury seen as a venous ulceration.

Evaluation of two different intermittent pneumatic compression cycle settings in the healing of venous ulcers: a randomized trial.

BACKGROUND: Intermittent pneumatic compression (IPC) has been successfully used in the treatment of venous ulcers, although the optimal setting of pressure, inflation and deflation times has not yet been established. The aim of this study was to compare the effect of two different combinations of IPC pump settings (rapid vs slow) in the healing of venous ulcers. MATERIAL/METHODS: 104 patients with pure venous ulcers were randomized to receive either rapid IPC or slow IPC for one hour daily. The primary and secondary end points were the complete healing of the reference ulcer and the change in the area of the ulcer over the six months observational period, respectively. RESULTS: Complete healing of the reference ulcer occurred in 45 of the 52 patients treated with rapid IPC, and in 32 of the 52 patients treated with slow IPC. Life table analysis showed that the proportion of ulcers healed at six months was 86% in the group treated with the fast IPC regimen, compared with 61% in the group treated with slow IPC (p=0.003, log-rank test). The mean rate of healing per day in the rapid IPC group was found to be significantly faster compared to the slow IPC group (0.09 cm2 vs 0.04 cm2, p=0.0002). CONCLUSIONS: Treatment with rapid IPC healed venous ulcers more rapidly and in more patients than slow IPC. Both IPC treatments were well tolerated and accepted by the patients. These data suggest that the rapid IPC used in this study is more effective than slow IPC in venous ulcer healing.

Pentoxifylline--efficient in the treatment of venous ulcers in the absence of compression?

The aim of the study was to test the efficacy and tolerability of pentoxifylline on the healing of venous ulcers in the absence of standard limb compression. The study used a prospective randomized, open, controlled, comparative, parallel group design. The study included 80 eligible patients with confirmed venous ulcers (with clinical and photoplethysmography findings). The patients received either pentoxifylline 1200 mg per day (3 x 400 mg) orally in addition of local therapy, or the same local therapy alone. The main outcome measures were complete healing of ulcers, change in the ulcer area over the six-month observation period, and tolerability of the drug. The results showed that complete healing occurred in 23 (57.5%) patients receiving pentoxifylline and 11 (27.5%) patients without pentoxifylline (log rank test =2.49, p=0.013). Unwanted effects of pentoxifylline occurred in 11/40 (27.5%) patients but were mild. Pentoxifylline is concluded to be efficacious in healing of venous ulcers in patients unable to tolerate compression therapy.