Clinicopathologic features of pityriasis rosea-like drug eruption secondary to imatinib: A case report and review of the literature.

Pityriasis rosea is an acute, self-limited exanthem that typically occurs in adolescence and young adulthood, classically featuring ovoid erythematous and scaly lesions on the trunk and proximal extremities. While its cause is not definitively known, the classic form of pityriasis rosea may result from the reactivation of latent human herpesvirus (HHV) infections (HHV-6 and HHV-7). Interestingly, drug eruptions that clinically and/or histopathologically resemble pityriasis rosea have also been reported. These pityriasis rosea-like drug eruptions tend to occur at an older age and have a shorter duration than the classic type. As there are different management paradigms, the distinction between classic pityriasis rosea and the mimicking drug eruption is important to recognize. Herein, we report a case of a pityriasis rosea-like drug eruption that occurred in association with imatinib mesylate treatment for chronic myeloid leukemia. We also review the clinicopathologic features of reported cases of pityriasis rosea-like drug eruption, including those due to imatinib. While the clinical morphology of the cutaneous drug-related eruption mimics the lesions seen in classic pityriasis rosea, the presence of unique histopathologic findings, including necrotic keratinocytes, interface dermatitis, and eosinophils, may aid in distinction.

Multiple primary dermatofibrosarcoma protuberans tumors in a single patient with chromosomal microarray analysis: A case report and review.

Dermatofibrosarcoma protuberans (DFSP) is a cutaneous sarcoma with a high propensity for local invasion and recurrence. Although it is a rare event, the occurrence of multiple tumors in a single patient raises a diagnostic dilemma, as metastatic disease should be differentiated from multiple primary malignant events. In more than 90% of DFSP, a pathogenic t(17;22) translocation leads to the expression of COL1A1::PDGFB fusion transcripts. Karyotype analysis, fluorescence in situ hybridization, and RT-PCR can be useful ancillary studies in detecting this characteristic rearrangement, and sequencing of the fusion transcript can be used to support a clonal origin in metastatic and multifocal disease. However, previous reports have demonstrated variable sensitivity of these assays, in part due to the high sequence variability of the COL1A1::PDGFB fusion. Here, we report a patient who developed two distinct DFSP tumors over the course of 7 years. Chromosomal microarray analysis identified distinctive genomic alterations in the two tumors, supporting the occurrence of multiple primary malignant events.

Cutaneous malakoplakia arising on the ankle of a patient with pyoderma gangrenosum.

Malakoplakia is a rare chronic inflammatory condition that most commonly involves the urogenital tract. Cutaneous malakoplakia is extremely rare and many patients diagnosed with skin involvement are immunosuppressed. While the clinical presentation of cutaneous malakoplakia is variable, the histopathologic features are quite distinct and include sheets of closely packed dermal histiocytes with foamy-appearing cytoplasm and Michaelis-Gutmann bodies that are positive with certain immunohistochemical stains. While the exact pathogenesis of malakoplakia is unknown, it has been associated with certain bacterial infections. Treatment generally involves a combination of surgery and antimicrobial agents and/or modulation of immunosuppressant therapy if appropriate. Herein, the authors report a unique case of cutaneous malakoplakia arising in a patient on chronic immunosuppressive therapy for the management of pyoderma gangrenosum.

Delusions of parasitosis and delusions of parasitosis by proxy in a mother and her children.

Delusions of parasitosis by proxy is an uncommon entity wherein an individual projects a delusional belief onto another person who lacks capacity to hold the same belief. We report a case of delusions of parasitosis by proxy in a mother who believed that she was infested with scabies and projected her fixed, delusional belief of scabies infestation onto her children. She subjected her children to numerous home remedies and medical treatments as well as removing them from school in an effort to cure them of the supposed infestation. Child maltreatment can be a concern in such cases with a low threshold for involving child protective services if harm to the children is suspected.

First Description of a Helicopter-Borne ECPR Team for Remote Refractory Out-of-Hospital Cardiac Arrest.

Introduction: Access time to extracorporeal cardiopulmonary resuscitation (ECPR) refractory out of hospital cardiac arrest (OHCA) is a crucial factor. In our region, some patients are not eligible to this treatment due to the impossibility to reach the hospital with reasonable delay (ideally 60 min). In order to increase accessibility for patients far from ECPR centers, we developed a helicopter-borne ECPR-team which is sent out to the patient for ECPR implementation on the scene of the OHCA.Methods: We conducted a retrospective monocentric study to evaluate this strategy. The team is triggered by the local emergency medical service and heliborne on the site of the OHCA. All consecutive patients implemented with ECPR by our heliborne ECPR team from January 2014 to December 2017 were included. We analyzed usual CA characteristics, different times (no-flow, low-flow, time between OHCA and dispatch…), and patient outcome.Results: During this 4-year study period, 33 patients were included. Mean age was 43.9 years. Mean distance from the ECPR-team base to OHCA location was 41 km. Mean low-flow time was 110 minutes. Five patients survived with good neurological outcome; 6 patients developed brain death and became organ donors.Conclusion: These results show the possibility to make ECPR accessible for patients far from ECPR centers. Survival rate is non negligible, especially in the absence of therapeutic alternative. An earlier trigger of the ECPR-team could reduce the low-flow time and probably increase survival. This strategy improves equity of access to ECPR and needs to be confirmed by further studies.

DNA Methylation and Allelic Polymorphism at the Dopamine Transporter Promoter Affect Internalizing and Externalizing Symptoms in Preschoolers.

The role of the dopamine transporter (DAT) in the onset and maintenance of emotional-behavioral difficulties is recognized in adults, adolescents and school-age children, whereas few studies in this field have focused on preschoolers. The study recruited 2-year old children (N = 152) in the general population assessing the possible effect of DAT methylation and allelic polymorphism on internalizing and externalizing symptoms, also exploring whether epigenetic and genetic variability interact. Our results showed that DAT methylation is significantly associated with all the dimensions of children's emotional/behavioral functioning in children carrying 10/10-3/3-8/10 polymorphisms but not in children carrying 9/10-9/9 allele repeats. Understanding the influence of genetic/epigenetic factors on maladaptive emotional/behavioral outcomes in young children, can be of great help in programming effective prevention and intervention plans and can be a valid aid to alleviate psychopathological symptoms before they crystalize into more severe clinical conditions in later life.

Chondrodermatitis nodularis helicis in a teenager caused by frequent headphone use.

Chondrodermatitis nodularis helicis is a benign condition that presents as a painful ear nodule and is commonly seen in older adults. Herein, we highlight a pediatric case of chondrodermatitis nodularis helicis caused by an increasingly common age-related behavior of frequent headphone use.

Association between hyperoxemia and mortality in patients treated by eCPR after out-of-hospital cardiac arrest.

OBJECTIVE: Assess whether elevated oxygen partial arterial pressure (PaO2) measured after the initiation of extra-corporeal cardiopulmonary resuscitation (eCPR), is associated with mortality in patients suffering from refractory out-of-hospital cardiac arrest (rOHCA). METHODS: Retrospective cohort study including rOHCA admitted to the ICU. Patients were divided into 3 groups, defined according to the PaO2 measured from arterial blood gas analysis 30 min after the initiation of eCPR. Hyperoxemia was defined as PaO2 ≥ 300 mmHg, hypoxemia as PaO2 ≤ 60 mmHg and normoxemia, as 60 < PaO2 < 300 mmHg. The main outcome was the mortality rate on day 28 after hospital admission. RESULTS: Sixty-six consecutive rOHCA, 77% male, with a mean age of 51 ±â€¯14 years, were admitted to the ICU. rOHCA were mainly due to acute coronary syndrome (67%), hypertrophic cardiomyopathy (8%) and cardiotoxic overdose (8%). Mortality at day 28 reached 61%. In the overall population, the mean PaO2 was 227 ±â€¯124 mmHg. An association between mortality and PaO2 was observed (OR = 1.01 [1.01-1.02]). The AUC for PaO2 after starting eCPR was 0.77 [0.65-0.89]. After adjustment for witnessed arrest, bystander's CPR, location, no-flow, low-flow, lactate and pH, age, and PaCO2, hyperoxemia had an ORa of 1.89 (CI95 [1.74-2.07]). CONCLUSION: We found an association between mortality and hyperoxemia in patients admitted to the ICU for rOHCA requiring eCPR. These data underline the potential toxicity of high dose of oxygen and suggest that controlled oxygen administration for these patients is crucial.

Epinephrine administration in non-shockable out-of-hospital cardiac arrest.

BACKGROUND: Epinephrine is recommended for the treatment of non-shockable out of hospital cardiac arrest (OHCA) to obtain return of spontaneous circulation (ROSC). Epinephrine efficiency and safety remain under debate. OBJECTIVE: We propose to describe the association between the cumulative dose of epinephrine and the failure of ROSC during the first 30 min of advanced life support (ALS). METHODOLOGY: A retrospective observational cohort study using the Paris SAMU 75 registry including all non-traumatic OHCA. All OHCA receiving epinephrine during the first 30 min of ALS were enrolled. Cumulative epinephrine dose given during ALS to ROSC was retrieved from medical reports. RESULTS: Among 1532 patients with OHCA, 776 (51%) had initial non-shockable rhythm. Fifty-four patients were excluded for missing data. The mean value of cumulative dose of epinephrine was 10 ±â€¯4 mg in patients who failed to achieve ROSC (ROSC-) and 4 ±â€¯3 mg (p = 0.04) for those who achieved ROSC. ROC curve analysis indicated a cut-off point of 7 mg total cumulative epinephrine associated with ROSC- (AUC = 0.89 [0.86-0.92]). Using propensity score analysis including age, sex and no-flow duration, association with ROSC- only remained significant for epinephrine > 7 mg (p ≤10-3, OR [CI95] = 1.53 [1.42-1.65]). CONCLUSION: An association between total cumulative epinephrine dose administered during OHCA resuscitation and ROSC- was reported with a threshold of 7 mg, best identifying patients with refractory OHCA. We suggest using this threshold in this context to guide the termination of ALS and early decide on the implementation of extracorporeal life support or organ harvesting in the first 30 min of ALS.

Predicting value of prehospital body temperature for ICU admission of septic shock patients.

To specify whether an association exists between pre-hospital body temperature collected by the emergency medical services (EMS) call centre, and intensive care unit (ICU) admission of patients with septic shock. An observational study based on data collected by the EMS of Paris. All septic shocks were included. Among, the 140 calls concerning septic shock, 22 patients (16%) were admitted to ICU. The mean core temperature was 37.4±1.6°C for ICU and 38.6±1.1°C (p<4.10^-5) for non-ICU patients. Using propensity score analysis, the relative risk for ICU admission of patients with pre-hospital fever or hypothermia was 0.31 and 2 respectively. The study highlights the potential usefulness of early temperature measurement in septic shock patients to allow early proper orientation.

Triage of Septic Patients Using qSOFA Criteria at the SAMU Regulation: A Retrospective Analysis.

PURPOSE: One of the major prognostic factors in the management of sepsis is the early initiation of appropriate treatment. To serve this purpose, early identification and triage of patients are crucial steps, which are still not optimal. The objective of this study was to determine whether the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) score is an accurate method for prehospital triaging of septic patients. We evaluated whether the use of qSOFA criteria collected by the Service Mobile d'Urgence et de Réanimation 15 (SAMU 15) regulation call center during prehospital care would facilitate appropriate intensive care unit (ICU) admission of patients with septic syndromes. METHODS: We conducted a retrospective observational register-based study using data collected between April 01 and May 31 2011. These data are based on call registry reports of calls received by the Paris Emergency regulation call centre during prehospital management of patients. All patients with suspected infection were included in the study and evaluated using qSOFA and systemic inflammatory response syndrome (SIRS) criteria. The primary outcome was Intensive Care Unit (ICU) admission. RESULTS: Among the 30 642 reports received, 141 patients with presumed sepsis were included. Twenty-two patients were admitted to an ICU. The qSOFA and SIRS scores were the same in predicting admission to an ICU (p = 0.26). The qSOFA had a sensitivity of 75% and a specificity of 68% for ICU admission whereas the SIRS had a sensitivity of 87% and a specificity of 43%. At day 28, 12 patients (9%) had died, 5 of them in the ICU. The negative predictive value reached 93% and 94% for pre-hospital qSOFA and SIRS respectively. Pre-hospital systolic blood pressure (SBP) ≤100 mmHg was significantly associated with ICU admission (OR = 4.19 [1.89-9.84]), while all other criteria were not. CONCLUSION: The current study reports no difference between the SIRS and the qSOFA scores for prehospital triage of septic patients to predict ICU admission. Both scores have comparable, pertinent, negative predictive value for ICU admission. Nevertheless, an improved score for pre-hospital triaging is needed to predict ICU admission of septic patients.

Prehospital triage of septic patients at the SAMU regulation: Comparison of qSOFA, MRST, MEWS and PRESEP scores.

PURPOSE: A couple of scoring systems have been developed for risk stratification of septic patients. Their performance in the management of out-of-hospital initial care delivery is not documented. This study try to evaluate the predictive ability of Quick Sequential Organ Failure Assessment (qSOFA), Robson Screening Tool (RST), Modified Early Warning Score (MEWS) and Prehospital Early Sepsis Detection (PRESEP) scores on out of-hospital triage of septic patients, to predict intensive care unit (ICU) admission. METHODS: A retrospective study using call records received by the SAMU 15 regulation call centre including all patients with presumed septic shock was performed. The primary outcome was the admission to the ICU. RESULTS: Among the 47 000 reports received, 37 patients with presumed septic shock were included. Twenty-two patients (59%) were admitted to ICU. AUCs of qSOFA, RST, MEWS and PRESEP scores were respectively 0.40 [0.22-0.59], 0.60 [0.43-0.78], 0.66 [0.47-0.85] and 0.67 [0.51-0.84]. RST outperformed PRESEP, MEWS and qSOFA for sensitivity (1, 0.92, 0.85 and 0.62 respectively). MEWS showed better specificity than PRESEP, MRST and qSOFA (0.33, 0.29, 0.16 and 0.16). MEWS showed comparable positive predictive value than PRESEP and outperformed MRST and qSOFA (0.41, 0.41, 0.39 and 0.29 respectively). Negative predictive value of MRST outperformed PRESEP, MEWS and qSOFA (1, 0.88, 0.80 and 0.44 respectively). CONCLUSION: Our findings suggest that screening patients at SAMU 15 regulation call centre using qSOFA, MRST, MEWS and PRESEP scores to predict ICU admission is irrelevant. Development of a specific scoring system for out-of-hospital triage of septic patients is needed.

Griffithsin-Modified Electrospun Fibers as a Delivery Scaffold To Prevent HIV Infection.

Despite current prophylactic strategies, sexually transmitted infections (STIs) remain significant contributors to global health challenges, spurring the development of new multipurpose delivery technologies to protect individuals from and treat virus infections. However, there are few methods currently available to prevent and no method to date that cures human immunodeficiency virus (HIV) infection or combinations of STIs. While current oral and topical preexposure prophylaxes have protected against HIV infection, they have primarily relied on antiretrovirals (ARVs) to inhibit infection. Yet continued challenges with ARVs include user adherence to daily treatment regimens and the potential toxicity and antiviral resistance associated with chronic use. The integration of new biological agents may avert some of these adverse effects while also providing new mechanisms to prevent infection. Of the biologic-based antivirals, griffithsin (GRFT) has demonstrated potent inhibition of HIV-1 (and a multitude of other viruses) by adhering to and inactivating HIV-1 immediately upon contact. In parallel with the development of GRFT, electrospun fibers (EFs) have emerged as a promising platform for the delivery of agents active against HIV infection. In the study described here, our goal was to extend the mechanistic diversity of active agents and electrospun fibers by incorporating the biologic GRFT on the EF surface rather than within the EFs to inactivate HIV prior to cellular entry. We fabricated and characterized GRFT-modified EFs (GRFT-EFs) with different surface modification densities of GRFT and demonstrated their safety and efficacy against HIV-1 infection in vitro We believe that EFs are a unique platform that may be enhanced by incorporation of additional antiviral agents to prevent STIs via multiple mechanisms.

Toxicodynetics: A new discipline in clinical toxicology.

OBJECTIVES: Regarding the different disciplines that encompass the pharmacology and the toxicology, none is specifically dedicated to the description and analysis of the time-course of relevant toxic effects both in experimental and clinical studies. The lack of a discipline devoted to this major field in toxicology results in misconception and even in errors by clinicians. MATERIAL AND METHODS: Review of the basic different disciplines that encompass pharmacology toxicology and comparing with the description of the time-course of effects in conditions in which toxicological analysis was not performed or with limited analytical evidence. RESULTS: Review of the literature clearly shows how misleading is the current extrapolation of toxicokinetic data to the description of the time-course of toxic effects. CONCLUSION: A new discipline entitled toxicodynetics should be developed aiming at a more systematic description of the time-course of effects in acute human and experimental poisonings. Toxicodynetics might help emergency physicians in risk assessment when facing a poisoning and contribute to a better assessment of quality control of data collected by poison control centres. Toxicodynetics would also allow a quantitative approach to the clinical effects resulting from drug-drug interaction.

Stroke volume variation and indexed stroke volume measured using bioreactance predict fluid responsiveness in postoperative children.

BACKGROUND: Postoperative fluid management can be challenging in children after haemorrhagic surgery. The goal of this study was to assess the ability of dynamic cardiovascular variables measured using bioreactance (NICOM®, Cheetah Medical, Tel Aviv, Israel) to predict fluid responsiveness in postoperative children. METHODS: Children sedated and mechanically ventilated, who require volume expansion (VE) during the immediate postoperative period, were included. Indexed stroke volume (SVi), cardiac index, and stroke volume variation (SVV) were measured using the NICOM® device. Responders (Rs) to VE were patients showing an increase in SV measured using transthoracic echocardiography of at least 15% after VE. Data are median [95% confidence interval (CI)]. RESULTS: Thirty-one patients were included, but one patient was excluded because of the lack of calibration of the NICOM® device. Before VE, SVi [33 (95% CI 31-36) vs 24 (95% CI 21-28) ml m(-2); P=0.006] and SVV [8 (95% CI 4-11) vs 13 (95% CI 11-15)%; P=0.004] were significantly different between non-responders and Rs. The areas under the receiver operating characteristic curves of SVi and SVV for predicting fluid responsiveness were 0.88 (95% CI 0.71-0.97) and 0.81 (95% CI 0.66-0.96), for a cut-off value of 29 ml m(-2) (grey zone 27-29 ml m(-2)) and 10% (grey zone 9-15%), respectively. CONCLUSIONS: The results of this study show that SVi and SVV non-invasively measured by bioreactance are predictive of fluid responsiveness in sedated and mechanically ventilated children after surgery.

Pleomorphic Dermal Sarcoma.

Pleomorphic dermal sarcoma (PDS) is a rare cutaneous/subcutaneous neoplasm of purported mesenchymal differentiation that exists along a clinicopathologic spectrum with atypical fibroxanthoma (AFX). While PDS and AFX share histopathologic and immunohistochemical features, PDS exhibits deeper tissue invasion and has a higher rate of metastasis and local recurrence than AFX. Given its aggressive clinical course, early recognition and clinical management of PDS are essential for optimizing patient outcomes. This review aims to provide a brief overview of the clinicopathologic and molecular features, prognosis, and treatment of PDS.

Myelodysplasia Cutis.

CONTEXT.­: Myelodysplasia cutis is an emerging concept in cutaneous neoplasia. Many of these cases were previously included under the umbrella of histiocytoid Sweet syndrome. However, with the advent of next-generation sequencing, cutaneous involvement by myelodysplastic syndrome is being increasingly recognized. OBJECTIVE.­: To review histiocytoid Sweet syndrome and myelodysplasia cutis and discuss our current understanding of these entities. Additionally, to discuss how next-generation sequencing can be applied in the evaluation of cutaneous infiltrates of immature histiocytoid cells. DATA SOURCES.­: The English-language literature from 2005 to 2023 on the topic of histiocytoid Sweet syndrome and myelodysplasia cutis was reviewed. CONCLUSIONS.­: Biopsy specimens showing infiltrates of histiocytoid, immature myeloid cells may represent cutaneous involvement by myelodysplastic syndrome. Close clinical correlation is recommended in these cases. Recent studies suggest that next-generation sequencing is useful in separating myelodysplasia cutis from true histiocytoid Sweet syndrome. This distinction has important implications for patients.