Nondermatophyte mould onychomycosis.

Nondermatophyte moulds (NDMs) onychomycosis is often difficult to diagnose as NDMs have been considered contaminants of nails. There are several diagnostic methods used to identify NDMs, however, repeated laboratory isolation is recommended to validate pathogenicity. With NDM and mixed infection (dermatophytes plus NDM) onychomycosis on the rise, accurate clinical diagnosis along with mycological tests is recommended. Systemic antifungal agents such as itraconazole and terbinafine (e.g. pulse regimen: 1 pulse = every day for one week, followed by no treatment for three weeks) have shown efficacy in treating onychomycosis caused by various NDMs such as Aspergillus spp., Fusarium spp., Scopulariopsis brevicaulis, and Onychocola canadensis. Studies investigating topical therapy and devices for NDM onychomycosis are limited. The emergence of antifungal resistance necessitates the incorporation of antifungal susceptibility testing into diagnosis when possible, for the management of recalcitrant infections. Case studies documented in the literature show newer azoles such as posaconazole and voriconazole as sometimes effective in treating resistant NDM onychomycosis. Treatment with broad-spectrum antifungal agents (e.g. itraconazole and efinaconazole) and other combination therapy (oral + oral and/or oral + topical) may be considerations in the management of NDM onychomycosis.

Potential use of microwave technology in dermatology.

BACKGROUND: Microwaves are used in medicine for diagnostics, and treatment of cancer. Recently, novel microwave devices (Swift®, Emblation Ltd, UK and miraDry®, Miramar Labs Inc., CA) have been cleared by the FDA and Health Canada for various dermatological conditions. OBJECTIVE AND METHODS: To review the dermatological use of microwave-based treatments (plantar warts, corns, actinic keratosis, dermatophytosis, axillary hyperhidrosis, osmidrosis, and hidradenitis suppurativa). Clinical trials, case reports, or in vitro studies for each condition are summarized. RESULTS AND CONCLUSION: Microwaves are a promising alternative therapy for cutaneous warts, actinic keratosis, axillary hyperhidrosis, and osmidrosis, with favorable safety profiles. However, patients with hidradenitis suppurativa have had negative clinical outcomes. Limited treatment of corns showed good pain reduction but did not resolve hyperkeratosis. A preliminary in vitro study indicated that microwave treatment inhibits the growth of T. rubrum. We present the first case of toenail onychomycosis successfully treated with microwaves. Despite the advancements in the use of microwaves, the mechanism of action in non-ablative treatment is not well understood; further research is needed. More high-quality randomized clinical trials with larger groups and long follow-up periods are also required to evaluate the clinical benefits and possible adverse effects of microwaves in treating dermatological conditions.

Minoxidil: a comprehensive review.

Topical minoxidil (5% foam, 5% solution, and 2% solution) is FDA-approved for androgenetic alopecia (AGA) in men and women.Mechanism of action: Minoxidil acts through multiple pathways (vasodilator, anti-inflammatory agent, inducer of the Wnt/ß-catenin signaling pathway, an antiandrogen), and may also affect the length of the anagen and telogen phases.Pharmacokinetics: Approximately 1.4% of topical minoxidil is absorbed through the skin. Minoxidil is a prodrug that is metabolized by follicular sulfotransferase to minoxidil sulfate (active form). Those with higher sulfotransferase activity may respond better than patients with lower sulfotransferase activity.Clinical efficacy (topical minoxidil): In a five-year study, 2% minoxidil exhibited peak hair growth in males at year one with a decline in subsequent years. Topical minoxidil causes hair regrowth in both frontotemporal and vertex areas. The 5% solution and foam were not significantly different in efficacy from the 2% solution.Oral and Sublingual minoxidil (not FDA approved; off-label): After 6 months of administration, minoxidil 5 mg/day was significantly more effective than topical 5% and 2% in male AGA. Low-dose 0.5-5 mg/day may also be safe and effective for female pattern hair loss and chronic telogen effluvium. Sublingual minoxidil may be safe and effective in male and female pattern hair loss.

Finasteride for hair loss: a review.

BACKGROUND AND OBJECTIVES: Finasteride 1 mg/day is indicated for androgen-dependent conditions such as male androgenetic alopecia (AGA). METHODS: The literature is comprehensively summarized on the pharmacodynamics, pharmacokinetics, mechanism of action, and metabolism of finasteride. Pairwise and network meta-analyses were performed to assess the efficacy of finasteride reported in clinical trials. The adverse events profile is described along with the post-marketing reports. RESULTS AND CONCLUSION: Finasteride 1 mg/day significantly increased total hair count compared to placebo after 24 weeks (mean difference = 12.4 hairs/cm2, p < .05), and 48 weeks (mean difference = 16.4 hairs/cm2, p < .05). The efficacy of the two doses of finasteride (5 mg/day and 1 mg/day) and topical finasteride (1% solution) were not significantly different. The most commonly reported sexual events include erectile dysfunction and decreased libido. Increasing patient complaints and analysis of the FAERS database led to the inclusion of depression in the FDA label in 2011, as men were found to be at a risk of suicide due to the persistent sexual side effects, commonly termed as post-finasteride syndrome. Finasteride is shown to be reasonably tolerated in both men and women; however, patients need to be educated about the possible short- and long-term side-effects.

Anterior Vertebral Body Tethering for Adolescent Scoliosis with Growth Remaining: A Retrospective Review of 2 to 5-Year Postoperative Results.

BACKGROUND: Anterior vertebral body tethering (VBT) is an early treatment option for progressive scoliosis in pediatric patients, allowing for continued deformity correction during normal growth. We report postoperative radiographic and clinical outcomes for patients treated with VBT. METHODS: This clinical and radiographic retrospective review of 31 consecutive patients included an analysis of preoperative, perioperative, and postoperative details, including the Lenke classification; Cobb angle measurements of the proximal thoracic, main thoracic, and lumbar curves; the sagittal profile; and skeletal maturity. Successful outcomes were defined by a residual curve of ≤30° in skeletally mature patients who did not undergo a posterior spinal fusion (PSF). RESULTS: Of the 31 patients treated, 29 met the inclusion criteria, and 2 were lost to follow-up. The mean patient age (and standard deviation) at the time of the surgical procedure was 12.7 ± 1.5 years (range, 10.2 to 16.7 years), with most patients classified as Risser grade 0 or 1 (52%) and Sanders stage 3 (32%). A mean of 7.2 ± 1.4 vertebral levels were instrumented, with a minimum preoperative Cobb angle of 42°. At the latest follow-up, 27 patients had reached skeletal maturity (Sanders stage ≥7) and 20 patients exhibited a curve magnitude ≤30°, for a success rate of 74%. A suspected broken tether occurred at ≥1 level in 14 patients (48%). Two patients underwent PSF and 4 had tether revision. The overall revision rate was 21% (6 of 29). CONCLUSIONS: This study shows the success and revision rates as well as the impact of a suspected broken tether on the procedural success of VBT. Despite our patient population being slightly more mature at the time of the surgical procedure compared with previous studies, we had a higher success rate and a lower revision rate. A PSF was avoided in 93% of patients, indicating that VBT may be a reliable treatment option for adolescent scoliosis in skeletally immature individuals. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hansen's disease: An unusual presentation.

Hansen's disease can present with varied and subtle symptoms which can be missed. A middle-aged gentleman presented with swelling of face and hands. Detailed examination and investigations confirmed borderline tuberculoid leprosy with lepra reaction. A high index of suspicion with vigilance can help to make an early diagnosis in this potentially treatable condition.

Suppression of B-lymphocyte function by T-lymphocytes in patients with advanced lung cancer.

The ability of B-lymphocytes to produce immunoglobulins in response to pokeweek mitogen stimulation was studied in 21 untreated stage III lung cancer patients by culture of their mononuclear cells in vitro. The number of immunoglobulin-producing cells was significantly lower in 20 of the 21 patients when compared to responses shown by normal control subjects. In contrast, the proliferative responses of many of the patients were within the normal range. When the T-lymphocytes of these patients were irradiated with 1,250 rad to eliminate the suppressor T-cell activity and then cultured with autologous B-cells, the number of immunoglobulin-producing cells was enhanced to the normal range in 7 of the 18 patients. These results indicate that B-cell function is impaired in most patients with advanced lung cancer. They also suggest that, in addition to suppression by radiosensitive suppressor T-cells, other mechanisms are involved in the observed B-cell functional abnormality.

Subpopulation of human helper and suppressor T lymphocytes.

Mitogen driven differentiation of normal human mononuclear cells is a well-established model for the study of antibody synthesis in man. In certain rare individuals who are clinically normal, unfractionated mononuclear cells or a mixture of purified B plus T lymphocytes differentiate into immunoglobulin producing cells in response to purified protein derivative of tuberculin (PPD) but not in response to pokeweed mitogen (PWM). To evaluate this observation we have irradiated T cells from such individuals to eliminate naturally occurring suppressor T cell activity and then added the irradiated T cells back to autologous B cells before culture. The B cells then responded to PWM. The original PPD responses of cells from these individuals were now significantly reduced. Although, there was no difference between PWM nonresponders and responders in the number of OKT-8 positive cells, elimination of OKT-8 positive cells in the PWM nonresponders with OKT-8 monoclonal antibody and complement resulted in a significantly increased response to PWM. This study indicates that there are suppressor T cells which specifically inhibit B cell response to PWM without affecting the PPD response. These results also show that the helper T cells involved in the PWM response are radioresistant and those involved in the PPD response are radiosensitive.

Giant cervical herniation of an apical pulmonary bulla.

A 60-year-old woman had a giant air cyst in the right side of the neck, which arose from the apex of the right lung. We are unable to find a similar case report in literature.

B-cell changes occur in patients with sickle cell anemia.

B- and T-lymphocytes were studied in patients with sickle cell anemia. Samples were analyzed during asymptomatic periods and during vasocclusive pain crises to assess a possible relationship to these periods. Assays of B-cell function and quantitation of B- and T-lymphocytes and their subsets were carried out. During crises, six of the eight patients showed a significant decrease in the number of immunoglobulin-producing cells, together with normal or enhanced blastogenic responses. The total number of T-lymphocytes was normal when measured by the monoclonal antibody OKT3 in contrast to the significantly lower level observed in some patients, as determined by the E-rosette technic. There were no significant changes in the percentage of either helper or suppressor T-cells or in the percentage of B-cells. The results show that changes in in vitro B-cell function occur during vasocclusive pain crises in patients with sickle cell anemia. These may be clinically important in these patients.

Coexistent double gammopathy, myeloproliferative disorder, and malignant lymphoma.

The authors report a patient with coexistent double gammopathy, a Philadelphia chromosome-negative, bcr rearrangement-negative myeloproliferative disease resembling chronic myelocytic leukemia and a malignant lymphoma of B-cell origin. The double gammopathy consisted of IgM (kappa) and IgG (kappa). Peripheral blood, spleen, and marrow lymphocytes had primarily an IgG (kappa) isotype, whereas lymph node lymphocytes had predominantly an IgM (kappa) surface isotype. Increased numbers of marrow lymphocytes stained doubly for both IgM (kappa) and IgG (kappa). The results suggest that doubly isotypic as well as single isotypic lymphocytes contributed to the double gammopathy. Organ localization differed for lymphocytes with different antibody isotypes. This cluster of findings has not been described previously.

Cystic fibrosis in children from ethnic minorities in the West Midlands.

BACKGROUND: We have observed that Doctors often perceive that cystic fibrosis (CF) is exceptionally rare in non-whites, and that this bias has repeatedly resulted in diagnostic delay. We therefore compared the age at diagnosis, genetic features and relative prevalence of CF in non-whites and white patients in the West Midlands. METHODS: Analysis of data on all CF patients diagnosed in childhood and stored in the West Midlands CF register. RESULTS: Sixteen of the 514 children on the register were not of white European extraction, comprising 13 patients whose families originated from the Indian subcontinent, two of mixed AfroCaribbean/white European extraction and one of mixed Pakistani/white European extraction. The median age of diagnosis was similar in the white European and non-white patients (0.42 vs. 0.33 years, 95% CI for the difference of the medians -0.15, 0.37). However, in five cases with typical clinical features the diagnosis appears to have been delayed because of the child's racial origin (median age of diagnosis 3.87 years), and in five others the diagnosis was obvious (two siblings with CF, three had meconium ileus). There was a degree of consanguinity in nine cases. Five patients were homozygous or heterozygous for the delta F508 mutation, but no mutation could be identified in the remaining 11 patients. CONCLUSIONS: The possibility of CF needs to be considered in any patient with relevant clinical problems, regardless of racial origin. These findings need to be considered when planning any mass population screening programme for CF.

Bilateral superficial femoral giant cell arteritis.

Giant cell arteritis is a rare, poorly understood, and often misdiagnosed entity. A case is reported of giant cell arteritis in a 30-year-old white male who developed severe bilateral peripheral claudication affecting both legs. The erythrocyte sedimentation rate (ESR) was markedly elevated. The diagnosis of vasculitis was established by histology postoperatively following exploration of both superficial femoral arteries and the placement of a reversed saphenous vein bypass graft to the right leg. Biopsy of the temporal artery revealed no pathology. The patient has been completely asymptomatic postoperatively and has resumed all previous normal activities. This condition has persisted in spite of a failed graft determined by an arteriogram performed 3 months after surgery. He has been treated with steroids continuously since the procedure.

Acid inhibiton in insulin test- a preliminary report.

The initial suppression of acid secretion in Insulin Test has been a subject of various interpretaitons. A study of hypothalamic recordings in a patient undergoing sedative neurosurgery for behaviour disorders revealed marked suppression of electrical activity in the lateral hypothalamic nucleus within three minutes after the injection of insulin, followed later by spike formation corresponding to parasympathetic stimulation, when hypoglycaemia is established. It appears that the initial suppression of acid secretion is due to a direct action of insulin, suppressing electrical activities of lateral nucleus, the spike formation occurring later, corresponding to onset of hypoglycaemia with stimulation of the nucleus and consequently gastric secretion.

T-antigen (Gal ß3 GaINAc α-) containing glycoproteins of human reace.

Desialation of cell surface glycoconjugates due to bacterial or viral infection can expose epitopes like T-antigenic structure which can also occur during oncological transformations. Human platelet plasma membrane glycoproteins were isolated by jacalin affinity chromatography. Potential T-antigen containing glycoproteins which were not reported before could be identified on the Western blot using peanut agglutinin-horse radish peroxidase (PNA-HRP) after neuraminidase treatment. Alpha-galactosyl epitopes recognized by anti-gal were found to be absent in human platelet plasma membrane glycoproteins. Under the experimental conditions employed, the Gp IIbα was identified most rich in T-antigenic structures. Probable role of exposed T-antigenic structures and α-galactosyl epitopes in pathological conditions is discussed. The identity of major glycoprotein bands was confirmed by differential lectin-binding studies with Concanavalin A on the Western blot. The higher binding affinity of jacalin for T-antigenic structures when compared to PNA enabled the isolation and detection of the antigen containing platelet surface glycoproteins which were not reported before.