Evaluation of microneedling depth of penetration in management of atrophic acne scars: a split-face comparative study.

BACKGROUND: Microneedling is a technique of repeated puncturing or drilling of the skin to induce repair and collagen induction. There are many reported important factors determining the efficacy of microneedling treatment. The extent of injury needed to produce the desired effect in each condition is one of these important factors. OBJECTIVES: We designed the present split-face comparative study to evaluate the use and effectiveness of two different depths of penetration of Dermapen needles in the management of atrophic postacne scars. PATIENTS AND METHODS: The present study involved 14 subjects with atrophic postacne scars. In each patient, both sides of the face were treated with six sessions of microneedling, using Dermapen at 2-week intervals. A split-face study design was performed. The right (Rt) side of the face was treated with Dermapen using 2.5 mm needle length, while the left (Lt) side was treated using 1.5 mm needle length. RESULTS: There was a significantly better percentage of improvement of acne scars on the Rt side of the face compared to the Lt side (P = 0.02) after six sessions. Both sides of the face showed improvement of collagen bundles and elastic fibers characteristics after six sessions. CONCLUSIONS: The use of 2.5 mm depth proved to be more effective both clinically and histologically in the management of atrophic postacne scars.

An Adapted Self-screening Tool for Peripartum Cardiomyopathy in Haiti.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is considered rare in the United States; however, the literature notes that the disease has a higher prevalence in developing countries such as Haiti. Dr. James D. Fett, a US cardiologist, developed and validated a self-assessment measure for PPCM in the United States to aid women to easily differentiate the signs and symptoms of heart failure from those related to a normal pregnancy. Although this instrument was validated, it lacks the adaptation necessary to account for the language, culture, and education of the Haitian population. OBJECTIVE: The aim of this study was to translate and culturally adapt the Fett PPCM self-assessment measure for use among a Haitian Creole speaking population. METHODS: A preliminary Haitian Creole direct translation was developed from the original English Fett self-test. A total of four focus groups with medical professionals and 16 cognitive interviews with members of a community advisory board were conducted to refine the preliminary Haitian Creole translation and adaptation. RESULTS: The adaptation focused on incorporating cues that would be tangible and connected to the reality of the Haitian population while maintaining the intended meaning of the original Fett measure. CONCLUSIONS: The final adaptation provides an instrument suitable for administration by auxiliary health providers and community health workers to help patients distinguish symptoms of heart failure from symptoms related to normal pregnancy and further quantify the severity of signs and symptoms that might be indicative of heart failure.

The role of invasive cardiopulmonary exercise testing in patients with unexplained dyspnea: a systemic review.

BACKGROUND: Dyspnoea is a common complaint that often remains unexplained with no diagnosis and poor management despite extensive, repetitive and costly testing. Invasive cardiopulmonary testing has been used in the evaluation of dyspnoea, however, its role is not yet well defined. We sought to perform a systematic review of the literature looking at the role of invasive cardiopulmonary testing in the evaluation of chronic dyspnoea and/or exercise intolerance. METHODS AND RESULTS: We performed a literature review in accordance with PRISMA, analysing articles published in peer-reviewed journals between January 1st 1985 and January 31st 2020, available in 3 databases. The aim was to identify randomised and non-randomised clinical studies that focussed on the utility of invasive cardiopulmonary exercise test in the evaluation of dyspnoea. Emphasis was placed on studies that noted the use of exercise stress testing with the concomitant use of right heart catheterisation to evaluate hemodynamics as part of the work up for dyspnoea. We identified 6 retrospective studies that assessed the use of exercise hemodynamics to identify the aetiology of dyspnoea. CONCLUSION: Invasive cardiopulmonary exercise test is a useful tool for identifying the cause of unexplained dyspnoea. It can be helpful in early recognition and prognostication of patients with heart failure with preserved ejection fraction and pulmonary hypertension. It has also shown to be beneficial for constructing a multidisciplinary approach to chronic dyspnoea.

Dual Antiplatelet Therapy in Patients Aged 75 Years and Older with Coronary Artery Disease: A Meta-Analysis and Systematic Review.

Objectives: This systematic review and meta-analysis evaluates the safety and efficacy of dual antiplatelet therapy (DAPT) in elderly patients with acute coronary syndrome (ACS). Background: The safety and efficacy of DAPT in elderly patients with ACS is not well characterized. Methods: We performed a systematic literature review to identify clinical studies that reported safety and efficacy outcomes after DAPT for ACS in elderly patients. The primary outcomes of primary efficacy endpoint rates and bleeding event rates were reported as random effects risk ratio (RR) with 95% confidence interval. No prior ethical approval was required since all data are public. Results: Our search yielded 660 potential studies. We included 8 studies reporting on 29,217 patients. There was a higher risk of bleeding event rates in elderly patients treated with prasugrel or ticagrelor when compared to clopidogrel with a risk ratio of 1.17 (95% CI 1.08 to 1.27, p < 0.05). There was no difference in primary efficacy endpoint rates between elderly patients treated with prasugrel or ticagrelor when compared to clopidogrel with a risk ratio of 0.85 (95% CI 0.68 to 1.07, p=0.17). Conclusions: This systematic review and meta-analysis suggests that DAPT with prasugrel or ticagrelor compared to clopidogrel is associated with a higher risk of bleeding events in elderly patients with ACS. There was no difference in the primary efficacy endpoints between the two treatment groups.

Management of Recurrent Pregnancy-Related Pericarditis.

The evidence on recurrent pregnancy-related pericarditis is limited, and management strategies are based on case reports and expert opinion. We describe a patient with myopericarditis complicated by cardiac tamponade presenting shortly after her first pregnancy, which was then complicated by refractory recurrent pericarditis. She was treated with standard first line therapies, such as NSAIDs, corticosteroids, and colchicine, and eventually initiated on the purine analog, azathioprine. Out of fear of teratogenicity, she self-discontinued her maintenance medications and thereafter, her course was complicated by a recurrent flare of pericarditis during a subsequent pregnancy. Our case illustrates the significant burden on our patient due to the incessant nature of her disease and on the providers due to the therapeutic dilemmas associated with family planning and pregnancy. Further data is required on this unique clinical scenario, and patient-centered management by a multidisciplinary team is critical.

The use of diflunisal for transthyretin cardiac amyloidosis: a review.

Transthyretin cardiac amyloidosis (ATTR-CM) is caused by the accumulation of misfolded transthyretin (TTR) protein in the myocardium. Diflunisal, an agent that stabilizes TTR, has been used as an off-label therapeutic for ATTR-CM. Given limited data surrounding the use of diflunisal, a systematic review of the literature is warranted. We searched the PubMed, MEDLINE, and Embase databases for studies that reported on the use of diflunisal therapy for patients with ATTR-CM. We included English language studies which assessed the effect of diflunisal in adult patients with ATTR-CM who received diflunisal as primary treatment and reported clinical outcomes with emphasis on studies that noted the safety and efficacy of diflunisal in cardiac manifestations of ATTR amyloidosis. We excluded studies which did not use diflunisal therapy or used diflunisal therapy for non-cardiac manifestations of TTR amyloidosis. We also excluded case reports, abstracts, oral presentations, and studies with fewer than 10 subjects. Our search yielded 316 records, and we included 6 studies reporting on 400 patients. Non-comparative single-arm small non-randomized trials for diflunisal comprised 4 of the included studies. The 2 studies that compared diflunisal versus no treatment found improvements in TTR concentration, left atrial volume index, cardiac troponin I, and global longitudinal strain. Overall, diflunisal use was associated with decreased mortality and number of orthotopic heart transplant in ATTR-CM patients. Although a smaller number of patients had to stop treatment due to gastrointestinal side effects and transient renal dysfunction, there were no severe reactions reported in the studies included in our review. This systematic review supports the use of diflunisal for ATTR-CM. Additional long-term analyses and randomized clinical trials are needed to confirm these results.

Effects of bromocriptine in peripartum cardiomyopathy: a systematic review and meta-analysis.

Peripartum cardiomyopathy (PPCM) is a rare but potentially life-threatening form of heart failure (HF). Bromocriptine, a dopamine D2 agonist, has been used as an adjunctive treatment for PPCM with controversial benefits. A comprehensive literature search was conducted through June 2021. We included studies comparing the outcomes of PPCM with or without bromocriptine use. Pooled risk ratio (RR) with 95% confidence intervals (CI) and I2 statistics were calculated. Composite major adverse outcomes were defined by a composite of death, need for advanced HF therapies, persistent New York Heart Association (NYHA) functional class III/V, or left ventricular ejection fraction (LVEF) ≤ 35% at 6-month follow-up. LVEF recovery was defined by improvement of LVEF to more than 50%. Eight studies (two randomized-controlled, six observational) involving 593 PPCM patients were included. Bromocriptine use was associated with significantly higher survival (91.6% vs. 83.9%, RR 1.11 p = 0.02). Baseline LVEF was not significantly different between the groups. LVEF at follow-up was significantly higher in the bromocriptine group (53.3% vs. 41.8%, p < 0.001). There was no significant association between bromocriptine use and lower composite major adverse outcomes (13.7% vs. 33.3%, RR 0.60 p = 0.54) or LVEF recovery (46.9% vs. 46.8%, RR 0.94 p = 0.74). In conclusion, the addition of bromocriptine to standard HF treatment in PPCM was associated with significantly higher survival and higher LVEF improvement. No association with lower composite adverse clinical outcomes or LVEF recovery was seen. The findings, although encouraging, warrant larger randomized-controlled studies.

Lifetime Risk of Heart Failure and Trends in Incidence Rates Among Individuals With Type 2 Diabetes Between 1995 and 2018.

Background There are limited data on the lifetime risk of heart failure (HF) in people with type 2 diabetes and how incidence has changed over time. We estimated the cumulative incidence and incidence rates of HF among Danish adults with type 2 diabetes between 1995 and 2018 using nationwide data. Methods and Results In total, 398 422 patients (49% women) with type 2 diabetes were identified. During follow-up, 36 400 (9%) were diagnosed with HF and 121 459 (30%) were censored due to death. Using the Aalen-Johansen estimators, accounting for the risk of death, the estimated residual lifetime risk of HF at age 50 years was calculated as 24% (95% CI 22%-27%) in women and 27% (25%-28%) in men. During the observational period, the proportion of patients treated with statins, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, and metformin increased from <30% to >60%. Similarly, the annual incidence rates of HF decreased significantly, with declines being greater in older versus younger individuals (5% versus 2% in age >50 versus ≤50 years, respectively; P<0.0001) and in women versus men (5% versus 4%, P=0.02), but similar in patients with and without IHD (4% versus 4%, P=0.53). Conclusions The current lifetime risk of HF in type 2 diabetes approximates 1 in 4 for men and women. Paralleled by an increase in use of evidence-based pharmacotherapy over the past decades, the risk of developing HF has declined across several subgroups and regardless of underlying IHD, suggesting that optimal diabetes treatment can mitigate HF risk.

Validation of a Crisis Standards of Care Model for Prioritization of Limited Resources During the Coronavirus Disease 2019 Crisis in an Urban, Safety-Net, Academic Medical Center.

OBJECTIVES: The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital. DESIGN: We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals. SETTING: An urban safety-net hospital ICU. PATIENTS: All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories. CONCLUSIONS: Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models.

The Developmental & Molecular Requirements for Ensuring that Human Pluripotent Stem Cell-Derived Hair Follicle Bulge Stem Cells Have Acquired Competence for Hair Follicle Generation Following Transplantation.

When using human induced pluripotent stem cells (hiPSCs) to achieve hair follicle (HF) replacement, we found it best to emulate the earliest fundamental developmental processes of gastrulation, ectodermal lineage commitment, and dermogenesis. Viewing hiPSCs as a model of the epiblast, we exploited insights from mapping the dynamic up- and down-regulation of the developmental molecules that determine HF lineage in order to ascertain the precise differentiation stage and molecular requirements for grafting HF-generating progenitors. To yield an integrin-dependent lineage like the HF in vivo, we show that hiPSC derivatives should co-express, just prior to transplantation, the following combination of markers: integrins α6 and ß1 and the glycoprotein CD200 on their surface; and, intracellularly, the epithelial marker keratin 18 and the hair follicle bulge stem cell (HFBSC)-defining molecules transcription factor P63 and the keratins 15 and 19. If the degree of trichogenic responsiveness indicated by the presence of these molecules is not achieved (they peak on Days 11-18 of the protocol), HF generation is not possible. Conversely, if differentiation of the cells is allowed to proceed beyond the transient intermediate progenitor state represented by the HFBSC, and instead cascades to their becoming keratin 14+ keratin 5+ CD200- keratinocytes (Day 25), HF generation is equally impossible. We make the developmental case for transplanting at Day 16-18 of differentiation-the point at which the hiPSCs have lost pluripotency, have attained optimal expression of HFBSC markers, have not yet experienced downregulation of key integrins and surface glycoproteins, have not yet started expressing keratinocyte-associated molecules, and have sufficient proliferative capacity to allow a well-populated graft. This panel of markers may be used for isolating (by cytometry) HF-generating derivatives away from cell types unsuited for this therapy as well as for identifying trichogenic drugs.

Impact of Renal Dysfunction on Outcomes after Left Ventricular Assist Device: A Systematic Review.

Background and Objectives: Renal dysfunction is a common comorbidity in patients with advanced heart failure who may benefit from left ventricular assist device (LVAD) therapy. The effect of preoperative renal dysfunction on clinical outcomes after LVAD implantation remains uncertain. We conducted a systematic review and meta-analysis to compare outcomes post-LVAD in patients with and without renal dysfunction. Methods: PubMed, MEDLINE, and Embase databases were searched for studies comparing outcomes in patients with and without renal dysfunction who underwent LVAD implantation for advanced heart failure. The primary outcome of all-cause mortality was reported as random effects risk ratio (RR) with 95% confidence interval (CI). Results: Our search yielded 5,229 potentially eligible studies. We included 7 studies reporting on 26,652 patients. Patients with renal dysfunction (glomerular filtration rate [GFR] <60 mL/min/1.73 m2) (n=4,630) had increased risk of all-cause mortality (RR, 2.21; 95% CI, 1.39-3.51; p<0.01) compared to patients with normal renal function (GFR >60 mL/min/1.73 m2) (n=22,019). Conclusions: Patients with renal dysfunction have increased mortality after LVAD implantation when compared to patients with normal renal function. GFR can be used to risk stratify patients and guide decision making prior to LVAD therapy.

Carboxytherapy for striae distensae: A promising modality.

BACKGROUND: Striae distensae (SD) is a very common skin problem. Although a lot of treatment modalities have been proposed, few of them are effective. Recently, carbon dioxide therapy (CDT) or carboxytherapy was used in many indications of cosmetic dermatology such as SD. OBJECTIVES: To objectively evaluate the use and effectiveness of CDT for treatment of SD. PATIENTS AND METHODS: Twenty patients were subjected to 8 sessions of CDT injection at 2-week intervals using carboxy-gun. Patients were photographed, and skin specimens were obtained from the treated area before and after 4 months of treatment. Using a computerized 3D camera, skin topography was objectively analyzed before and after treatment. Evaluation of collagen and elastic fibers by special histopathological staining, in addition to histometric analysis, was also done to evaluate treatment efficacy. RESULTS: Clinically, SD was statistically significantly improved after CDT injection compared with baseline (mean percentage of improvement of length and width, 59.8 ± 15.9; P < .05). Meanwhile, the improvement observed by the 3D camera correlated with the clinical improvement. Histometric analysis showed an increase in epidermal thickness (P < .0001) in association with re-appearance of rete ridges following treatment. Histochemical evaluation of changes in elastic and collagen fibers after treatment showed better organization of curled and fragmented elastic fibers, which was accompanied by an increase in collagen content that became denser, arranged in bundles and parallel to the epidermis. CONCLUSIONS: CDT is an effective, promising, and simple minimally invasive procedure for improving SD with few side effects and low downtime.

Deriving Keratinocyte Progenitor Cells and Keratinocytes from Human-Induced Pluripotent Stem Cells.

Skin or hair loss (alopecia) may occur due to a wide variety of causes ranging from trauma to pathological processes including acquired or congenital causes. It would be ideal to replace them with immunologically compatible cells to avoid potentially exacerbating the condition. Deriving the replacement cells from human-induced pluripotent stem cells (hiPSCs) allows for sufficient scale up and using hiPSCs as the choice of human pluripotent stem cells (hPSC) will ensure immunocompatibility. Here we offer a protocol for differentiating hiPSCs into keratinocyte progenitor cells (KPC) and keratinocytes employing all-trans retinoic acid (ATRA) and L-ascorbic acid, (L-AA), bone morphogenic protein-4 (BMP4), and epidermal growth factor (EGF). We observed that the hiPSC-derived KPCs express the same panel of markers as primary hair follicle bulge stem cells (HFBSCs), including CD200, integrin α-6 (ITGA6), integrin ß-1 (ITGB1), the transcription factor P63, keratin 15 (KRT15), and keratin 19 (KRT19). If permitted to differentiate further, the hiPSC-derived KPC lose CD200 expression and rather come to express keratin 14 (KRT14) indicating emergence of more mature terminally-differentiated keratinocytes. The HFBSCs are transplantable for hair follicle (HF) restoration, and the keratinocytes may be transplantable for therapy for large burns or ulcers. © 2020 Wiley Periodicals LLC. Basic Protocol 1: Reprogramming of normal human skin fibroblasts into normal hiPSCs using episomal DNA cocktail Basic Protocol 2: Differentiation of hiPSCs into KPCs and keratinocytes Alternate Protocol 2: EBS formation protocol using AggreWell™ plates (Antonchuk, 2013) Support Protocol 1: Passage hiPSC-KPC Support Protocol 2: Immunocytochemistry (ICC) Support Protocol 3: Immunofluorescence staining of cells for flow cytometry (FC).

Facial rejuvenation using stem cell conditioned media combined with skin needling: A split-face comparative study.

BACKGROUND: The use of stem cells derived growth factors is representing a novel treatment modality in facial rejuvenation. Nowadays, skin needling is considered a very famous treatment of skin aging. However, the addition of such derived products, augments its therapeutic efficacy in the management and delay of skin aging. OBJECTIVE: Comparing the effect of amniotic fluid mesenchymal stem cell derived conditioned media (AF-MSC-CM) combined with skin needling versus the needling alone in the management of facial aging. METHODS: Both sides of the face of ten volunteers, suffering from facial aging, were treated with five sessions of skin needling, 2 weeks apart. After skin microneedling, AF-MSC-CM was added topically to the right side only. Clinical, histological, and morphometrical assessment of the treated skin was done at 1 month after the last session. RESULTS: The percentage of improvement of aged skin increased significantly on the combined treated side (AF-MSC-CM and dermaroller [DR]), when compared with the other side (DR only) (P < .001). Remodeling of the dermal structures was observed mainly on the combined side. Meanwhile, histometry of the epidermis revealed a significant increase in the epidermal thickness on both treated sides. CONCLUSION: AF-MSC-CM combined with skin needling was more efficient in managing facial aging than skin needling alone.

Prognostic Assessment of Right Ventricular Systolic Dysfunction on Post-Transcatheter Aortic Valve Replacement Short-Term Outcomes: Systematic Review and Meta-Analysis.

Background Right ventricular systolic dysfunction (RVSD) is a known risk factor for adverse outcome in surgical aortic valve replacement. Transcatheter aortic valve replacement (TAVR), on the other hand, has been shown to be either beneficial or have no effect on right ventricular systolic function. However, the prognostic significance of RVSD on TAVR has not been clearly determined. We conducted a systematic review and meta-analysis to define the impact of RVSD on outcomes in terms of 1-year mortality in patients with severe aortic stenosis undergoing TAVR. Methods and Results An extensive literature review was performed, with an aim to identify clinical studies that focused on the prognosis and short-term mortality of patients with severe symptomatic aortic stenosis who underwent TAVR. A total of 3166 patients from 8 selected studies were included. RVSD, as assessed with tricuspid annular plane systolic excursion, fractional area change or ejection fraction, was found to be a predictor of adverse procedural outcome after TAVR (hazard ratio, 1.31; 95% CI, 1.1-1.55; P=0.002). Overall, we found that RVSD did affect post-TAVR prognosis in 1-year mortality rate. Conclusions Patients with severe, symptomatic aortic stenosis and concomitant severe RVSD have a poor 1-year post-TAVR prognosis when compared with patients without RVSD. Right ventricular dilation and severe tricuspid regurgitation were associated with increased 1-year morality post-TAVR and should be considered as independent risk factors. Further evaluations of long-term morbidity, mortality, as well as sustained improvement in functional class and symptoms need to be conducted to determine the long-term effects.

The use of Carboxytherapy alone or in combination with fractional CO2 laser for facial rejuvenation: A split-face comparative study.

BACKGROUND: A wide variety of minimally invasive treatments are available for skin aging. Recently, carbon dioxide therapy (CDT) or carboxytherapy was used in many cosmetic indications including facial rejuvenation. OBJECTIVE: To compare the efficacy of CDT alone versus combined CDT and fractional CO2 laser in management of facial aging. METHODS: Twenty-Five female patients with bilateral and symmetrical facial aging were included in the study. The right (Rt) hemiface received 8 sessions of CDT whereas the left (Lt) side was treated with combined technique (6 sessions of CDT and 2 sessions of fractional CO2 in between. Clinical and objective evaluation using 3D skin analysis, histological, and morphometric analysis were performed. RESULTS: Clinical evaluation demonstrated that all patients (100%) were satisfied with no significant difference between both sides of the face (P > .05). Regarding texture and pigmentation improvement, the Lt side (combined) showed significant improvement compared to the Rt side (P < .05). Using Antera 3D camera, there was a significant difference (P < .05) in 3D improvement percent in textural changes while there was no significant difference (P > .05) in the 3D percent of wrinkles improvement between both sides. The Lt side showed more significant increase in epidermal thickness after treatment when compared to the Rt side (P < .05) with evident neocollagen formation. CONCLUSION: Carboxytherapy is an easy, safe, simple, and a relatively effective method for facial rejuvenation with minimal downtime. Better results were achieved when used in combination with fractional CO2 laser.

Amniotic fluid-derived mesenchymal stem cell products combined with microneedling for acne scars: A split-face clinical, histological, and histometric study.

BACKGROUND: Postacne scars are still a challenge in its management. Microneedling is a popular minimally invasive technique in treatment of such scars. However, the addition of topical stem cell products after microneedling is considered a new treatment regimen for these scars. OBJECTIVE: To compare efficacy of amniotic fluid-derived mesenchymal stem cell-conditioned media (AF-MSC-CM) and microneedling vs microneedling alone in management of atrophic acne scars. METHODS: Ten cases with atrophic postacne scars received five sessions of microneedling, with 2-week interval on both sides of the face. Then, AF-MSC-CM was topically applied to right side of the face after microneedling. Clinical examination with histopathological and computerized histometric analysis was done 1 month after the sessions. RESULTS: There was significant increase in the improvement percentage of acne scars on right side (dermaroller and AF-MSC-CM) vs left side of face (dermaroller; P < 0.001). Histologically, improvement of character of collagen and elastic fibers was noticed, especially on right side. Meanwhile, significant increase in epidermal thickness on both sides of face was detected. CONCLUSION: Amniotic fluid-derived mesenchymal stem cell-conditioned media combined with microneedling is more effective in management of atrophic postacne scars than microneedling alone.

Gender and Editorial Authorship in High-Impact Epidemiology Journals.

Women comprise about half of senior epidemiologists, but little is known about whether they are also viewed as leaders (i.e., authorities) in the field. We believe editorial roles are markers of leadership in a field. Our objective was to describe the distribution of gender across authorship of editorials published in 5 high-impact epidemiology journals over the past 8 years. We included editorials and commentaries published in American Journal of Epidemiology, European Journal of Epidemiology, Epidemiology, International Journal of Epidemiology, and Journal of Clinical Epidemiology between 2010 and 2017. We classified genders of all authors as woman, man, or unknown and computed the proportions of women editorial authors over all journals and according to position (e.g., first author). Only 31% (682/2,228) of all editorial authors and 36% (524/1,477) of unique editorial authors (i.e., counting each editorial author name only once) were women. We identified 1,180 editorials; 594 had sole authors, 24% (141/594) of whom were women, and 586 had 2 or more authors, 31% (184/586) of which had women as first authors. If women are underrepresented as editorial authors across epidemiology journals (e.g., as a marker of epidemiology leadership), the situation merits immediate correction.

Brugada Syndrome Caused by Autonomic Dysfunction in Multiple Sclerosis.

Only one case report has previously described a patient with multiple sclerosis and a type 1 Brugada pattern on the electrocardiogram. Patients with multiple sclerosis have several neurological deficits including sensory symptoms, acute or subacute motor weakness, gait disturbance, and balance problems that may lead to an increased risk of falls. Concurrent autonomic dysfunction and neurologic consequences of multiple sclerosis may precipitate both mechanical falls and falls with loss of consciousness. While mechanistically different, the type 1 Brugada pattern presents similarly with syncope due to an insufficient cardiac output during dysrhythmia. In such patients, intracardiac defibrillators have shown to prevent sudden cardiac death in patients with the Brugada syndrome. In light of these similarly presenting but unique clinical entities, MS patients who develop a syncopal event in the setting of a spontaneous type I Brugada pattern pose a diagnostic and therapeutic dilemma. This case illustrates an approach to the risks and benefits of an ICD placement in an MS patient with the type 1 Brugada pattern.