Predictors of future haemorrhage from cerebral cavernous malformations: a retrospective cohort study.

Cerebral cavernous malformations (CCMs) are commonly diagnosed, with a low reported rate of haemorrhage on long-term follow-up. The identification of factors predictive of future haemorrhage risk would assist in guiding the management of patients with CCM. The aim of this study was to identify variables associated with haemorrhage, and calculate haemorrhage risk in CCM. We conducted a retrospective study of patients diagnosed with a CCM, managed at a specialist tertiary neuroscience centre (2007-2019). The primary outcome was symptomatic haemorrhage, and secondary outcomes were variables associated with increased risk of haemorrhage, using multivariable Cox regression analysis. Included were 545 patients, with 734 confirmed cavernomas. Median age at diagnosis was 47 (interquartile range [IQR] 35-60), with a median follow-up duration after diagnosis of 46 months (IQR 19-85). Of the patients, 15.0% had multiple lesions (N = 82/545). Symptomatic presentation was observed in 52.5% of patients (N = 286/545). The annual haemorrhage rate was 1.00% per lesion-year (25 events in 2512 lesion-years), and higher in those with symptoms at presentation (1.50% per lesion-year, 22 events vs 0.29%, 3 events, P < 0.001). The variables associated with symptomatic haemorrhage were increased size (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.01-1.07, P = 0.004), eloquent location (HR 2.63, 95% CI 1.12-6.16, P = 0.026), and symptomatic haemorrhage at presentation (HR 5.37, 95% CI 2.40-11.99, P < 0.001). This study demonstrated that CCMs have a low haemorrhage rate. Increased size, eloquent location, and haemorrhage at presentation appear to be predictive of a higher risk of haemorrhage, and could be used to stratify management protocols.

COVID-19 infection is a major cause of acute telogen effluvium.

BACKGROUND: Acute telogen effluvium is a non-scaring hair loss, usually occurs 3 months after the stressful event that causes hair shedding, and lasts up to 6 months. It can be associated with post COVID-19 infection. OBJECTIVE: To study the possible effects of COVID-19 on the hair growth cycle and the relationship between COVID-19 and acute telogen effluvium. PATIENTS AND METHODS: This is an observational cross-sectional study that had been conducted during the period from September 2020 to March 2021 years. Thirty-nine patients with post COVID-19 hair loss are confirmed by polymerase chain reaction (PCR) or antibody testing. Hair pull test was carried out to confirm the diagnosis and severity of telogen effluvium. RESULTS: Thirty-nine patients were evaluated; their ages ranged from 22 to 67 years with a mean and SD of 41.3 ± 11.6 years with 36 (92.3%) females and 3 (7.69%) males. All patients with a diagnosis of ATE were enrolled in this study and had a laboratory-confirmed diagnosis of prior SARS-CoV-2 infection; 15 (38.46%) patients reported mild symptoms, 24 (61.53%) patients presented with moderate disease, and no patient required hospitalization. They all experienced excessive hair loss within 2-3 months after infection. Pull tests were strongly positive (> 10-50% with a mean of 35% of pulled hair away from scalp). CONCLUSION: COVID-19 infection is now a frequent and a common cause of acute telogen effluvium. Hence, clinicians should be aware about the relation between this infection and this pattern of hair loss. Drugs that have been used for the treatment of COVID-19 were excluded as a cause of acute telogen effluvium.

Burn Hemangioma: A New Variant of Hemangioma.

BACKGROUND: Burn hemangioma, also known as scalded pyogenic granuloma, is considered a variant of pyogenic granuloma, but unlike the classic type it presents with rapid progression. Most patients are infants and young children with a history of burns caused by liquids. OBJECTIVE: The present study aims to present all patients with burn hemangiomas treated at our institutions with a full clinical and histopathological assessment. PATIENTS AND METHODS: This case series includes 34 cases that were treated during the period from 2016 to 2021. RESULTS: A total of 34 patients (16 female/18 male, mean age of 17.6 years) were included. Two age groups presented: infants and children (n = 22, age range 0.5-8 years, 10 female/12 male), and adults (n = 11, age range 25-44 years, 6 female/6 male). Lesions appeared 1-2 weeks following predominantly second-degree burns, and multiple lesions predominated in infants and children. The lesions evolved to large lesions within weeks, and these appeared to be either static or involute. The histopathology was compatible with hemangioma, rather than pyogenic granuloma. CONCLUSION: Burn hemangioma should be considered a new variant of hemangioma rather than a type of pyogenic granuloma that follows second-degree burns. They have many similarities with infantile hemangioma, both clinically and histopathologically.

Traction Alopecia: Clinical and Cultural Patterns.

BACKGROUND: Traction alopecia is common and preventable but frequently overlooked disorder. OBJECTIVE: To evaluate patients with traction alopecia. PATIENTS AND METHODS: This study was conducted at the Dermatology Center, Medical City, Baghdad, Iraq, during the period from November 2005 to October 2019. Demographic features like age, gender, disease duration and special hair styling practices and accessories were recorded. Clinical patterns were studied. RESULTS: Thirty female patients were included in this study. Their ages ranged from 6 to 47 years with mean age ± SD was 15.63 ± 9.806. Twenty-one (70%) were below the age of 16 years. No patient had tightly curled hair. All cases were asymptomatic apart from hair loss. The fringe sign was observed in 27 (90%) of cases. The response to therapy was poor. CONCLUSION: Traction alopecia is an important type of pressure-induced hair loss evident in children and adults with or without curly hair due mainly due to cultural hair styling practices with its frequency apparently increasing in recent years. The fringe sign is common and of diagnostic importance. It is a preventable form of hair loss which can be reversed if diagnosed early; otherwise, permanent scarring alopecia results. It represents a pressure phenomenon evident worldwide in both non-Sub-Saharan lineage and Sub-Saharan lineage individuals.

Nevus depigmentosus: the analysis of 37 cases.

BACKGROUND: Nevus depigmentosus (ND) is an uncommon congenital nonprogressive hypopigmented skin disorder that can be seen anywhere on the body. We considered other depigmenting disorders and focused on distinguishing ND from vitiligo and tuberous sclerosis complex in infancy. METHODS: The diagnosis of patients with nevus depigmentosus was made differentiating it from nevus anemicus, pityriasis alba, tuberous sclerosis complex, vitiligo and other depigmenting disorders. RESULTS: Of the 37 individuals with nevus depigmentosus evaluated, 36 were children, twenty-two (59.4%) were males and 15 (40.5%) were females, with male to female ratio 1.4:1. CONCLUSIONS: Distinguishing ND from other disorders with depigmentation can be challenging, in particular in case of tuberous sclerosis complex and vitiligo in infancy.

Total dose iron dextran infusion versus oral iron for treating iron deficiency anemia in pregnant women: a randomized controlled trial.

STUDY OBJECTIVE: To test safety, efficacy, and cost-effectiveness of total dose infusion (TDI) of low molecular weight (LMW) iron dextran for treatment of iron deficiency anemia (IDA) during pregnancy in comparison to oral ferrous fumarate. DESIGN: Prospective interventional randomized controlled trial (RCT). Design classification. Canadian Task Force II3. SETTING: Antenatal clinic and causality unit of a tertiary care referral facility and University Hospital. PATIENTS: A total 66 anemic pregnant women (hemoglobin level between 7-10 g/dl). INTERVENTION: Administration of a LMW iron dextran as a TDI (group A) or Oral iron ferrous fumarate 60 mg elemental iron three times daily (group B) followed by remeasurement of hemoglobin after 4 weeks. MEASURES AND MAIN RESULTS: The main outcome measure was clinical and laboratory improvement of anemia after 4 weeks of starting the therapy. Both groups showed a significant clinical improvement of anemia 4 weeks post-therapy. However, the first improvement of symptoms was significantly faster in group A. Complete blood count (CBC) as well as all iron indices were improved in both groups after 4 weeks of therapy, but were significantly better in group A than B. Side effects in group B were mainly gastrointestinal (GIT) while one case of mild hypersensitivity to TDI and another one case of local reaction at the site of injection were reported in group A. CONCLUSIONS: It is concluded that despite being equally effective in improving both clinical and laboratory evidence of IDA, TDI allows iron restoration with a single dose faster than oral iron therapy with a reasonable safety profile. It is a good example of office one-stop therapy. Nevertheless, noninvasive selfusage at home is a clear advantage of the cheaper oral iron therapy which makes it the first choice for treating IDA in the second and third trimesters of pregnancy in tolerable cases.

Psoriasis and vitiligo are close relatives.

BACKGROUND: Both vitiligo and psoriasis are chronic inflammatory autoimmune diseases with genetic elements. OBJECTIVE: To estimate the frequencies of psoriasis in vitiligo patients and vice versa and to compare them with healthy controls. PATIENTS AND METHODS: A total of 1000 subjects were included, 250 of them had vitiligo, 250 had psoriasis, and 500 were healthy controls. Measurement of the frequencies of vitiligo in psoriatic patients and psoriasis in vitiligo patients was carried out. Thereafter the frequencies of both diseases were assessed in healthy controls. The frequency of vitiligo among psoriatic patients was compared with that of vitiligo in healthy controls. A similar comparison was done between the frequency of psoriasis among vitiligo patients with that in healthy controls. Other comparisons were performed between the frequency of family history of psoriasis among vitiligo patients with that in healthy controls and between the frequency of family history of vitiligo in psoriatic patients with that in healthy controls. RESULTS: The frequency of psoriasis among vitiligo patients was 15 (6%) and among healthy controls was 2 (0.4%); there is a statistically significant difference (P=0.001). The frequency of vitiligo among psoriatic patients was 5 (2%) and among healthy controls was 3 (0.6%); no statistically significant difference was found (P=0.16). The family history of psoriasis among vitiligo patients was 23 (9.2%) and among healthy controls was 20 (4%); there is a significant association (P=0.043). The family history of vitiligo among psoriatic patients was 24 (9.6%) and among healthy controls was 40 (8%); the difference is statistically significant (P=0.042). CONCLUSION: The present work has confirmed the close relationship between vitiligo and psoriasis.

High-depth sequencing of paired primary and metastatic tumours: Implications for personalised medicine.

BACKGROUND: Next-generation sequencing of large panel of genes had been associated with clinical benefit in a significant proportion of patients with advanced cancer. However, the molecular profile of the primary tumour from the initial surgical specimen might significantly differ from the molecular profile in a tumour sample obtained from a biopsy of a metastatic site. PATIENTS AND METHODS: We compare the genetic profile of primary tumours and paired metastases by using a large panel of cancer genes. Training and validation set including a total of 152 primary and metastatic tumour pairs were sequenced (up to 429 genes) focussing on variants described in the Catalogue of Somatic Mutations in Cancer (COSMIC). RESULTS: Training and validation set including a total of 152 primary and metastatic tumour pairs were sequenced focussing on variants described in COSMIC. Agreement rate between the couples of primary and metastasis on COSMIC variants was 65% (24/37) and 43% (49/115) in the training and validation cohort, respectively. That rose to 74% (20/27) and 58% (42/73) when focussing on targetable mutations. In five cases, the discordance was related to appearance of secondary resistance mutation, giving a targetable refined agreement rate of 67% (67/100). CONCLUSION: Up to 40% of paired primary tumour/metastases have discordant molecular profile. Liquid biopsies may overcome, in the near future, the limits of tumour tissue genotyping.

Panniculitis is a common unrecognized histopathological feature of cutaneous leishmaniasis.

BACKGROUND: Cutaneous leishmaniasis (CL) is a parasitic cutaneous infection caused by Leishmania parasite. The histopathology is usually granulomatous in nature. AIMS: The aim of the present study is to elucidate the histology of CL and evaluate the presence and the frequency of panniculitis among the affected patients. SETTINGS AND DESIGN: Case series interventional study. MATERIALS AND METHODS: Thirty-five patients with CL were diagnosed clinically between December-2012 and May-2013. Diagnostic confirmation established by smears, culture, and polymerase chain reaction (PCR). The histopathological assessment was carried out to study the general pathology and to look for the presence of panniculitis. STATISTICAL ANALYSIS USED: Simple statistics utilized via SPSS version 16.0 (SPSS, Inc., Chicago, USA). RESULTS: Eighteen women and 17 men with CL were enrolled in the present work with a mean duration of their disease was 3 months. The results of the diagnostic tests were as follow: The smear was positive in 21 (60%) of cases, Leishman-Donovan (LD) bodies were seen in 7 (20%) patients, culture was positive in 24 (68%), and PCR was positive in 32 (91.4%) patients. The epidermal changes included acanthosis, pseudoepitheliomatous hyperplasia, ulceration, focal spongiosis, and interface dermatitis while the dermal changes were dependent on the spectrum of the disease, so in the ulcerative lesions there was lymphohistiocytic infiltration with foci of plasma cells and sometimes aggregate of LD bodies, whereas in the dry lesions the pathology is mainly of epithelioid granuloma. Panniculitis was seen in 16 (46%) cases as a diffuse lymphohistiocytic infiltration of both the septum and lobules of the subcutaneous layer of the skin. CONCLUSION: Panniculitis is an important feature of CL that must be differentiated from other diseases that can simulate CL such as chronic skin infections, Discoid lupus erythematosus, and cutaneous lymphoma.

The effect of temporary meiotic attenuation on the in vitro maturation outcome of bovine oocytes.

The aim of this study was to investigate the effect of delaying maturation by extended culture of immature bovine oocytes in prematuration medium (PMC) containing single maturation inhibitor on their meiotic resumption and embryonic development. Bovine immature oocytes were cultured in M199 containing 10 µM of either inhibitor (roscovitine, cilostamide, or forskolin) for either 72 or 120 h followed by up to 48 h in maturation media supplemented with 7.5 IU follicle-stimulating hormone (FSH)/luteinizing hormone (LH). Two control groups were used. In untreated control, immature oocytes were cultured in the same medium as the experimental group without any inhibitors. In the FSH/LH control group, oocytes were cultured directly in the maturation medium supplemented with FSH/LH up to 48 h. In vitro matured oocytes were then inseminated with frozen-thawed bull sperm. Fertilization, defined as two-cell division 48 h post-insemination, and blastocyst formation were recorded. Total maturation rate for the 72-h group was 73%, 70%, 66%, and 69% for roscovitine, forskolin, cilostamide, and FSH/LH control, respectively, with no significant difference indicating that inhibitors have no negative effect on the oocyte maturation rate. The total fertilization rate for the 72-h group revealed that cilostamide (47%) and roscovitine (35%) were significantly higher than FSH/LH control (20%). The total blastocyst formation rates per inseminated oocytes revealed that among treatment groups, roscovitine (20%) had significantly higher rate than forskolin (9%). Overall, 72-h exposure period had better outcomes than 120 h in all the treated groups. In conclusion, prematuration culture of the bovine oocytes in the presence of maturation inhibitor for 72-h period at 10 µM concentration is sufficient in improving the bovine oocyte developmental competence.

Helicobacter pylori, anemia, iron deficiency and thrombocytopenia among pregnant women at Khartoum, Sudan.

BACKGROUND: Helicobacter pylori is a common gut pathogen that is linked to many complications of pregnancy such as iron deficiency anemia, pre-eclampsia and thrombocytopenia. There are no published data on H. pylori in Sudan. METHODS: A cross-sectional study was conducted during the period May-June 2012 at the antenatal care unit of Khartoum Hospital, Sudan, to investigate prevalence of H. pylori and its association, if any, with anemia and thrombocytopenia. Obstetric and medical histories were gathered using questionnaires. Hemoglobin and serum ferritin were measured and H. pylori antibodies (IgA and IgG) investigated using ELISA. RESULTS: Among 179 women, rates of positivity for specific IgG formed against H. pylori were 69.8% (125/179), 94.0% (168/179) and 5.6% (10/179) for IgA, IgG and both IgG and IgA, respectively. There was no association between the expected risk factors (age, parity, education) and H. pylori seropositivity. Of these women, 42/179 (24.3%), 50/179 (28.9%) and 19/179 (11%), respectively, were anemic (hemoglobin <11 g/dl) or had iron deficiency (serum ferritin <15 µg/l) or iron deficiency anemia. There was no association between H. pylori infection and anemia (OR=1.0, 95% CI=0.3-3.2, p=1.0), iron deficiency (OR=0.6, 95% CI=0.1-3.8, p=0.367) or thrombocytopenia (OR=2.0, 95% CI=0.4-8.4, p=0.322). CONCLUSION: There is a high prevalence of H. pylori infection among pregnant women in Khartoum, Sudan, and it is not associated with anemia or thrombocytopenia.

Skin tumors and skin infections in kidney transplant recipients vs. patients with pemphigus vulgaris.

BACKGROUND: Pemphigus vulgaris is an autoimmune disease of the skin and mucous membrane. Renal transplantation is a common procedure in Iraq, and these patients required prolonged use of immunosuppressive drugs. OBJECTIVE: To study the frequency of skin tumors and infections in patients with pemphigus vulgaris compared with renal transplant recipients and normal controls. PATIENTS AND METHODS: One hundred kidney transplant recipients, their ages ranged from 14 to 70 (46.65 ± 4.74) years, and 50 patients with pemphigus vulgaris, their ages ranged from 22 to 70 (43.32 ± 3.46) years, were studied in Baghdad Hospital from June 2009 to August 2010. Patients were treated with immunosuppressive drugs for 0.5-25 years. Patients were examined for tumors and infections and compared with the general population as controls (100 individuals). RESULTS: In renal transplant recipients, the following infections were observed: herpetic, 25 patients (25%); bacterial, 11 (11%); and fungal, 22 (22%). These infections appeared early in the course of immunosuppression. Benign tumors increased, most importantly viral warts in 40 (40%) and actinic keratosis, 14 (14%). The malignant tumors were basal cell carcinomas in 4 (4%), squamous cell carcinomas 2 (2%), and Kaposi's sarcoma 3 (3%). These malignancies usually appeared late in the course of immunosuppression. Patients with pemphigus vulgaris showed no important skin infections or tumors. Healthy controls showed no infections apart from herpetic infections in 7 (7%) and viral warts in 9 (9%). No tumors were seen. CONCLUSIONS: Pemphigus vulgaris in prolonged immunosuppression is immunoprotective against skin infections and skin tumors while kidney transplant recipients are not protective.

The therapeutic role of isotretinoin in the management of Behçet's disease: a single-blinded, controlled therapeutic study.

OBJECTIVES: To evaluate the long-term remission efficacy and safety of isotretinoin in the treatment of Behcet's disease (BD). PATIENTS AND METHODS: This single-blind, controlled therapeutic study was conducted in the Department of Dermatology and Venereology at Baghdad Teaching Hospital from February 2011 to January 2012. Thirty patients with BD were included in this work. Each patient received isotretinoin 20 mg orally once daily for 3 months. They were assessed at week 2 and then monthly depending on the Clinical Manifestation Index (CMI) and to record any side effects. At week 12, isotretinoin was stopped and patients were given placebo therapy in a form of glucose capsules for another 3 months. RESULTS: Thirty patients were treated, 14 (46.6%) males and 16 (53.3%) females, with a male to female ratio of 1:1. Their ages ranged from 16 to 64 years (mean +/- standard deviation [SD], 38.4 +/- 10.9 years). During the first 3 months of therapy, the pathergy test, oral pathergy test, and C-reactive protein were significantly minimized. The CMI before isotretinoin therapy ranged between 2 and 8 (mean +/- SD, 4.933 +/- 1.91). After therapy, within the first 14 days, the mean CMI started to decline to a lower level, and it continued to decline significantly until week 12. It then started to increase through week 4 of placebo therapy, but remained statistically significant until the second month of placebo therapy. Isotretinoin therapy also had a statistically significant effect in reducing oral ulcers and skin manifestations. CONCLUSION: Isotretinoin is an effective therapeutic and prophylactic drug in the management of BD.

Melanocytes transplantation in patients with vitiligo using needling micrografting technique.

BACKGROUND: Some cases of vitiligo require melanocyte transplantation, but these surgical techniques have varying degrees of success. OBJECTIVES: To perform melanocytes transplantion in patients with vitiligo using a new needling micrografting technique. PATIENTS AND METHODS: This interventional case study took place at the Department of Dermatology and Venereology at Baghdad Teaching Hospital from December 2010 to September 2011. Twelve patients with vitiligo were included. A split-thickness skin graft was taken from the normal area and cut into micropieces ranging from 0.1 mm to 0.3 mm in diameter. The recipient area was anesthetized, and the micrografts were then implanted into the dermis using the needling technique. The number of implanted micrografts depended on the size of the recipient area. Follow-up was conducted every 2 weeks for the first month and then every 4 weeks for a further 16 weeks. RESULTS: The intake rate of grafting at week 2 ranged from 90% to 100%. The micrografts started producing noticeable pigmentation at week 2, and pigmentation was obvious at week 4. At week 8, the rate of pigmentation ranged from 10% to 90% (25.24%), and at week 16 it ranged from 10% to 100% (61.36%). CONCLUSION: This new approach to the treatment of vitiligo delivers rapid and satisfactory pigmentation.

Lactic Acid as a new therapeutic peeling agent in the treatment of lifa disease (frictional dermal melanosis).

BACKGROUND: Lifa disease (frictional dermal melanosis) is a common dermatological problem. Full strength lactic acid has been proved to be effective and safe peeling agent in the treatment of melasma. OBJECTIVE: To assess the effectiveness and the safety of lactic acid chemical peeling in the treatment of lifa disease. MATERIALS AND METHODS: This open label therapeutic trial was conducted in Department of Dermatology in Najaf and Baghdad Teaching Hospitals, from March 2007-October 2008. Full strength lactic acid (92%, pH 3.5) was used as a peeling agent. The treatment sessions were done every 2 weeks until the desired response was achieved (but not more than 6 sessions). The response to therapy was evaluated by objective and subjective methods. All patients were followed monthly for 3 months after the last treatment session. RESULTS: 52 patients with typical clinical features of lifa disease were included. All patients were slim with prominent bones and low body mass index, and gave history of using the lifa (washing agent) during bathing. The number of sessions ranged from 2-6 sessions. The pigmentation was improved in all patients as revealed by objective and subjective methods, and this response was statistically highly significant. No significant side effects were recorded in all treated patients. The improvement has been sustained without any obvious relapse throughout the follow-up period. CONCLUSION: Lactic acid peel is a new, non-costly mode of therapy in treating dermal melanosis in patients with lifa disease.

Panniculitis is an important feature of cutaneous leishmaniasis pathology.

Background. Cutaneous leishmaniasis is an inflammatory parasitic infection characterized by superficial and deep perivascular infiltration with or without granuloma formation. Clinical diagnosis usually requires seeing Leishmania bodies. Methods. We report two cases of cutaneous leishmaniasis with unusual histological finding of panniculitis. Case 1: a 36-year-old male presented with multiple ulcerative nodules involving the left leg for two months duration which was greatly responsive to antimony intralesional therapy. Case 2: A 45-year-old woman presented with painless nodules on her upper chest of a 10-week duration which were successfully treated with oral and topical zinc sulphate. Results. Diagnosis of both cases was confirmed by finding the Leishmania bodies with Gimesa stain in addition to the diffuse dermal inflammatory cellular infiltration of the dermis forming granulomatous dermatitis. Mixed cellular infiltration of lymphocytes, histiocytes, and plasma cells of the panniculus caused both septal and lobular panniculitis. Conclusion. Cutaneous leishmaniasis can cause panniculitis and this could be seen more commonly if deep biopsies were taken. So cutaneous leishmaniasis must be considered in evaluating pathology of panniculitis especially in endemic regions.