Laser therapy for genital lichen sclerosus: A systematic review of the current evidence base.

Background: Lichen sclerosus (LS) is a chronic, inflammatory dermatosis. Initial treatment with superpotent topical corticosteroids is the accepted and evidence-based first-line therapy. For those who do not respond after exclusion of other potentiating factors, the best second-line therapy is unclear. Laser therapy is an emerging treatment for genital LS and despite uncertain efficacy its use is gaining popularity in the private sector. Objectives: We aimed to review the effectiveness of laser therapy for genital LS in men, women and children. Methods: We conducted a systematic review of all primary studies reporting the use of laser in genital LS. Ovid MEDLINE, PubMed, Ovid Embase, Cochrane CENTRAL, Web of Science, CINAHL and PsycINFO were searched from inception to February 2021. The quality of the studies was assessed using the revised Cochrane risk-of-bias tool for randomized trials, ROBINS-I tool for non-randomized trials and Joanna Briggs Institute checklist for case studies. Results: A total of 24 studies, involving 616 adults, met inclusion criteria. These were six randomized controlled trials (RCTs), one non-randomized trial, nine single arm trials and eight case series. Where assessed, most studies suggest that laser therapy in patients with LS may improve symptoms, clinical signs, quality of life and sexual function. However, results were highly heterogeneous and methodological quality was very low, therefore meta-analysis was not possible. Conclusions: There is poor evidence to support the use of laser therapy for genital LS at present. Effectiveness of laser needs to be robustly investigated in well-conducted RCTs.

Dermatological games: Part 1. Original description and critique.

'Dermatological games' by J. A. Cotterill was a seminal article published in 1981, which attempted to explain the interaction between dermatologists and patients using Berne's game theory. In Part 1 of this series of two reviews, we review Cotterill's original list of games and how they applied to dermatology in the context of when they were written. We then critically appraise Cotterill's article and arguments. Although the article was deliberately provocative, we found Cotterill's arguments to be well-structured and logical, and the 'games' described are well-conceived. Cotterill's candid analysis of doctors' motivations and the potential impact on the patient is refreshing and insightful. It is striking that, 40 years on, many of the original 'games' described remain recognizable in current practice. In Part 2, a list of new 'games' that might be observed in modern dermatological practice is introduced. The relevance of Cotterill's paper and an explanation for why his educational article remains relevant to dermatology practice and training today is scrutinized in order to stimulate discussion, promote education and improve patient care.

Dermatological games: Part 2. What has changed 40 years on?

In this two-part report, we review and critically appraise 'Dermatological games' by J. A. Cotterill, a seminal article published in 1981, which attempted to explain the interaction between dermatologists and patients using Berne's game theory. Part 1 described and critically appraised the educational value of Cotterill's original list of games in relation to how they apply to dermatology practice. In Part 2, a list of new 'games' that might be observed in current dermatological practice is introduced. The relevance of Cotterill's paper and an explanation for why his article remains relevant to dermatology practice and training today is scrutinized, in order to stimulate discussion and improve patient care.

What's new in atopic eczema? An analysis of systematic reviews published in 2018. Part 1: prevention and topical therapies.

This review is part of a series of annual updates that summarize the evidence base for atopic eczema (AE). The aim is to provide a succinct guide for clinicians on the key findings from 14 systematic reviews on the prevention and topical treatment of AE published or indexed in 2018. Various supplements, including long-chain polyunsaturated fatty acids, vitamin D and the probiotic Lactobacillus rhamnosus GG, given prenatally and postnatally, have not been shown to prevent AE in infants, although mixed strains of probiotics may decrease the risk of AE if given to the mother during pregnancy and to the infant for the first 6 months of life. In the postnatal period, there is no evidence that hydrolysed formula, compared with cow's milk formula (CMF), reduces the risk of AE in partially breastfed infants. However, weak evidence suggests that a specific partially hydrolysed whey formula decreases the risk of AE compared with CMF. No specific skin practices can be recommended to reduce the eczema risk in healthy term babies. There is weak evidence of a low risk of reversible hypothalamic-pituitary-adrenal axis suppression following 2-4 weeks of treatment with low-potency topical steroids, and conflicting evidence as to whether bleach bathing affects skin flora or AE severity. A single study demonstrated that the topical Janus kinase inhibitor tofacitinib at 2% significantly reduces the Eczema Area and Severity Index compared with vehicle. Topical naltrexone cream 1% improves pruritus (measured using a visual analogue scale) by 30% more than placebo. There is weak evidence that topical alternative therapies, including antioxidants, micronutrients and some herbal medicines, may improve AE.

'Efficacy and safety of imiquimod 5% cream for basal cell carcinoma: a meta-analysis of randomized controlled trial': a critical appraisal.

AIM: Jia and He aimed 'to compare the efficacy and safety of imiquimod with other treatments in patients with basal cell carcinoma' (BCC). DESIGN AND INCLUSION CRITERIA: Meta-analysis of studies that included patients with histologically confirmed BCC treated with imiquimod 5% cream compared with all other treatments, including vehicle, excisional surgery, cryosurgery, fluorouracil and methyl aminolaevulinate photodynamic therapy. OUTCOMES: The main outcome measures included histological and composite clearance rates, success rates, complete response rates, tumour-free survival and adverse events. RESULTS: Thirteen studies with a total of 4265 patients were included in the review. Pooled analyses comparing imiquimod with all or any of the listed comparators, including vehicle, demonstrated higher histological clearance rates [risk ratio (RR) 9·28, 95% confidence interval (CI) 5·56-15·5; P < 0·001], higher composite clearance rates (RR 34·2, 95% CI 21·3, 55·1; P = 0·001), no significant difference in success rates (RR 0·98, 95% CI 0·89-1·08; P = 0·73), higher complete response rates (RR 3·15, 95% CI 1·55-6·38; P = 0·001), no significant difference in tumour-free survival (RR 1·15, 95% CI 0·98-1·35; P = 0·088) and increased incidence of adverse events (RR 2·00, 95% CI 1·39-2·88; P < 0·001). CONCLUSIONS: The authors state that 'imiquimod significantly exhibited benefit effect in improving the histological/composite clearance rates' compared with other treatments, and they suggest it could be used as the first-choice treatment for patients with BCC. COMMENT: The main concerns related to the article by Jia and He are that the research question is replicative, it makes little sense to combine all BCC types in a meta-analysis, and it also makes no sense to combine an active treatment against a combination of vehicle and other active treatments. There are also concerns about bias related to the use of the same study data more than once in a meta-analysis. Furthermore, we have identified an example of covert duplicate publication, which further compounds the profusion of misleading systematic reviews.

Contrast media and cutaneous reactions. Part 2: Delayed hypersensitivity reactions to iodinated contrast media.

Contrast media (CM) are an indispensable part of modern medical imaging. Adverse reactions to CM are uncommon, but frequently involve cutaneous symptoms. This two-part article reviews adverse events secondary to CM that are relevant to the practising dermatologist. Part 1 covers the classification of CM, immediate hypersensitivity reactions to CM and the newly described condition, gadolinium deposition disease. Given that there has only been two case reports to our knowledge of a delayed adverse reaction to gadolinium-based CM, this second part will focus on cutaneous delayed reactions caused by iodinated CM (ICM). Delayed hypersensitivity reactions to ICM commonly present as maculopapular exanthems, but more rarely, they can manifest as fixed drug eruptions, acute generalized exanthematous pustulosis, drug-related eosinophilia and systemic symptoms, Stevens-Johnson syndrome/toxic epidermal necrolysis, symmetrical drug-related intertriginous and flexural exanthema, graft-versus-host disease, vasculitis and iododerma. Delayed reactions to ICM may be underdiagnosed, as cutaneous symptoms may be attributed to oral medications, particularly if patients are on multiple drugs.

Contrast media and cutaneous reactions. Part 1. Immediate hypersensitivity reactions to contrast media and gadolinium deposition.

Contrast media (CM) are commonly used worldwide to enhance the quality of imaging, which is invaluable for diagnostic accuracy. Adverse reactions to CM are uncommon, but frequently involve cutaneous symptoms. This two-part article reviews adverse events secondary to CM that are relevant to the practising dermatologist. Part 1 will classify CM, address immediate hypersensitivity reactions and review the newly described condition, gadolinium deposition disease. Part 2 will cover the delayed hypersensitivity reactions of iodinated contrast medium including severe cutaneous adverse reactions and iododerma.

Intermediate and long-term outcomes following uterine artery fibroid embolization.

OBJECTIVE: To assess patients' satisfaction and the intermediate and long-term patterns of symptom progression following uterine artery fibroid embolization (UAE). STUDY DESIGN: Intermediate (2-6 years) and long-term (9-14 years) follow-up questionnaire survey to women who underwent UAE during the period 1996-2000, at a tertiary referral centre. RESULTS: The mean (SD) age of women at the time of embolization was 43 (5.58) years. A total of 142/197 (72.1%) women had the embolization in view of heavy menstrual periods, while 87/197 (44%) indicated a desire to retain fertility. 160/197 (81.7%) women who completed Q1 reported an improvement in menstrual symptoms compared to 41/80 (51.2%) for Q2 [p<0.01]. The majority indicated they would recommend the procedure to a friend (Q1: 165 (83.8%), Q2: 62/80 (77.5%)) [p=0.75]. 23/80 (28.8%) required further surgical treatment following UAE, and within the latter group, only 7/23 (30.4%) were satisfied with the embolization. 22/80 (27.5%) tried for a pregnancy following the procedure, and of these 3/22 (13.6%) had a live birth. The mean (SD) age at the menopause for women who returned Q2 was 49.1 (4.91) years. CONCLUSIONS: The majority of women were satisfied with the embolization and noted an improvement in menstrual symptoms. However, this improvement diminished over time following the embolization, and over a quarter of women required further surgical intervention. Findings from this study may provide useful information in counselling women undergoing UAE and help guide clinicians in their patient selection criteria when discussing the procedure.

Febrile neutropaenia and chemotherapy discontinuation in women aged 70 years or older receiving adjuvant chemotherapy for early breast cancer.

AIMS: Low rates of adjuvant chemotherapy use are frequently reported in older women with early breast cancer. One of the reasons for this may be the risk of febrile neutropaenia or the perception that older patients will probably not complete the chemotherapy course prescribed. There are no data regarding these adverse outcomes in routine clinical practice. PATIENTS AND METHODS: We identified 128 patients aged 70 years or over who received neoadjuvant or adjuvant chemotherapy for early breast cancer in seven UK cancer centres between 2006 and 2012. Data were collected regarding standard clinical and pathological variables and treatment toxicity and outcomes. RESULTS: Twenty-four patients (19%) had an episode of febrile neutropaenia. Overall, 27 patients (21%) did not complete their planned therapy. Chemotherapy discontinuation was more common in those patients with an episode of febrile neutropaenia (46% versus 16%, P = 0.004). Thirty patients (23%) were admitted with chemotherapy-related complications. There were no treatment-related deaths. CONCLUSIONS: The rates of febrile neutropaenia and treatment discontinuation are high in women aged 70 years or over receiving adjuvant chemotherapy for breast cancer. Close attention should be paid to the choice or regimen and the use of supportive therapies in this patient population.

Development and validation of a blinded hybrid device according to the European Hypertension Society protocol: Nissei DM-3000.

Both automated and auscultatory blood pressure (BP) devices have their strengths and accuracy limitations. Hybrid devices, such as the Nissei DM-3000, are mercury free and provide both automated and auscultatory measurement modes. The aim of this study was to validate all measurement modes of the Nissei DM-3000 device according to the European Society of Hypertension (ESH) protocol, as well as to develop and validate a 'blinded' auscultatory measurement mode. Different measurement modes were developed and evaluated in separate studies. Nine sequential same-arm BP measurements were taken alternating between simultaneous mercury sphygmomanometer readings and the device. The latter seven measurements were analysed according to the requirements of the ESH protocol. All measurement modes of the device passed the ESH protocol. The blinded mode achieved the best results with a mean difference+/-s.d. of -0.1+/-2.6 and 0.04+/-2.4 mm Hg for systolic BP (SBP) and diastolic BP (DBP), respectively. The most accurate auscultatory measurement results were obtained with a deflation rate of 2.5 mm Hg s(-1) achieving a mean difference+/-s.d. of -0.6+/-4.4 (for SBP) and -1.4+/-2.8 mm Hg (for DBP). The automated mode achieved a mean difference+/-s.d. of -0.8+/-6.0 (SBP) and 0.8+/-4.8 mm Hg (DBP). The Nissei DM-3000 device is a suitable replacement for the mercury sphygmomanometer.

The role of co-mothers in planned lesbian-led families.

Summary The present study examined the role of co-parents in children's lives by comparing the role of co-mothers in 15 British lesbian mother families with the role of resident fathers in two different groups of heterosexual families (43 families where the study-child was conceived through donor insemination, and 41 families where the child had been naturally conceived). Birth mothers in all three types of family were administered a semi-structured interview to assess the quality of family relationships. Questionnaire data on stress associated with parenting were obtained from co-mothers and fathers, and the children were administered the Family Relations Test. The results indicated that co-mothers played a more active role in daily caretaking than did most fathers. However, father-child and co-mother-child relationships were found to be equally warm and affectionate in all three groups and no group differences were found for children's scores on the Family Relations Test or co-mothers/fathers' scores on the Parenting Stress Index.

Children raised in fatherless families from infancy: family relationships and the socioemotional development of children of lesbian and single heterosexual mothers.

The aim of the study was to investigate family functioning and the psychological development of children raised in fatherless families from their first year of life. Thirty lesbian mother families and 42 families headed by a single heterosexual mother were compared with 41 two-parent heterosexual families using standardised interview and questionnaire measures of the quality of parenting and the socioemotional development of the child. The results show that children raised in fatherless families from infancy experienced greater warmth and interaction with their mother, and were more securely attached to her, although they perceived themselves to be less cognitively and physically competent than their peers from father-present families. No differences were identified between families headed by lesbian and single heterosexual mothers, except for greater mother-child interaction in lesbian mother families.

Adults raised as children in lesbian families.

A longitudinal study of 25 young adults from lesbian families and 21 raised by heterosexual single mothers revealed that those raised by lesbian mothers functioned well in adulthood in terms of psychological well-being and of family identity and relationships. The commonly held assumption that lesbian mothers will have lesbian daughters and gay sons was not supported by the findings.

Colorectal cancer and cardiac risk reduction using computer-assisted dietary counseling in a low-income minority population.

Three nurses offered computer-assisted 24-hour dietary analysis to patients waiting to see their physicians in a general medicine clinic in a public hospital. The nurses showed the participants their results, recommended food substitutions, and suggested reevaluation of the patients' diets at their next scheduled clinic visit. Follow-up data showed a decrease in fat, dietary cholesterol, kilocalories, and weight, and an increase in dietary fiber. This article discusses the use of this and other interventions to assist low-income minority patients in understanding and complying with dietary recommendations that promote cardiovascular health and decrease the risk of developing colorectal cancer.