Self-induced panniculitis in adolescence: Three cases and review of the literature.

Self-induced trauma is a rare cause of panniculitis in adolescents and may be associated with undiagnosed underlying psychological conditions. The condition often poses a diagnostic challenge as patients usually present with non-specific signs and symptoms, and often a concealed history of self-induced trauma. Here, we present three adolescent patients with self-induced traumatic panniculitis. All three patients were repeatedly admitted with non-specific cutaneous lesions as well as multiple somatic complaints. After extensive evaluation to exclude organic causes, psychiatric assessment eventually revealed underlying psychosomatic disorders as a cause of the self-induced trauma.

An evaluation of concordance between head and neck advanced practice radiation therapist and radiation oncologists in toxicity assessment for nasopharyngeal carcinoma patients.

BACKGROUND: Weekly toxicity assessments for patients undergoing head and neck (HN) radiotherapy are essential to ensure that acute side effects are appropriately managed in order for patients to complete their treatment in a safe and timely manner. The incorporation of Advanced Practice Radiation Therapist (APRT) led treatment reviews has been reported for various subsites, but there is currently a lack of published literature regarding this role for patients with HN cancer. The purpose of this study is to assess the concordance of toxicity assessments performed during weekly radiotherapy treatment reviews for patients undergoing HN radiotherapy between the HN APRT and Radiation Oncologist (RO). METHODS: Twenty-three patients with nasopharyngeal cancer (NPC) under the care of 3 ROs were recruited from June to December 2018; weekly assessments were independently performed by HN APRT and ROs. The HN toxicity assessment was graded according to the Common Terminology Criteria for Advanced Events v4.0. Both assessors were blinded to each other's assessments. The percentage agreement of concordance and agreement level were interpreted by Cohen's Kappa statistic (κ), with the ROs' assessments deemed as the 'gold standard'. RESULTS: The overall concordance for all graded toxicity assessments between HN APRT and ROs was 78.4%. Xerostomia, dysgeusia, pharyngeal pain and dermatitis assessment were evaluated as 'Good' with agreement ranging from κ = 0.608-0.640 between the HN APRT and ROs while dysphagia scored an 'Almost Perfect' agreement of κ = 0.834. 'Moderate' agreement between the HN APRT and ROs was observed for oral pain and mucositis assessment. A scoring discrepancy of 1 and 2 grades was observed in 21.2% and 0.4% for these two toxicities. CONCLUSION:  There was high concordance in scoring of acute toxicity between the HN APRT and ROs. The results support the continuing involvement of HN APRT in weekly assessments for NPC patients.

The implementation of an advanced practice radiation therapy (APRT) program in Singapore.

BACKGROUND: The exploration of Advanced Practiced Radiation Therapists (APRTs) development in Singapore started in 2011. This study aims to provide an overview of the development of the APRT roles, and to discuss the approaches used to develop and implement these roles in Singapore. MATERIALS AND METHODS: A mixed methods approach was used in the development of the APRT program. A literature review was carried out to define the APRT scope of practice and core responsibilities. A competency and assessment framework were setup to assess the core competency areas. With this framework, a structured 1-year residency training program was developed. RESULTS: The scope of practice and core responsibilities of APRTs were defined with five proposed advanced practice profiles being successfully validated. A competency framework was set up to assess the core competency domains: clinical, technical and professional competencies, research, education and leadership. A 4-point scoring system was developed for the competency assessment based on two criteria; the frequency with which RTTs would demonstrate competency, and the ability of performing the task competently. A 1-year structured APRT residency program was developed and implemented. The programme consisted of structured lectures, and clinical practice-based modules where APRT residents receive structured mentoring under a mentorship program. CONCLUSION: The APRT program in Singapore employed an evidence-based implementation process that tested the feasibility of a new practice model. Multidisciplinary involvements, mentorship and clinical training were important factors for the success of the APRT program.

The role of breath hold intensity modulated proton therapy for a case of left-sided breast cancer with IMN involvement. How protons compare with other conformal techniques?

PURPOSE: To evaluate the dosimetric impact of four different radiotherapy techniques for a case of left-sided breast cancer with Internal Mammary lymph Nodes (IMN) involvement. MATERIALS AND METHODS: To identify the best radiotherapy technique for this patient, four methods were compared: 3D Conformal Radiotherapy (3D-CRT), Volumetric Modulated Arc Therapy (VMAT), Tomotherapy (TOMO) and Intensity Modulated Proton Therapy (IMPT). Patient was treated using deep inspiration breath-hold (DIBH) technique. Prescribed dose was 40.05y in 15 fractions. Plan evaluation was performed on target coverage and dose to the organs-at-risk (OARs) using 3D-CRT as a baseline. RESULTS: TOMO has the most ideal Conformity Index (CI) at 1.139, followed by IMPT at 1.158, VMAT at 0.765, and 3D-CRT at 0.685. Using 3D-CRT as a baseline, VMAT, TOMO and IMPT all showed improved dose coverage. IMPT has the best dose coverage. TOMO has the most ideal homogeneity index (HI) and Conformity Number (CN). Mean heart dose (MHD) is lowest for IMPT at 0.55 Gy and highest for VMAT at 4.79 Gy. V20Gy of left lung is the lowest for IMPT at 11.11%, compared to 17.53% for TOMO, 18.19% for VMAT and 33.33% for 3D-CRT. V5Gy for the contralateral breast ranges from 0.01% in IMPT to 72.32% in TOMO. CONCLUSION: 3D-CRT compromising target coverage but achieving good OAR sparing for the contralateral right breast, left lung and right lung. Overall, IMPT performed best in terms of target coverage and OAR-sparing. Protons delivered superior target dose coverage and sparing of normal structures for this patient. As dose value parameters are expected to correlate with acute and chronic toxicities, proton therapy should be given due consideration as the preferred technique for the treatment of left-sided breast cancers with IMN involvement. Further studies with more patients can be done to evaluate the effectiveness of proton therapy on acute and chronic toxicities.

Rumpel-Leede Phenomenon-An alarming rash with benign etiology in 4 healthy infants.

The Rumpel-Leede phenomenon (RLP) is a rare clinical presentation and in some cases shown to be related to serious systemic conditions. In children, it has been described in association with idiopathic thrombocytopenic purpura and Henoch-Schönlein purpura. We present a series of pediatric cases of RLP with mechanical etiologies that had a benign course. We propose minimal investigations for pediatric RLP cases who are systemically well and have a clear suggestive history of a mechanical cause.

The effects of Tel2 on cardiomyocyte survival.

AIMS: Overexpression of the mechanistic target of rapamycin (mTOR), a member of the PIKK (phosphoinositide kinase-related kinase) family, protects cardiomyocytes from cell death induced by pathological stimuli such as ischemia. We previously reported that posttranslational modification of mTOR plays an important role in regulating cardiac mTOR expression. The aim of this study was to see if Tel2 (telomere maintenance 2), a protein that regulates the abundance of PIKKs, confers similar cardioprotective effects as mTOR. Tel2 is not well-characterized in cardiomyocytes, therefore we examined the effects of Tel2 on cardiomyocyte viability under ischemic stress conditions. MATERIALS AND METHODS: We overexpressed Tel2 or silenced Tel2 with siRNA in the HL-1 cardiomyocyte cell line to survey the effects of Tel2 overexpression and downregulation on cell survival during hypoxia. Adult mouse cardiomyocytes transfected with Tel2 adenoviruses were used to test whether Tel2 sufficiently prevented cardiomyocyte cell death against hydrogen peroxide (H2O2). KEY FINDINGS: Overexpressing Tel2 increased mTOR expression with a concomitant increase in mTOR Complex 1 (mTORC1) and mTORC2 activity in HL-1 cells. Tel2 deletion decreased mTOR expression, and mTORC1 and mTORC2 activity accordingly. In both HL-1 cells and adult mouse cardiomyocytes, Tel2 overexpression protected cardiomyocytes under ischemic stress. These effects were mTOR-dependent, as mTOR inhibitors blunted the effects of Tel2. While gene silencing of Tel2 did not affect cell survival under normoxia, Tel2 silencing made cardiomyocytes more vulnerable to cell death under hypoxia. SIGNIFICANCE: Upregulating Tel2 expression increases mTOR-mediated cardiomyocyte survival and targeting Tel2 could be another therapeutic strategy against ischemic heart disease.

Drug reaction with eosinophilia and systemic symptoms in a cohort of Asian children.

BACKGROUND/OBJECTIVES: Drug reaction with eosinophilia and systemic symptoms (DRESS) is rare but potentially fatal in children. Fever and rash, which are salient features of DRESS, may mimic other commonly encountered pediatric conditions. We profiled the DRESS cases in a tertiary children's hospital in Singapore. METHODS: The medical records of all pediatric DRESS patients diagnosed from 2006 to 2016. Data on epidemiology, inciting drugs, clinical, pathologic manifestations, and treatment were assessed. RESULTS: Ten patients aged 4-16 years old were diagnosed with DRESS within the 10-year period. Drugs implicated were antibiotics, such as trimethoprim-sulfamethoxazole, and anticonvulsants, such as carbamazepine, phenobarbitone, and levetiracetam. All patients had fever and pruritic exanthems. Desquamation, purpura, and oral mucositis were also observed. Lymphadenopathy, hepatomegaly, and facial edema occurred frequently. There was liver involvement in all cases, but none progressed to liver failure. Seven patients had eosinophilia, and nine had atypical lymphocytosis. Other laboratory abnormalities included low hemoglobin, thrombocytosis, and prolonged coagulation times. All patients received systemic corticosteroids of varying durations and dosages. Systemic steroids were weaned after 19 days to 4 months. Disease resolution, with liver enzyme levels returning to normal, occurred within 28-90 days. One patient developed TSH-receptor-antibody-positive hyperthyroidism 6 months after the onset of DRESS, while another patient developed chronic urticaria 4 months after resolution of DRESS. CONCLUSION: Early recognition of DRESS is important to ensure that the inciting drug is discontinued, and supportive treatment started expediently. Liver involvement was very common but responded well to systemic steroids.

Intensity-modulated radiotherapy for whole pelvis irradiation in prostate cancer: A dosimetric and plan robustness study between photons and protons.

PURPOSE: To evaluate the dosimetric impact and plan robustness of using Pencil Beam Scanning (PBS) in patients that requires prophylactic pelvic lymph nodes (PLNs) irradiation for prostate cancer. MATERIAL AND METHODS: Five intermediate to high-risk prostate patients previously treated using volumetric modulated arc therapy (VMAT), were selected for this study. Comparative proton radiotherapy plans were generated, where a three-field intensity modulated proton therapy (IMPT) plan was for the phase 1 planning target volume (PTV1) with PLNs. A technique with two posterior oblique fields using single field uniform dose (SFUD) was used for phase 2 (PTV2) volume, that comprises of the prostate and proximal seminal vesicles (Pro + proxSVs). Plan evaluation was performed on PTV coverage and dose to the organs at risk (OARs) using VMAT plans as a baseline (BL). Robust analysis on clinical target volume (CTV) coverage for the PBS plans was simulated with a 3 and 5 mm setup errors and a 3.5% range uncertainty. RESULTS: For target coverage, PTV1 and PTV2 showed negligible differences with a comparable homogeneity index (HI) values for both modalities. Proton plans produced a statistically significant lower mean dose to the bladder (32.5 Gy(RBE) vs. 46.5 Gy) and rectum (33.6 Gy(RBE) vs. 42.7 Gy). Dose to the bladder and rectum was equivalent at the high dose region. For the bowel cavity, the mean dose for proton plans were 45% lower compared to VMAT plans. Similarly, proton plans were able to achieve an overall reduction in integral dose for both treatment phase. CTV coverage remained high with all the simulated setup and range errors. CONCLUSIONS: Proposed beam geometries for PTV1 and PTV2 proton plans presented good treatment accuracy with similar target coverage as the VMAT plans. Better sparing of OARs was achieved at the low-medium dose region for the proton plans.