Superficial Acral Fibromyxoma on the Thumb-Nail Bed.

Superficial acral fibromyxoma, also known as digital fibromyxoma, is a benign soft tissue tumor. The acral regions, including the palms, soles, fingers, toes, and nail units, are the commonly affected locations. The subungual region of the great toe is the most common site reported in current literature. The tumor is slowly progressive and benign in nature. Histology commonly reveals a fibromyxoid neoplasm with immunoreactivity to CD34 and CD99 markers.1,2,3 We present the case of a 39-year-old female with a nine-year history of repetitive digital trauma presenting with superficial acral fibromyxoma of the thumb-nail bed. Our case is unique due to the tumor location and the patient's prior long history of trauma to the tumor site.

Nonmelanoma skin cancer in the setting of erosive pustular dermatosis of the scalp: A case series and comment on management implications.

BACKGROUND: Erosive pustular dermatosis of the scalp (EPDS) is an inflammatory cutaneous disorder typically affecting sun-damaged skin of mature individuals. Clinical features of EPDS include sterile pustules and chronic crusted erosions that can be hyperkeratotic and lead to scarring alopecia, atrophy, and telangiectasia. While the condition occurs on sun-damaged skin, a relationship with non-melanoma skin cancer (NMSC) has not been investigated. OBJECTIVES: Here we attempted to identify cases of NMSC developing in the setting of EPDS. METHODS: Retrospective review of EPDS cases in a dermatology practice. RESULTS: Six patients with mean (range) age 82 (65-92) years that developed NMSC in the setting of EPDS are reported. Five patients had skin phototype I or II associated with substantial solar elastosis. Four patients had history of NMSC. Four patients developed squamous cell carcinoma and two patients basal cell carcinoma on the scalp in the setting of EPDS. A morphologic change in an EPDS lesion, such as a crusted plaque becoming nodular and/or growing significantly within a relatively short period of time, prompted a biopsy that revealed NMSC. CONCLUSIONS: NMSC may develop in the setting of EPDS. Possible mechanisms underlying this association include the chronic inflammation associated with EPDS and ultraviolet light exposure. It is crucial to promptly obtain a biopsy in EPDS cases showing signs suspicious for NMSC. Further studies are required to confirm whether NMSC shows a higher prevalence in the setting of EPDS.

Collapsing FSGS with Concurrent Class 2 and 3 Lupus Nephritis: A Case Report and Review of the Literature.

Lupus nephritis (LN) and the collapsing variant of focal segmental glomerulosclerosis (cFSGS) are separate histologic diagnoses that are generally thought to have separate etiologies. We describe the presentation of a 20-year-old African American female with advanced renal failure (creatinine 7.16 mg/dL), nephrotic-range proteinuria, and a 30-pound weight loss. Renal biopsy demonstrated class 2 and 3 LN as well as cFSGS. A review of the current literature demonstrates that the dual diagnosis of LN and cFSGS may not be as rare as previously understood. Whether the presence of one of these pathophysiologic processes predisposes a patient to the development of the other, or whether genetic variation increases the risk for development of both conditions, remains unclear. Currently there is no standard therapy to manage these patients, and overall renal prognosis is poor.

The Effect of a Student Pharmacist Directed Health-Education Program for Elementary-School Children.

OBJECTIVE: The primary objective of this study was to measure the effect of an annual student pharmacist led elementary-school health education program by assessing children's comprehension of educational sessions. Secondary objectives were to evaluate student pharmacists' knowledge of health-related topics and practice skills. METHODS: Student pharmacists led interactive learning sessions for elementary school students on nutrition, physical activity, summer safety, hygiene, medication safety, and tobacco prevention. Pre- and post-intervention surveys were administered to measure change in knowledge of health promotion and healthy lifestyles. Student pharmacists also completed pre- and post-health education intervention surveys to measure change in self-perception of knowledge, confidence, and practice application of health-related topics and practice skills. RESULTS: Three-hundred and four elementary school children participated in the study with significant knowledge improvements observed in medication safety and tobacco prevention. Twenty-five student pharmacists completed surveys, resulting in a collective self-improvement in each area measured. CONCLUSION: Interactive educational sessions led by student pharmacists have a positive impact on elementary school children's knowledge. Student pharmacists also demonstrated professional growth through increased knowledge, confidence, and communication skills in interacting with pediatric populations. PRACTICE IMPLICATION: A co-curricular educational activity allowed student pharmacists to promote health and wellness to elementary students, a Healthy People 2020 goal, while also providing an opportunity to develop professional skills for future practice with pediatric patients.

Bartonella Endocarditis Mimicking Crescentic Glomerulonephritis with PR3-ANCA Positivity.

Bartonella henselae is a fastidious organism that causes cat scratch disease, commonly associated with fever and lymphadenopathy but, in rare instances, also results in culture-negative infectious endocarditis. We describe a patient who presented with flank pain, splenic infarct, and acute kidney injury with an active urinary sediment, initially suspicious for vasculitis, which was subsequently diagnosed as B. henselae endocarditis. Bartonella endocarditis may present with a crescentic glomerulonephritis (GN) and elevated PR3-ANCA antibody titers, mimicking ANCA-associated GN, with 54 cases reported in the literature. Unique to our case in this series is a positive PR3-ANCA antibody despite a negative IIF-ANCA. Thus, the presentation of Bartonella can mimic ANCA-associated GN, and renal biopsy showing immune complex deposition is critical for diagnosis and appropriate treatment.

Costs and effectiveness of pharmacist-led group medical visits for type-2 diabetes: A multi-center randomized controlled trial.

OBJECTIVES: The effectiveness and costs associated with addition of pharmacist-led group medical visits to standard care for patients with Type-2 Diabetes Mellitus (T2DM) is unknown. METHODS: Randomized-controlled-trial in three US Veteran Health Administration (VHA) Hospitals, where 250 patients with T2DM, HbA1c >7% and either hypertension, active smoking or hyperlipidemia were randomized to either (1) addition of pharmacist-led group-medical-visits or (2) standard care alone for 13 months. Group (4-6 patients) visits consisted of 2-hour, education and comprehensive medication management sessions once weekly for 4 weeks, followed by quarterly visits. Change from baseline in cardiovascular risk estimated by the UKPDS-risk-score, health-related quality-of-life (SF36v) and institutional healthcare costs were compared between study arms. RESULTS: After 13 months, both groups had similar and significant improvements from baseline in UKPDS-risk-score (-0.02 ±0.09 and -0.04 ±0.09, group visit and standard care respectively, adjusted p<0.05 for both); however, there was no significant difference between the study arms (adjusted p = 0.45). There were no significant differences on improvement from baseline in A1c, systolic-blood-pressure, and LDL as well as health-related quality-of-life measures between the study arms. Compared to 13 months prior, the increase in per-person outpatient expenditure from baseline was significantly lower in the group visit versus the standard care arm, both during the study intervention period and at 13-months after study interventions. The overall VHA healthcare costs/person were comparable between the study arms during the study period (p = 0.15); then decreased by 6% for the group visit but increased by 13% for the standard care arm 13 months post-study (p<0.01). CONCLUSIONS: Addition of pharmacist-led group medical visits in T2DM achieved similar improvements from baseline in cardiovascular risk factors than usual care, but with reduction in the healthcare costs in the group visit arm 13 months after completion compared to the steady rise in cost for the usual care arm. TRIAL REGISTRATION: NCT00554671 ClinicalTrials.gov.

Parallel Pbx-Dependent Pathways Govern the Coalescence and Fate of Motor Columns.

The clustering of neurons sharing similar functional properties and connectivity is a common organizational feature of vertebrate nervous systems. Within motor networks, spinal motor neurons (MNs) segregate into longitudinally arrayed subtypes, establishing a central somatotopic map of peripheral target innervation. MN organization and connectivity relies on Hox transcription factors expressed along the rostrocaudal axis; however, the developmental mechanisms governing the orderly arrangement of MNs are largely unknown. We show that Pbx genes, which encode Hox cofactors, are essential for the segregation and clustering of neurons within motor columns. In the absence of Pbx1 and Pbx3 function, Hox-dependent programs are lost and the remaining MN subtypes are unclustered and disordered. Identification of Pbx gene targets revealed an unexpected and apparently Hox-independent role in defining molecular features of dorsally projecting medial motor column (MMC) neurons. These results indicate Pbx genes act in parallel genetic pathways to orchestrate neuronal subtype differentiation, connectivity, and organization.

Molecular Mechanisms of Malignant Transformation by Low Dose Cadmium in Normal Human Bronchial Epithelial Cells.

Cadmium is a carcinogenic metal, the mechanisms of which are not fully understood. In this study, human bronchial epithelial cells were transformed with sub-toxic doses of cadmium (0.01, 0.05, and 0.1 µM) and transformed clones were characterized for gene expression changes using RNA-seq, as well as other molecular measurements. 440 genes were upregulated and 47 genes were downregulated in cadmium clones relative to control clones over 1.25-fold. Upregulated genes were associated mostly with gene ontology terms related to embryonic development, immune response, and cell movement, while downregulated genes were associated with RNA metabolism and regulation of transcription. Several embryonic genes were upregulated, including the transcription regulator SATB2. SATB2 is critical for normal skeletal development and has roles in gene expression regulation and chromatin remodeling. Small hairpin RNA knockdown of SATB2 significantly inhibited growth in soft agar, indicating its potential as a driver of metal-induced carcinogenesis. An increase in oxidative stress and autophagy was observed in cadmium clones. In addition, the DNA repair protein O6-methylguanine-DNA-methyltransferase was depleted by transformation with cadmium. MGMT loss caused significant decrease in cell viability after treatment with the alkylating agent temozolomide, demonstrating diminished capacity to repair such damage. Results reveal various mechanisms of cadmium-induced malignant transformation in BEAS-2B cells including upregulation of SATB2, downregulation of MGMT, and increased oxidative stress.

Promoting Safe Use of Medications: Providing Medication Education to Seniors Receiving Meals on Wheels.

STUDY OBJECTIVES: To assess whether pharmacist-provided medication education and counseling to Meals on Wheels (MOW) participants decreases medication-related preventable harm and improves adherence. DESIGN: Prospective, quasi-experiment. SETTING: Ambulatory congregrate dining centers. PATIENTS: Persons 60 years of age and older participating in MOW receiving prescription, nonprescription, or complementary products were eligible. In total, 42 patients consented. Five patients did not complete the first visit, and 13 patients did not complete the six-month follow-up visit. INTERVENTIONS: Pharmacists provided comprehensive medication education about prescription, nonprescription, and complementary products at baseline. Additional resources to enhance adherence and avoid medication-related preventable harm were provided and discussed. MAIN OUTCOME MEASURES: Medication-related preventable harm and medication adherence were assessed before pharmacist intervention and six months after intervention. Adherence was assessed and compared with baseline using the Morisky scale and pill counts. RESULTS: Women constituted the majority of participants (94.4%) with an average age of 74.5 ± 8.2 years. Mean difference in Morisky score from baseline to six months was 0.28 (-0.11 to 0.56). After adjustment for age and living situation, the change in Morisky score was associated with a 14% improvement in adherence. Mean differences in drug-drug and drug-supplement interactions, and medication-related harm were not significantly reduced from baseline to study end. CONCLUSION: Pharmacist intervention with MOW participants appeared to improve medication adherence rates but had limited effect on medication-related preventable harm. No findings reached statistical significance as the sample size was inadequate. Larger studies are needed to confirm these findings.

Metagenomics reveals sediment microbial community response to Deepwater Horizon oil spill.

The Deepwater Horizon (DWH) oil spill in the spring of 2010 resulted in an input of ∼4.1 million barrels of oil to the Gulf of Mexico; >22% of this oil is unaccounted for, with unknown environmental consequences. Here we investigated the impact of oil deposition on microbial communities in surface sediments collected at 64 sites by targeted sequencing of 16S rRNA genes, shotgun metagenomic sequencing of 14 of these samples and mineralization experiments using (14)C-labeled model substrates. The 16S rRNA gene data indicated that the most heavily oil-impacted sediments were enriched in an uncultured Gammaproteobacterium and a Colwellia species, both of which were highly similar to sequences in the DWH deep-sea hydrocarbon plume. The primary drivers in structuring the microbial community were nitrogen and hydrocarbons. Annotation of unassembled metagenomic data revealed the most abundant hydrocarbon degradation pathway encoded genes involved in degrading aliphatic and simple aromatics via butane monooxygenase. The activity of key hydrocarbon degradation pathways by sediment microbes was confirmed by determining the mineralization of (14)C-labeled model substrates in the following order: propylene glycol, dodecane, toluene and phenanthrene. Further, analysis of metagenomic sequence data revealed an increase in abundance of genes involved in denitrification pathways in samples that exceeded the Environmental Protection Agency (EPA)'s benchmarks for polycyclic aromatic hydrocarbons (PAHs) compared with those that did not. Importantly, these data demonstrate that the indigenous sediment microbiota contributed an important ecosystem service for remediation of oil in the Gulf. However, PAHs were more recalcitrant to degradation, and their persistence could have deleterious impacts on the sediment ecosystem.

The impact of chlorinated solvent co-contaminants on the biodegradation kinetics of 1,4-dioxane.

1,4-Dioxane (dioxane), a probable human carcinogen, is used as a solvent stabilizer for 1,1,1-trichloroethane (TCA) and other chlorinated solvents. Consequently, TCA and its abiotic breakdown product 1,1-dichloroethene (DCE) are common co-contaminants of dioxane in groundwater. The aerobic degradation of dioxane by microorganisms has been demonstrated in laboratory studies, but the potential effects of environmentally relevant chlorinated solvent co-contaminants on dioxane biodegradation have not yet been investigated. This work evaluated the effects of TCA and DCE on the transformation of dioxane by dioxane-metabolizing strain Pseudonocardia dioxanivorans CB1190, dioxane co-metabolizing strain Pseudonomas mendocina KR1, as well as Escherichia coli expressing the toluene monooxygenase of strain KR1. In all experiments, both TCA and DCE inhibited the degradation of dioxane at the tested concentrations. The inhibition was not competitive and was reversible for strain CB1190, which did not transform the chlorinated solvents. For both strain KR1 and toluene monooxygenase-expressing E. coli, inhibition of dioxane degradation by chlorinated solvents was competitive and irreversible, and the chlorinated solvents were degraded concurrently with dioxane. These data suggest that the strategies for biostimulation or bioaugmentation of dioxane will need to consider the presence of chlorinated solvents during site remediation.

Primary cutaneous amyloidosis of the external ear: a clinicopathological and immunohistochemical study of 17 cases.

Primary cutaneous amyloidosis includes several forms of localized amyloidosis characterized by superficial amyloid deposits occurring at or near the dermal-epidermal junction in the absence of systemic involvement. Primary cutaneous amyloidosis of the auricular concha and external ear represents a rarely described variant. There have been 27 cases reported in the English language literature, and herein we report 17 additional cases. This article demonstrates that the amyloid observed in this context is generally positive for Congo red, crystal violet and thioflavin T. It also expresses cytokeratin 34ßE12 via immunohistochemistry. Our immunohistochemical results and review of the literature suggest that the amyloid in amyloidosis of the external ear is the result of basal keratinocyte degeneration and does not signify deposition from a systemic or generalized process.

Pharmacist-led shared medical appointments for multiple cardiovascular risk reduction in patients with type 2 diabetes.

PURPOSE: To assess whether VA MEDIC-E (Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction[EM DASH] Extended for 6 months), a pharmacist-led shared medical appointments program, could improve attainment of target goals for hypertension, hyperglycemia, hyperlipidemia, and tobacco use in patients with type 2 diabetes compared to standard primary care after 6 months of intervention. METHODS: A randomized, controlled trial of VA MEDIC-E (n = 50) versus standard primary care (n = 49) in veterans with type 2 diabetes, hemoglobin A1c (A1C) > 7%, blood pressure (BP) > 130/80 mmHg, and low density lipoprotein cholesterol (LDL-C) > 100mg/dl (2.59 mmol/l) in the previous 6 months was conducted. The VA MEDIC-E intervention consisted of 4 weekly group sessions followed by 5 monthly booster group sessions. Each 2-hour session included 1 hour of multidisciplinary diabetes specific healthy lifestyle education and 1 hour of pharmacotherapeutic interventions performed by a clinical pharmacist. Evaluation measures included lab values of A1C, LDL cholesterol, BP, and goal attainment of these values, and diabetes self-care behavior questionnaires at 6 months. RESULTS: The randomization groups were similar at baseline in all cardiovascular risk factors except for LDL, which was significantly lower in the MEDIC-E arm. At 6 months, significant improvements from baseline were found in the intervention arm for exercise, foot care, and goal attainment of A1C, LDL-C, and BP but not in the control arm. CONCLUSIONS: The results of this study demonstrate that the pharmacist-led group intervention program for 6 months was an efficacious and sustainable collaborative care approach to managing diabetes and reducing associated cardiovascular risk.

Pharmacist-led group medical appointments for the management of type 2 diabetes with comorbid depression in older adults.

BACKGROUND: Depression is associated with poor glycemic control, increased number of microvascular and macrovascular complications, functional impairment, mortality, and 4.5 times higher total health care costs in patients with diabetes. Shared medical appointments (SMAs) may be an effective method to attain national guideline recommendations for glycemic control in diabetes for patients with depression through peer support, counseling, problem solving, and improved access to care. OBJECTIVE: To test the efficacy as assessed by attainment of a hemoglobin A(1c) (A1C) <7% of pharmacist-led group SMA visits, Veterans Affairs Multidisciplinary Education in Diabetes and Intervention for Cardiac Risk Reduction in Depression (VA-MEDIC-D), in patients with type 2 diabetes mellitus. METHODS: This was a randomized controlled trial of VA-MEDIC-D added to standard care versus standard care alone in depressed patients with diabetes with A1C >6.5%. VA-MEDIC-D consisted of 4 once-weekly, 2-hour sessions followed by 5 monthly 90-minute group sessions. Each SMA session consisted of multidisciplinary education and pharmacist-led behavioral and pharmacologic interventions for diabetes, lipids, smoking, and blood pressure. No pharmacologic interventions for depression were provided. The change in the proportion of participants who achieved an A1C <7% at 6 months was compared. RESULTS: Compared to standard care (n = 44), a lower proportion of patients in VA-MEDIC-D (n = 44) had systolic blood pressure (SBP) <130 mm Hg at baseline, but were similar in other cardiovascular risk factors and psychiatric comorbidity. The change in the proportion of participants achieving an A1C <7% was greater in the VA-MEDIC-D arm than in the standard care arm (29.6% vs 11.9%), with odds ratio 3.6 (95% CI 1.1 to 12.3). VA-MEDIC-D participants also achieved significant reductions in SBP, low-density lipoprotein cholesterol, and non-high-density lipoprotein (HDL) cholesterol from baseline, whereas significant reductions were attained only in non-HDL cholesterol with standard care. There was no significant change in depressive symptoms for either arm. CONCLUSIONS: Pharmacist-led group SMA visits are efficacious in attainment of glycemic control in patients with diabetes and depression without change in depression symptoms.

The spectrum of kidney involvement in lymphoma: a case report and review of the literature.

Kidney involvement is an under-recognized complication of both Hodgkin and non-Hodgkin lymphoma. The diversity of lymphoma-related renal manifestations makes diagnosis difficult. Although abrupt worsening of kidney function may be the first sign of malignant disease, renal effects can be subtle or even silent. The causes of renal involvement similarly are varied. We discuss a case of non-Hodgkin lymphoma and associated kidney failure from several distinct malignancy-related mechanisms and review the spectrum of lymphoma-related kidney involvement.

Pharmacist-led group medical appointment model in type 2 diabetes.

PURPOSE: The purpose of this study was to assess whether the VA-MEDIC (Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction), a pharmacist-led group medical visit program, could improve achievement of target goals in hypertension, hyperglycemia, hyperlipidemia, and tobacco use in patients with type 2 diabetes compared to usual care. METHODS: This was a randomized controlled trial of VA-MEDIC intervention in addition to usual care versus usual care alone in diabetic patients to reduce cardiac risk factors. VA-MEDIC consisted of a 40- to 60-minute educational component by nurse, nutritionist, physical therapist, or pharmacist followed by pharmacist-led behavioral and pharmacological interventions over 4 weekly sessions. Measures The attainment of target goals in hemoglobin A1C (A1C), blood pressure, fasting lipids, and tobacco use recommended by the American Diabetes Association. RESULTS: Of 118 participants, 109 completed the study. VA-MEDIC (n = 58) participants were younger and had greater tobacco use at baseline than usual care but were similar in other cardiovascular risk factors. After 4 months, a greater proportion of VA-MEDIC participants versus controls achieved an A1C of less than 7% and a systolic blood pressure less than 130 mm Hg. No significant change was found in lipid control or tobacco use between the 2 study arms. CONCLUSION: Pharmacist-led group medical visits are feasible and efficacious for improving cardiac risk factors.

De novo intraepidermal epithelioid melanocytic dysplasia: a review of 263 cases.

BACKGROUND: De novo intraepidermal epithelioid melanocytic dysplasia (DNIEMD) is a newly characterized lesion that is associated with a personal and/or family history of malignant melanoma (MM) and/or dysplastic nevi (DN). However, the biological significance is still uncertain and the persons predisposed to this lesion have not been adequately described. METHODS: Clinicopathologic data of 258 patients, from 263 biopsies diagnosed with DNIEMD, was obtained. A brief voluntary questionnaire was used to obtain demographic, risk factor and disease history. RESULTS: There is an 82% (n=263) predominance of women with DNIEMDs. For men and women, the distributions of these lesions occur on the lower extremities (71%), the upper extremities (24%) and trunk (5%). Thirty-one percent of the 258 patients responded to the questionnaires. 48% of the 60 respondents had green or blue eyes. 26% of 62 respondents had a history of non-melanoma skin cancer (NMSC). Combined data revealed that 68% of 134 patients had a history of DN. As well, 24% of 89 patients had personal histories of melanoma, while 24% of 72 patients had a family history of melanoma. CONCLUSION: Most of these DNIEMD lesions are found on the lower extremities of women and men, and they have an increased association with MM, DN and NMSC.

Array-CGH reveals recurrent genomic changes in Merkel cell carcinoma including amplification of L-Myc.

Merkel cell carcinoma (MCC) is an aggressive neuroendocrine skin cancer with poorly characterized genetics. We performed high resolution comparative genomic hybridization on 25 MCC specimens using a high-density oligonucleotide microarray. Tumors frequently carried extra copies of chromosomes 1, 3q, 5p, and 6 and lost chromosomes 3p, 4, 5q, 7, 10, and 13. MCC tumors with less genomic aberration were associated with improved survival (P=0.04). Tumors from 13 of 22 MCC patients had detectable Merkel cell polyomavirus DNA, and these tumors had fewer genomic deletions. Three regions of genomic alteration were of particular interest: a deletion of 5q12-21 occurred in 26% of tumors, a deletion of 13q14-21 was recurrent in 26% of tumors and contains the well-characterized tumor suppressor RB1, and a previously unreported focal amplification at 1p34 was present in 39% of tumors and centers on L-Myc (MYCL1). L-Myc is related to the c-Myc proto-oncogene, has transforming activity, and is amplified in the closely related small cell lung cancer. Normal skin showed no L-Myc expression, whereas 4/4 MCC specimens tested expressed L-Myc RNA in relative proportion to the DNA copy number gain. These findings suggest several genes that may contribute to MCC pathogenesis, most notably L-Myc.