Lumbar osteoporotic fractures develop in segments with less degenerated discs which then become more degenerated.

PURPOSE: Our aim was to study the influence of segmental variations in intervertebral disc degeneration on the location of acute osteoporotic compression fractures and to investigate chronic effect of such fractures on adjacent discs. METHODS: This retrospective study included 83 patients (69 females; mean ± SD age: 72.3 ± 14.0 years) with osteoporotic vertebral fractures. Using lumbar MRI, two neuroradiologists evaluated 498 lumbar vertebral segments for the presence and acuity of fractures and graded adjacent intervertebral disc degeneration on Pfirrmann's scale. Absolute and relative (to average patient-specific degeneration grade) segmental degeneration grades were compared against the presence and chronicity of vertebral fractures for all segments and for upper (T12-L2) and lower (L3-L5) subgroups. Intergroup analysis was conducted using Mann-Whitney U tests, with p value of < .05 considered significant. RESULTS: Fractures involved 149/498 (29.9%; 15.1% acute) vertebral segments, majority (61.1%) involving T12-L2 segments. Segments with acute fractures had significantly lower degeneration grades (mean ± SD: absolute: 2.72 ± 0.62; relative: 0.91 ± 0.17) than those with no (absolute: 3.03 ± 0.79, p = 0.003; relative: 0.99 ± 0.16, p < 0.001) or chronic fractures (absolute: 3.03 ± 0.62, p = 0.003; relative: 1.02 ± 0.16, p < 0.001). Degeneration grades were higher in the lower lumbar spine (p < 0.001) in the absence of fractures, but comparable to upper spine for segments with acute or chronic fractures (p = 0.28 and 0.56, respectively). CONCLUSIONS: Osteoporotic vertebral fractures favour segments with lower burden of disc degeneration, but likely contribute to subsequent worsening of adjacent disc degeneration.

Interpretation of Morphological Details of Nondegenerated Lumbar Intervertebral Discs on Magnetic Resonance Imaging: Insights From a Comparison Between Computed Tomography Discograms and Magnetic Resonance Imaging.

OBJECTIVE: To gain better insight into the magnetic resonance imaging (MRI) appearance of morphological intervertebral disc (IVD) details, such as annular and nucleus pulposus dimensions, by comparing contemporaneously obtained MRI and postdiscogram computed tomography (CT) scans of nondegenerated IVDs. METHODS: Axial T2-weighted images and same-day postdiscography CTs, acquired after the MRI, of 26 normal-appearing lumbar IVDs (control IVDs at discography) were compared. The location and extent of central hyperintense zone on MRI and the extent of contrast distribution on CT relative to the IVD width (in anteroposterior [AP] and lateral planes) were assessed, with difference in measures between the modalities used to provide apparent inner annulus thickness and to estimate dimensions of also the outer annulus and location of nucleus pulposus. RESULTS: The mean (SD) extent of contrast distribution on CT discograms (53.1% [6.6%] and 58.1% [8.7%] of AP and lateral IVD width) was smaller than (P < 0.001 for both), and correlated weakly (r = 0.31 and 0.32 for AP and lateral planes) with corresponding measurements (58.4% [5.3%] and 65.7% [5.9%], respectively) for central hyperintense zone at MRI. The center of contrast opacification on CT discograms was located posterior to that of central T2 hyperintense zone on MRI in AP (P < 0.01), without any difference in lateral direction (P = 0.60). CONCLUSIONS: Normal-appearing lumbar IVDs are supported by outer annulus of larger relative thickness anteriorly, seen on both modalities. The shown discrepancy between the central T2 hyperintense zone and contrast distribution on CT discogram might reflect the inner annulus or structural changes within the borderzone nucleus and annulus. The exact nucleus size and inner annulus thickness could not be established due to a variable permeation of contrast across the central hyperintense zone on T2-weighted images.

Evaluation of 2D FLAIR hyperintensity of the optic nerve and optic nerve head and visual parameters in idiopathic intracranial hypertension.

BACKGROUND AND PURPOSE: T2/FLAIR hyperintensity of the optic nerve/optic nerve head has been described as a sensitive finding in idiopathic intracranial hypertension using post-contrast 3D-T2/FLAIR imaging. The purpose of this study is to assess whether hyperintensity on non-enhanced 2D-T2/FLAIR imaging occurs more likely in diseased patients than controls and to evaluate the relationship between FLAIR signal and visual parameters MATERIALS AND METHODS: A retrospective case-control study was performed of patients with idiopathic intracranial hypertension and controls who underwent orbital MRI. Three neuroradiologists reviewed the FLAIR images, subjectively evaluating for hyperintense signal within the optic nerves/optic nerve heads using a 5-point Likert Scale. Quantitative assessment of optic nerve signal using regions of interests was performed. Clinical parameters were extracted. The diagnostic performance was evaluated, and Spearman correlation calculated to assess the relationship between FLAIR signal and visual outcomes. RESULTS: The sensitivity of abnormal FLAIR signal within the optic nerves and optic nerve heads in patients with idiopathic intracranial hypertension ranged from 25-54% and 4-29%, respectively, with specificities ranging from 67-92% and 83-100%. Quantitative assessment revealed a significant difference in CNR between cases and controls in the left posterior optic nerve (p=.002). A positive linear relationship existed between abnormal optic nerve head signal and papilledema grade (OD: p=.02, OS: p=.008) but not with other visual parameters. CONCLUSION: T2/FLAIR hyperintensity in the optic nerve/optic nerve head may support the diagnosis of idiopathic intracranial hypertension but its absence should not dissuade it. If present, abnormal signal in the optic nerve head correlates with papilledema.

Successful follicular unit extraction in a case of inactive, recalcitrant alopecia barbae.

Alopecia areata (AA) is a non-scarring autoimmune type of alopecia. Hair transplantation in AA is not practiced as the implanted follicular grafts might be destroyed due to underlying autoimmune pathology. A biopsy proven 28 year old male patient of AA presented to us with an 8-year history of a hairless patch over the beard area. He underwent many treatments by other dermatologist with oral, topical, and intralesional immunosuppressants, which curtailed his disease progression but failed to re-grow hair. Biopsy during his visit revealed absence of inflammatory infiltrates and empty hair tracts replaced by fibrotic tracts. Follicular unit extraction (FUE) was done successfully after counseling the patient about the controversial role of hair transplant surgery in AA. Hair growth was achieved within 6 months with no recurrence during 1-year follow up. FUE can be opted for long-standing and clinically stable cases of AA; histopathology and dermoscopy being the guiding lights in determining the disease inactivity.

Evaluating the effect of a post-processing algorithm in detection of annular fissure on MR imaging.

BACKGROUND AND PURPOSE: Visualization of annular fissures on MRI is becoming increasingly important but remains challenging. Our purpose was to test whether an image processing algorithm could improve detection of annular fissures. MATERIALS AND METHODS: In this retrospective study, two neuroradiologists identified 56 IVDs with annular fissures and 97 IVDs with normal annulus fibrosus in lumbar spine MRIs of 101 patients (58 M, 43 F; age ± SD 15.1 ± 3.0 years). Signal intensities of diseased and normal annulus fibrosus, and contrast-to-noise ratio between them on sagittal T2-weighted images were calculated before and after processing with a proprietary software. Effect of processing on detection of annular fissures by two masked neuroradiologists was also studied for IVDs with Pfirrmann grades of ≤ 2 and > 2. RESULTS: Mean (SD) signal baseline intensities of diseased and normal annulus fibrosus were 57.6 (23.3) and 24.4 (7.8), respectively (p < 0.001). Processing increased (p < 0.001) the mean (SD) intensity of diseased annulus to 110.6 (47.9), without affecting the signal intensity of normal annulus (p = 0.14). Mean (SD) CNR between the diseased and normal annulus increased (p < 0.001) from 11.8 (14.1) to 29.6 (29.1). Both masked readers detected more annular fissures after processing in IVDs with Pfirrmann grade of ≤ 2 and > 2, with an apparent increased sensitivity and decreased specificity using predefined image-based human categorization as a reference standard. CONCLUSIONS: Image processing improved CNR of annular fissures and detection rate of annular fissures. However, further studies with a more stringent reference standard are needed to assess its effect on sensitivity and specificity.

Comparison of 5% minoxidil lotion monotherapy versus its combination with autologous platelet rich plasma in androgenetic alopecia in hundred males.

BACKGROUND: Androgenetic alopecia (AGA) is the most common form of alopecia in men, affecting 70% by the age of 20 years. The present study was conducted with the objective of comparing the efficacy of monotherapy with topical 5% minoxidil and its combination with intradermal platelet rich plasma (PRP), in male AGA. METHODS: This observational study was conducted at the dermatology department of a tertiary care hospital over a duration of 2 years. 100 patients with AGA were selected and divided randomly into 2 treatment arms: Group A (MM): received topical 5% Minoxidil monotherapy for 12 months and; Group B (M + PRP): received combination therapy of PRP and topical 5% Minoxidil for 12 months. The following parameters were subsequently analyzed on follow up: Physician-assessed global photography by a 4-point improvement scale and trichoscopic improvement of mean hair diameter. RESULTS: The combination was statistically superior to the monotherapy group in promoting hair growth in men with AGA for both measures of hair growth - photographic assessment and trichoscopic mean diameter. CONCLUSION: We hereby conclude that intradermal PRP injections should be offered to all patients with AGA along with the existing therapeutic modalities, for faster hair regrowth and improved compliance.

Will teledermatology be the silver lining during and after COVID-19?

The novel coronavirus disease (COVID-19) has limited traditional consultation and minimized health care access. Teledermatology (TD) has come to the rescue in this situation by extending consultation for nonessential conditions to the comfort of patient's homes. This limits the risk of exposure of both doctors and patients to the coronavirus (SARS-CoV-2). And while there is a reported increase in teleconsultations during the ongoing pandemic, there are some demerits that avert the shift to virtualized health care. The authors conducted an online survey to further understand the hesitancy, limitations, merits, and the demographic of dermatologists who were conducive to TD and these data were analyzed and presented in this article. While TD might never replace physical consultation, it definitely serves an adjunctive role in the post-COVID era, provided adequate regulatory measures are in place.

Evaluating the efficacy of primary excision and closure for the management of lip leukoderma and introducing the surgical site morbidity score as an effective tool for assessment of postoperative morbidity.

The lips are considered of great importance for the perception of beauty and there is still a lacuna in the attempt to successfully re-pigment resistant areas of vitiligo especially the lips. No technique evolved so far ensures 100% pigmentation with a good cosmetic appearance. To study the efficacy and cosmetic outcome following primary excision and closure in the management of lip vitiligo and assessing postoperative morbidity using the created surgical site morbidity score (SSMS). Twenty-five patients with vitiligo involving the inner margin of lower lips were posted for primary excision and closure of the vitiliginous area. Patients were followed up at 7 days and every 6 months. A SSMS including pain (P), healing time (H), and presence of complications (C) as parameters for assessment of postoperative morbidity were recorded at every follow-up visit. All patients showed healthy lip mucosa within 7 days of the procedure and no recurrence was noted at 24 months of follow up. The postoperative morbidity based on the SSMS was minimal, with a mean score of P2H8C0. Primary excision and closure technique is a safe and inexpensive modality in the management of lip vitiligo with immediate results and excellent cosmetic outcomes.

Reversal of steroid-induced lipoatrophy with serial injections of isotonic saline in a child.

The problem of side-effects of injectable corticosteroids has gradually become more acute with rampant and unlimited misuse of the drug, particularly by non-dermatologists. Serial saline injections at the site of steroid-induced lipoatrophy in a child served as a safe, relatively rapid, and cost-effective solution.

Coronavirus disease (COVID-19): An updated review based on current knowledge and existing literature for dermatologists.

The world entered the year 2020 with reports of the emergence of a new viral illness in Wuhan city, Hubei province, China. In January 2020, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified to be the causative novel coronavirus for the cluster of patients suffering from pneumonia in China. The disease was later named as coronavirus disease (COVID-19) and was declared a pandemic by the World Health Organization on March 11, 2020. Several studies, since then, have tried to study and explain the origin of SARS-CoV-2, its structure and pathogenicity, epidemiology, modes of transmission, spectrum of illness and causes of mortality and morbidity. The current management strategies focus on supportive care and prevention of complications. With no definite treatment, as of now, encouraging reports of some anti-viral and anti-malarial drugs in the management of COVID-19 generate some hope. This review intends to cover the current known aspects of COVID-19 and SARS-CoV-19, based on the available literature.

Interleukin 23p19 inhibitors in chronic plaque psoriasis with focus on mirikizumab: A narrative review.

Psoriasis, a T-cell mediated chronic dermatosis, has a complex etiopathogenesis. There has been extensive research into the aberrant immune response, which leads to the formation of clinical lesions, and the need for developing better and safer drugs has been unrelenting. The past two decades of research has opened up new areas of the immune pathway that can be targeted in order to control the disease. Therefore, we have seen the emergence of biologics which either target T-cell receptors or inhibit Tumor Necrosis Factor-alpha (TNF-α) or inhibit interleukins (IL) like IL-12, IL-17, IL-17 receptor, and more recently IL-23. Drugs specifically targeting the p19 subunit of IL-23 have shown promising results in the management of chronic plaque psoriasis. This has given way to the development of a new class of biologics, that is, the IL-23p19 inhibitors that have a better safety profile as compared to its predecessors. In this review, we shall scrutinize the role of IL-23 and Th17 cell signaling in the evolution of the psoriatic lesions and summarize the clinical experience with IL-23p19 inhibitors especially mirikizumab in the treatment of chronic plaque psoriasis.

5-Alpha reductase inhibitors in androgenetic alopecia: Shifting paradigms, current concepts, comparative efficacy, and safety.

Androgenetic alopecia (AGA) is a multifactorial disease that carries a significant psychological burden with it. Dihydrotestosterone, the main pathogenic androgen in AGA, is produced by conversion of testosterone, which is catalyzed by the 5-alpha reductase (5-AR) isoenzyme family. Finasteride and dutasteride are inhibitors of these enzymes. Finasteride, which is a single receptor 5-alpha reductase inhibitor (5-ARI), acts by blocking dihydrotestosterone (DHT). Dutasteride, a dual receptor DHT blocker, has a higher potency than its predecessor, finasteride. This review corroborates the evidence of superiority of dutasteride over finasteride, and its comparable safety profile concerning fertility, teratogenicity, neurotoxicity, and hepatotoxicity.

A 26-Year-Old Woman With Diplopia and Nystagmus.

A 26-year-old woman presented for a routine contact lens evaluation but was found to have a subtle right sixth nerve paresis and adducting nystagmus of the left eye. She reported horizontal diplopia on far right gaze as well as subjective right-sided weakness and poor balance for 1 year. Brain and spinal MRI revealed multiple cystic lesions with variable enhancement throughout the posterior fossa and cervical spinal cord. These MRI findings were highly suspicious for an infectious central nervous system process, such as neurocysticercosis; however, primary or metastatic tumors were also important considerations. Tumor location and imaging characteristics were most helpful in differentiating among these etiologies. A brain biopsy ultimately established the diagnosis of a rosette-forming glioneuronal tumor.

Systemic Medications of Dermatological Importance in COVID-19.

Early December 2019 witnessed an international outbreak of a novel coronavirus (COVID 19) designated severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2). Since then, a number of therapeutic molecules have been explored to have potential efficacy against the SARS-Cov-2 per se or its sequelae. There are no Food and Drug Administration specific therapies approved so far; however, numerous drugs based on varying levels of evidence, in vitro studies and compassionate drug trials are being established as therapeutic agents, especially drugs approved for previous emergence of the severe acute respiratory syndrome (SARS-CoV-1) and Middle east respiratory syndrome coronavirus (MERS-Cov). Numerous active clinical trials for COVID-19 with more than 150 drugs and products are under study. Needless to say, many dermatological drugs are being employed to mitigate this pandemic threat. We aim to review drugs with potential against SARS-Cov-2 widely used in dermatology practice. Additionally, rampant and overzealous use of these drugs as well as introduction of new molecules might lead to emergence of adverse effects associated with these agents. Dermatologists must be on lookout for any cutaneous adverse effects of these drugs. J Drugs Dermatol. 2020;19(9):889-892. doi:10.36849/JDD.2020.5323.

Monozygotic twins with atrophia maculosa varioliformis cutis.

Atrophia maculosa varioliformis cutis (AMVC) is a sporadic or inherited childhood disorder, signified by the occurrence of pitted scars, usually over the face. We report two cases of AMVC occurring in monozygotic twins.

An image processing algorithm to aid diagnosis of mesial temporal sclerosis in children: a case-control study.

BACKGROUND: Mesial temporal sclerosis (MTS) is an important cause of intractable epilepsy. Early and accurate diagnosis of MTS is essential to providing curative and life-changing therapy but can be challenging in children in whom the impact of diagnosis is particularly high. Magnetic resonance imaging (MRI) plays an important role in the diagnosis of MTS, and image processing of MRI is a recently studied strategy to improve its accuracy. OBJECTIVE: In a retrospective case-control study, we assessed the performance of an image processing algorithm (Correlative Image Enhancement [CIE]) for detecting MTS-related hippocampal signal abnormality in children. MATERIALS AND METHODS: Twenty-seven pediatric MTS cases (9 males, 18 females; mean age: 16±standard deviation [SD] 6.7 years) were identified from a pathology database of amygdylo-hippocampectomies performed in children with epilepsy. Twenty-seven children with no seizure history (9 males, 18 females; mean age: 13.8±SD 2.8 years), and with normal brain MRI, were identified for the control group. Blinded investigators processed the MRI coronal FLAIR (fluid-attenuated inversion recovery) images with CIE, saved the processed images as a separate series, and made equivalent region of interest measurements on the processed and unprocessed series to calculate contrast-to-noise ratio. Six blinded reviewers then rated the randomized series for hippocampal signal abnormality and MTS disease status. RESULTS: CIE increased signal intensity and contrast-to-noise ratio in 26/27 hippocampi with pathologically confirmed MTS (96.3%) with the mean (SD) contrast-to-noise ratio of cases increasing from 14.9 (11.1) to 77.7 (58.7) after processing (P<0.001). Contrast-to-noise ratio increased in 1/54 normal control hippocampi (1.9%), with no significant change in the mean contrast-to-noise ratio of the control group after processing (P=0.57). Mean (SD) reader sensitivity for detecting abnormal signal intensity increased from 83.3% (14.2) to 94.8% (3.3) after processing. Mean specificity for abnormal signal intensity increased from 94.4% (7.3) to 96.3% (0). While sensitivity improved after processing for detection of MTS disease status in 4/6 readers, the mean reader sensitivity and specificity for MTS detection increased only minimally after processing, from 79.6% to 80.7% and from 95.7% to 96.3%, respectively. CONCLUSION: The CIE image processing algorithm selectively increased the contrast-to-noise ratio of hippocampi affected by MTS, improved reader performance in detecting MTS-related hippocampal signal abnormality and could have high impact on pediatric patients undergoing work-up for seizures.

Mission impossible: Dermal delivery of growth factors via microneedling.

The clinical application of transdermal delivery has been limited to lipophilic drugs with a molecular weight of less than 500 Da. The development of polymeric microneedles enabled the transdermal delivery of larger proteins and drugs. Extensive research has been conducted on the molecular size, solubility, pH, concentration, and polarity of transdermal delivery; however, the maximal molecular weight for transdermal microneedle delivery has not been established. Clinicians often use simple microneedles to deliver high molecular weight growth factors of platelet-rich plasma across the skin; thus, we set out to explore the feasibility of delivering growth factors through microneedling. In this communication, we present histological evidence that microneedling do not enhance transdermal delivery of growth factors and thus provide no clinical benefit.

Tretinoin enhances minoxidil response in androgenetic alopecia patients by upregulating follicular sulfotransferase enzymes.

Minoxidil sulfate is the active metabolite required to exert the vasodilatory and hair growing effects of minoxidil. For hair growth, sulfotransferase enzymes expressed in outer root sheath of the hair follicle sulfonate minoxidil. The large intra-subject variability in follicular sulfotransferase was found to predict minoxidil response and thus explain the low response rate to topical minoxidil in the treatment of androgenetic alopecia. A method to increase minoxidil response would be of significant clinical utility. Retinoids have been reported to increase minoxidil response. The purported mechanism of action was retinoid modulation of skin permeation to minoxidil; however, evidence to the contrary supports retinoids increase dermal thickness. In order to elucidate the effect of topical retinoids on minoxidil response, we studied the effect of topical tretinoin on follicular sulfotransferase. In this study, we demonstrate that topical tretinoin application influences the expression of follicular sulfotransferase. Of clinical significance, in our cohort, 43% of subjects initially predicted to be nonresponders to minoxidil were converted to responders following 5 days of topical tretinoin application. To the best of our knowledge, this is the first study to elucidate the interaction mechanism between topical minoxidil and retinoids and thus provides a pathway for the development of future androgenetic alopecia treatments.

Measuring and reporting of vertebral endplate bone marrow lesions as seen on MRI (Modic changes): recommendations from the ISSLS Degenerative Spinal Phenotypes Group.

PURPOSE: The positive association between low back pain and MRI evidence of vertebral endplate bone marrow lesions, often called Modic changes (MC), offers the exciting prospect of diagnosing a specific phenotype of chronic low back pain (LBP). However, imprecision in the reporting of MC has introduced substantial challenges, as variations in both imaging equipment and scanning parameters can impact conspicuity of MC. This review discusses key methodological factors that impact MC classification and recommends guidelines for more consistent MC reporting that will allow for better integration of research into this LBP phenotype. METHODS: Non-systematic literature review. RESULTS: The high diagnostic specificity of MC classification for a painful level contributes to the significant association observed between MC and LBP, whereas low and variable sensitivity underlies the between- and within-study variability in observed associations. Poor sensitivity may be owing to the presence of other pain generators, to the limited MRI resolution, and to the imperfect reliability of MC classification, which lowers diagnostic sensitivity and thus influences the association between MC and LBP. Importantly, magnetic field strength and pulse sequence parameters also impact detection of MC. Advances in pulse sequences may improve reliability and prove valuable for quantifying lesion severity. CONCLUSIONS: Comparison of MC data between studies can be problematic. Various methodological factors impact detection and classification of MC, and the lack of reporting guidelines hinders interpretation and comparison of findings. Thus, it is critical to adopt imaging and reporting standards that codify acceptable methodological criteria. These slides can be retrieved under Electronic Supplementary Material.