Dermatologic toxicities of targeted antineoplastic agents and immune checkpoint inhibitor therapy in pediatric patients: A systematic review.

Cutaneous adverse events (cAEs) from targeted antineoplastic agents and immune checkpoint inhibitors are common in children with cancer and may lead to dose reduction or cessation of critical oncologic treatment. Timely diagnosis and proper management of cAEs in pediatric oncology patients is essential to optimize ongoing cancer-directed therapy and improve quality of life. This systematic review of published studies summarizes dermatologic toxicities to targeted anticancer treatments and immune checkpoint inhibitors.

Eyebrows Are Important in the Treatment of Alopecia Areata.

Alopecia areata affects not only scalp hair but also other sites of body hair, including eyebrows. Our objective was to investigate the importance of eyebrows in the treatment goals of patients with alopecia areata. Through an online questionnaire, subjects were asked to assess satisfaction with the visually depicted level of response to treatment, using edited photographs depicting a range of eyebrows and scalp hair growth. The questionnaire was completed by 1,741 adults. Absent or partial growth of eyebrows and scalp hair elicited <25% satisfaction. Images depicting either complete eyebrows or complete scalp hair achieved satisfaction in >50% of participants. More participants were satisfied with complete eyebrows and no scalp hair (69%) than complete eyebrows and partial scalp hair (51%). Only when both eyebrows and scalp hair were completely regrown did extreme satisfaction levels reach 90.4%. Limitations include the online nature of the survey, lack of control group, and self-reported severity of alopecia areata in participants. These results suggest that eyebrows may be as important as scalp hair for patients assessing theoretical responses to treatment for alopecia areata. Future clinical studies should consider growth of eyebrows as an outcome measure on par with scalp hair growth.

Tofacitinib for the treatment of alopecia areata and variants in adolescents.

BACKGROUND: There are no reliably effective therapies for alopecia areata (AA). OBJECTIVE: We sought to evaluate the benefit and adverse effects of the Janus kinase 1/3 inhibitor, tofacitinib, in a series of adolescent patients with AA. METHODS: We reviewed the records of 13 adolescent patients with AA treated with tofacitinib. Severity of disease was assessed using the Severity of Alopecia Tool (SALT). Adverse events were evaluated by laboratory monitoring, physical examinations, and review of systems. RESULTS: Thirteen patients, aged 12 to 17 years, with AA were treated with tofacitinib. Nine patients experienced clinically significant hair regrowth. Median percent change in SALT score was 93% (mean 61%; 1%-100%) at an average of 6.5 months of treatment. Adverse events were mild. LIMITATIONS: Limitations include the retrospective nature of the data, small sample size, and lack of a control group. CONCLUSION: Tofacitinib is a promising therapy for AA in adolescents. The use of tofacitinib and other Janus kinase inhibitors for the treatment of AA in this age group should be further evaluated in prospective clinical trials.

Tofacitinib for the treatment of severe alopecia areata and variants: A study of 90 patients.

BACKGROUND: Alopecia areata (AA) is a common autoimmune disorder. There are no reliably effective therapies for AA. OBJECTIVE: We sought to evaluate the safety and efficacy of the Janus kinase 1/3 inhibitor, tofacitinib, in a series of patients over an extended period of time. METHODS: This is a retrospective study of patients age 18 years or older with AA with at least 40% scalp hair loss treated with tofacitinib. The primary end point was the percent change in Severity of Alopecia Tool (SALT) score during treatment. RESULTS: Ninety patients met inclusion criteria. Of 65 potential responders to therapy, defined as those with alopecia totalis or alopecia universalis with duration of current episode of disease of 10 years or less or alopecia areata, 77% achieved a clinical response, with 58% of patients achieving greater than 50% change in SALT score over 4 to 18 months of treatment. Patients with AA experienced a higher percent change in SALT score than did patients with alopecia totalis or alopecia universalis (81.9% vs 59.0%). Tofacitinib was well tolerated, and there were no serious adverse events. LIMITATIONS: The retrospective nature of the data, the relatively small number of patients, and lack of a control group are limitations. CONCLUSION: Tofacitinib should be considered for the treatment of severe AA, alopecia totalis, and alopecia universalis; tofacitinib dose response will be better defined by randomized controlled trials.

Repigmentation in vitiligo using the Janus kinase inhibitor tofacitinib may require concomitant light exposure.

BACKGROUND: Vitiligo is an autoimmune disease in which cutaneous depigmentation occurs. Existing therapies are often inadequate. Prior reports have shown benefit of the Janus kinase (JAK) inhibitors. OBJECTIVE: To evaluate the efficacy of the JAK 1/3 inhibitor tofacitinib in the treatment of vitiligo. METHOD: This is a retrospective case series of 10 consecutive patients with vitiligo treated with tofacitinib. Severity of disease was assessed by body surface area of depigmentation. RESULTS: Ten consecutive patients were treated with tofacitinib. Five patients achieved some repigmentation at sites of either sunlight exposure or low-dose narrowband ultraviolet B phototherapy. Suction blister sampling revealed that the autoimmune response was inhibited during treatment in both responding and nonresponding lesions, suggesting that light rather than immunosuppression was primarily required for melanocyte regeneration. LIMITATIONS: Limitations include the small size of the study population, retrospective nature of the study, and lack of a control group. CONCLUSION: Treatment of vitiligo with JAK inhibitors appears to require light exposure. In contrast to treatment with phototherapy alone, repigmentation during treatment with JAK inhibitors may require only low-level light. Maintenance of repigmentation may be achieved with JAK inhibitor monotherapy. These results support a model wherein JAK inhibitors suppress T cell mediators of vitiligo and light exposure is necessary for stimulation of melanocyte regeneration.

Neonatal Subgaleal Hematoma from Trauma During Vaginal Delivery without Instrument Use.

Neonatal subgaleal hematomas (SGHs) are rare but potentially life-threatening complications of vacuum extraction deliveries. We report a rare case of four enlarging SGHs in an 11-day-old boy born without use of instruments during delivery. It is likely that trauma from the provider's fingers caused these SGHs during a normal vaginal delivery. Ultrasound findings confirmed the diagnosis of SGH, distinct from other birth trauma such as cephalohematoma or caput succedaneum.

Health-related quality of life (HRQoL) among patients with alopecia areata (AA): A systematic review.

Alopecia areata (AA) is a common skin disease that is frequently emotionally devastating. Several studies have examined the effect of AA on health-related quality of life (HRQoL). We performed a systematic review of all published studies of HRQoL in patients with AA. Eleven studies met inclusion criteria, incorporating data from 1986 patients. Patients with AA consistently demonstrate poor HRQoL scores, with greater extent of scalp involvement associated with lower HRQoL. HRQoL experienced by patients with AA is similar to that seen in patients with other chronic skin diseases including atopic dermatitis and psoriasis.

Neuromonitoring Using Motor and Somatosensory Evoked Potentials in Aortic Surgery.

BACKGROUND: Motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) are established methods of neuromonitoring aimed at preventing paraplegia after descending or thoracoabdominal aortic repair. However, their predictive impact remains controversial. The aim of this study was to evaluate our single-center experience using this monitoring technique. METHODS: Between 2009 and 2014, 78 patients (mean age 66 ± 12, 53% male) underwent either descending or thoracoabdominal aortic repairs. Of these, 60% had an aortic aneurysm, 30% dissection, and 10% other etiologies. Intraoperatively, MEPs and SSEPs were monitored and, if necessary, clinical parameters (blood pressure, hematocrit, oxygenation) were adjusted in response to neuromonitoring signals. This analysis is focused on the neurological outcome (paraplegia, stroke) after the use of intraoperative neuromonitoring. RESULTS: Thirty-day mortality was 10 (12.8%). All patients with continuously stable signals or signals that returned after signal loss developed no spinal cord injury, whereas two out of six of the evaluable patients with signal loss (without return) during the procedure suffered from postoperative paraplegia (one transient and one permanent). Sensitivity and specificity of use of MEP and SSEP were 100% and 94.20% regarding paraplegia, respectively. CONCLUSIONS: (1) Preservation of signals or return of signals is an excellent prognostic indicator for spinal cord function. (2) Intraoperative modifications in direct response to the signal change may have averted permanent paralysis in the patients with signal loss without neurologic injury. We have found MEP and SSEP neuromonitoring to be instrumental in the prevention of paraplegia. doi: 10.1111/jocs.12739 (J Card Surg 2016;31:383-389).

Assessment of biofilm formation of E. meningoseptica, D. acidovorans, and S. maltophilia in lens cases and their growth on recovery media.

PURPOSE: Bacterial biofilm formation in contact lens cases is a risk factor in the development of both microbial and infiltrative keratitis. This investigation evaluated three emerging pathogens: Stenotrophomonas maltophilia, Elizabethkingia meningoseptica, and Delftia acidovorans for biofilm formation and metabolic activity in lens cases. Also, growth of these bacteria on different media was assessed to optimize recovery conditions. METHODS: The three bacteria were incubated in lens cases with different concentrations of tryptic soy broth. Biofilm formation was evaluated by measuring metabolic activity using MTT and enumerating the number of viable bacteria. To determine the optimal recovery media, dilutions of these microorganisms were plated on six different media. The number of colony forming units (CFU) was recorded after 48, 72, and 96 h of incubation at 32°C and 37°C for S. maltophilia, and at 37°C for E. meningoseptica and D. acidovorans. RESULTS: All three microorganisms established biofilms in the lens cases, with significant numbers of CFU recovered. Biofilms of S. maltophilia and E. meningoseptica were metabolically active. Significant reduction in metabolic activity and number of viable S. maltophilia occurred when the incubation temperature was raised from 32°C to 37°C (p<0.05). The metabolic activity of the biofilms increased with greater organic load present. The highest percent recovery for all three organisms was given by Columbia blood agar, followed by chocolate. CONCLUSION: Based on the results, the presence of the three emerging pathogens present in lens cases and from corneal isolates can be accurately determined if proper growth media and incubation temperatures are utilized.