Characterization of initial/early histologic features of proliferative leukoplakia and correlation with malignant transformation: a multicenter study.

The aim of this multicenter retrospective study is to characterize the histopathologic features of initial/early biopsies of proliferative leukoplakia (PL; also known as proliferative verrucous leukoplakia), and to analyze the correlation between histopathologic features and malignant transformation (MT). Patients with a clinical diagnosis of PL who have at least one biopsy and one follow-up visit were included in this study. Initial/early biopsy specimens were reviewed. The biopsies were evaluated for the presence of squamous cell carcinoma (SCCa), oral epithelial dysplasia (OED), and atypical verrucous hyperplasia (AVH). Cases that lacked unequivocal features of dysplasia were termed "hyperkeratosis/parakeratosis not reactive (HkNR)". Pearson chi-square test and Wilcoxon test were used for statistical analysis. There were 86 early/initial biopsies from 59 patients; 74.6% were females. Most of the cases had a smooth/homogenous (34.8%) or fissured appearance (32.6%), and only 13.0% had a verrucous appearance. The most common biopsy site was the gingiva/alveolar mucosa (40.8%) and buccal mucosa (25.0%). The most common histologic diagnosis was OED (53.5%) followed by HkNR (31.4%). Of note, two-thirds of HkNR cases showed only hyperkeratosis and epithelial atrophy. A lymphocytic band was seen in 34.8% of OED cases and 29.6% of HkNR cases, mostly associated with epithelial atrophy. Twenty-eight patients (47.5%) developed carcinoma and 28.9% of early/initial biopsy sites underwent MT. The mortality rate was 11.9%. Our findings show that one-third of cases of PL do not show OED with most exhibiting hyperkeratosis and epithelial atrophy, but MT nevertheless occurred at such sites in 3.7% of cases.

Generalized Multinucleate Cell Angiohistiocytoma: Histopathological and Immunohistochemical Analyses of 10 Lesions.

ABSTRACT: Multinucleate cell angiohistiocytoma (MCAH) is an uncommon fibrohistiocytic disorder that usually presents as a localized solitary papule or multiple grouped papules. Generalized presentation is very rare with less than 20 cases reported in the literature. In this article, we present histopathological and immunohistochemical studies of 10 lesions from a patient with generalized MCAH. In all lesions, the histopathological changes were confined to a discrete zone of the superficial dermis that consisted of (1) an increase in the number of capillary-sized vessels with thickened walls, (2) presence of oval to dendritic spindle cells and stellate hyperchromatic multinucleated cells, (3) fibrosis marked by compact collagen, (4) hypertrophy and hyperplasia of small nerve fibers, and (5) a moderately dense lymphocytic infiltrate. The entire population of the cellular component including the multinucleated cells stained for CD10, whereas a subpopulation of the mononuclear spindle cells stained for factor XIIIa and CD68. CD34 highlighted only the blood vessels. The results confirm that the multinucleated cells lack expression of CD68 and factor XIIIa and that CD10 may be used to highlight the entire cellular component. The rarely reported hypertrophy and hyperplasia of nerve fibers in MCAH may be a common finding as it was observed in all 10 lesions.

Shunt disconnection is less likely using a surgeon's knot compared with a surgical constrictor knot.

INTRODUCTION: Ventriculo-peritoneal shunt malfunction is a common neurosurgical presentation, which may occur as a result of shunt disconnection at the level of the valve. Previous studies assessing ligatures have suggested that the constrictor knot is stronger in securing a ligature compared to the surgeon's knot. Our study compared the ability of each knot to secure shunt tubing to the valve. METHODS: A medtronic shunt valve was secured to a peritoneal catheter using the surgeon's knot versus constrictor's knot. The weight and subsequent force (N) required to pull off the shunt tubing at the knot site were recorded. RESULTS: The mean pull-off force was 11.7 N for the surgeon knot, and 8.9 N for the constrictor knot. There was significant difference in favour for the surgeon's knot compared to the constrictor knot. CONCLUSIONS: The surgeon's knot is significantly stronger than the constrictor knot for securing a peritoneal catheter to a CSF shunt valve.

Unusual cranial infection caused by Citrobacter Koseri.

A 60-year-old female had a frontal bone intraosseous meningioma resected 10 years previously. On follow up CT head, an enlarging intraosseous frontal bone lesion was noted. This was thought to be a recurrent frontal meningioma. Intraooperatively, she was found to have an abscess deep to the cranioplasty.

Sex-specific roles of cellular inflammation and cardiometabolism in obesity-associated depressive symptomatology.

BACKGROUND: Obesity and depression are complex conditions with stronger comorbid relationships among women than men. Inflammation and cardiometabolic dysfunction are likely mechanistic candidates for increased depression risk, and their prevalence differs by sex. Whether these relationships extend to depressive symptoms is poorly understood. Therefore, we analyzed sex in associations between inflammation and metabolic syndrome (MetS) criteria on depressive symptomatology. Specifically, we examined whether sex positively moderates the relationship between depressive symptoms and inflammation among women, and whether MetS has parallel effects among men. METHODS: Depressive symptoms, MetS, and inflammation were assessed in 129 otherwise healthy adults. Depressive symptoms were assessed using Beck Depression Inventory (BDI-Ia). Monocyte inflammation regulation (BARIC) was quantified using flow cytometry measurement of TNF-α suppression by ß-agonist. Moderation effects of sex on associations between BARIC, MetS criteria, and BDI were estimated using two-way ANOVA and linear regression, adjusting for BMI, and by sex subgroup analyses. RESULTS: Obese individuals reported more depressive symptoms. Sex did not formally moderate this relationship, though BDI scores tended to differ by BMI among women, but not men, in subgroup analysis. Poorer inflammation control and higher MetS criteria were correlated with somatic depressive symptoms. Sex moderated associations between MetS criteria and somatic symptoms; among men, MetS criteria predicted somatic symptoms, not among women. Subgroup analysis further indicated that poorer inflammation control tended to be associated with higher somatic symptoms in women. CONCLUSIONS: These results indicate that obesity-related inflammation and MetS factors have sex-specific effects on depressive symptoms in a non-clinical population. Although pathophysiological mechanisms underlying sex differences remain to be elucidated, our findings suggest that distinct vulnerabilities to depressive symptoms exist between women and men, and highlight the need to consider sex as a key biological variable in obesity-depression relationships. Future clinical studies on comorbid obesity and depression should account for sex, which may optimize therapeutic strategies.

Paediatric focal intracranial suppurative infection: a UK single-centre retrospective cohort study.

BACKGROUND: Paediatric focal intracranial suppurative infections are uncommon but cause significant mortality and morbidity. There are no uniform guidelines regarding antibiotic treatment. This study reviewed management in a tertiary healthcare centre in the United Kingdom and considers suggestions for empirical treatment. METHODS: A retrospective, single-centre cohort review of 95 children (< 18 years of age) with focal intracranial suppurative infection admitted between January 2001 and June 2016 in Newcastle upon Tyne, United Kingdom. Microbiological profiles and empirical antibiotic regimens were analysed for coverage, administration and duration of use. Mortality and neurological morbidity were reviewed. Data was analysed using t-tests, Mann-Whitney U tests, independent-samples median tests, and χ2-tests where appropriate. P-values < 0.05 were considered statistically significant. RESULTS: Estimated annual incidence was 8.79 per million. Age was bimodally distributed. Predisposing factors were identified in 90.5%, most commonly sinusitis (42.1%) and meningitis (23.2%). Sinusitis was associated with older children (p < 0.001) and meningitis with younger children (p < 0.001). The classic triad was present in 14.0%. 43.8% of 114 isolates were Streptococcus spp., most commonly Streptococcus milleri group organisms. Twelve patients cultured anaerobes. Thirty one empirical antibiotic regimens were used, most often a third-generation cephalosporin plus metronidazole and amoxicillin (32.2%). 90.5% would have sufficient cover with a third generation cephalosporin plus metronidazole. 66.3% converted to oral antibiotics. Median total antibiotic treatment duration was 90 days (interquartile range, 60-115.50 days). Mortality was 3.2, 38.5% had short-term and 24.2% long-term neurological sequelae. CONCLUSIONS: Paediatric focal intracranial suppurative infection has a higher regional incidence than predicted from national estimates and still causes significant mortality and morbidity. We recommend a third-generation cephalosporin plus metronidazole as first-choice empirical treatment. In infants with negative anaerobic cultures metronidazole may be discontinued.

The influence of short-term fixture congestion on position specific match running performance and external loading patterns in English professional soccer.

The aim of the current study was to investigate positional specific physical performance and external load responses to short term fixture congestion in English professional soccer. A total of 515 match observations were categorised as G1: the first game in a week with >4 days following a previous game, G2: the second game in a week played <4 days since G1, and G3: the third game in a week played with <4 days between each of the previous games. Global positioning system and accelerometer-based metrics were partitioned into fifteen-minute epochs. These data were then analysed using a linear mixed model to assess both the within and between game positional differences. Total, low-intensity (<4.0 m·s-1), medium-intensity (MID; 4.0-5.5 m·s-1), and sprint distance (>7.0 m·s-1) were significantly different across games. No between game positional differences were identified; however, within match position specific differences were observed for measures of MID and HID. No significant differences were evident for accelerometer derived metrics between games or across positions. The current data suggests that the use of fifteen minute within game epochs enables the detection of alterations in physical output during congested schedules. The observed within game positional differences has implications for player specific conditioning and squad rotation strategies.

Rituximab-Treated Pemphigus Foliaceus in a Schizophrenic Patient: A Challenging Exercise in Diagnosis, Management, and Follow-Up.

Dermatology was consulted in the care of a 58-year-old man with a history of paranoid schizophrenia, neuroleptic malignant syndrome, a positive purified protein derivative test, and a lack of bathing for approximately 4 years who had been admitted to the hospital because of thick, crusted lesions over an increasing portion of his body. Admitted involuntarily, he was disinterested in the history, physical examination, and diagnostic testing. Comorbid schizophrenia presented a unique challenge because he was unable to participate in his care effectively. His story was told through caregivers. Although mostly compliant, the patient was reserved and indifferent, and had little to add even with direct questions.

Discrimination of curvature from motion during smooth pursuit eye movements and fixation.

Smooth pursuit and motion perception have mainly been investigated with stimuli moving along linear trajectories. Here we studied the quality of pursuit movements to curved motion trajectories in human observers and examined whether the pursuit responses would be sensitive enough to discriminate various degrees of curvature. In a two-interval forced-choice task subjects pursued a Gaussian blob moving along a curved trajectory and then indicated in which interval the curve was flatter. We also measured discrimination thresholds for the same curvatures during fixation. Motion curvature had some specific effects on smooth pursuit properties: trajectories with larger amounts of curvature elicited lower open-loop acceleration, lower pursuit gain, and larger catch-up saccades compared with less curved trajectories. Initially, target motion curvatures were underestimated; however, ∼300 ms after pursuit onset pursuit responses closely matched the actual curved trajectory. We calculated perceptual thresholds for curvature discrimination, which were on the order of 1.5 degrees of visual angle (°) for a 7.9° curvature standard. Oculometric sensitivity to curvature discrimination based on the whole pursuit trajectory was quite similar to perceptual performance. Oculometric thresholds based on smaller time windows were higher. Thus smooth pursuit can quite accurately follow moving targets with curved trajectories, but temporal integration over longer periods is necessary to reach perceptual thresholds for curvature discrimination.NEW & NOTEWORTHY Even though motion trajectories in the real world are frequently curved, most studies of smooth pursuit and motion perception have investigated linear motion. We show that pursuit initially underestimates the curvature of target motion and is able to reproduce the target curvature ∼300 ms after pursuit onset. Temporal integration of target motion over longer periods is necessary for pursuit to reach the level of precision found in perceptual discrimination of curvature.

Striae Distensae: Preventative and Therapeutic Modalities to Improve Aesthetic Appearance.

BACKGROUND: Striae distensae (SD) are aesthetically troublesome to patients and therapeutically challenging. OBJECTIVE: Herein, the authors comprehensively review the literature pertaining to the history, pathogenesis, clinical presentation, clinical rating scales, and laboratory, imaging, and histologic features of SD. METHODS AND MATERIALS: A review of PubMed, MEDLINE, Scopus, Embase, and Google scholar was conducted, including literature published from 1773 to August 6, 2016. RESULTS: The authors identified 68 articles that met inclusion and exclusion criteria. CONCLUSION: There are few randomized controlled trials evaluating the long-term efficacy and safety of various topical and energy-based devices. Based on clinical and anecdotal experience, both nonablative and ablative fractionated lasers have shown modest SD improvement compared with other treatment modalities (including Excimer laser, CuBr laser, pulsed dye laser, and 1,064-nm Nd:YAG laser). In the authors' experience, 1,540-nm nonablative fractionated laser is a worthy first-line modality for the treatment of SD. Future researchers may consider greater focus on enhanced study design, including larger, long-term split-body, or split-SD head-to-head randomized comparative trials with objective outcome measures and end points, such as biopsy and molecular studies demonstrating increased collagen and elastic fibers that correlate to clinical improvement.

Eruptive Milia Within a Tattoo: A Case Report and Review of the Literature.

Of the many tattoo reactions the most common are allergic, granulomatous, lichenoid, photosensitive, pseudolymphomatous, and infectious. Eruptive milia are a rare complication with only three prior reports in the English literature. A 19-year-old African American female presented with tiny, white papules confined within the margins of a tattoo. She denied trauma or associated symptoms at the site. Biopsy demonstrated deposits of black granular material within the dermis and a small infundibular cyst; a diagnosis of eruptive milia within tattoo was made. The milia responded to treatment with urea 40% cream and tretinoin 0.1% cream. Given its rarity, it is important to recognize the presentation of this disorder as other tattoo reactions require more aggressive management. While further research is necessary to determine the exact pathogenesis of this condition, the authors propose a mechanism along with a review of the literature to discuss management.

J Drugs Dermatol. 2017;16(6):621-624.

Evaluating cultural competency and patient satisfaction in an urban dermatology clinic.

Cultural competency continues to gain increased attention in medicine. Not only does it play a significant role in the delivery of health care and patient outcomes, but it also remains a major determinant of patient satisfaction. This study investigated how patients in an urban dermatology clinic rated their satisfaction with cultural competency. Compared to White patients, satisfaction scores were greater for Hispanic or Latino patients and less for Asian patients, while there was no significant difference for Black or African American patients. There were clear differences in patient satisfaction rates of various dimensions of cultural competency. A follow-up study with a larger sample size is needed for closer examination into the conclusions.

Evaluation of a 1540-nm and a 1410-nm Nonablative Fractionated Laser for the Treatment of Striae.

BACKGROUND: Aesthetically, striae distensae (SD) are a source of great concern. No treatment modality is currently considered the gold standard. However, studies of nonablative fractionated lasers (NAFLs) have been promising. OBJECTIVE: To evaluate and compare the clinical and histopathologic efficacy and safety of a 1540-nm NAFL and a 1410-nm NAFL for the treatment of SD. METHODS AND MATERIALS: Nine patients with abdominal striae were treated for 6 sessions-half of the abdomen was treated with a 1540-nm NAFL whereas the other half was treated with a 1410-nm NAFL. Photographs were taken at baseline and at the 3-month follow-up visit, when subjects were given a questionnaire. Two blinded dermatologists scored the photographs using a pre-established clinical scale. Biopsies were taken from 2 subjects and graded by 2 dermatopathologists using a pre-established pathology scale. RESULTS: All 9 subjects demonstrated clinical improvement bilaterally after treatment. Skin biopsies after treatment showed an increase in epidermal thickness, dermal thickness, and collagen and elastin density when compared with baseline. Clinical and histopathological differences between the 2 lasers were not statistically significant. CONCLUSION: Treatment with both the 1540-nm and the 1410-nm NAFL was shown to improve SD clinically and histopathologically. Further studies are needed to optimize treatment parameters.

Follicular Lymphomatoid Papulosis: An Eosinophilic-Rich Follicular Subtype Masquerading as Folliculitis Clinically and Histologically.

Lymphomatoid papulosis (LyP) is an uncommon CD30 lymphoproliferative disorder with a relatively excellent prognosis. Ten to twenty percent of cases, however, are associated with a lymphoma, typically systemic or cutaneous anaplastic large cell lymphoma, mycosis fungoides, or Hodgkin lymphoma. Subtypes divide LyP into infiltrate-descriptive categories along a spectrum of histological manifestation. Classically, LyP shows a patchy, wedge-shaped, perivascular dermal infiltrate of small- to intermediate-sized lymphoid cells, larger lymphoid, with one, 2, or multiple prominent nucleoli, and a variable admixture of neutrophils, eosinophils, and histiocytes. Follicular LyP shares these characteristics, although its infiltrate is folliculocentric. Variable folliculotropism, follicular dilation, rupture, and mucinosis can occur. This entity is commonly misdiagnosed and underreporting likely because its histopathologic features can masquerade as more common follicular-based entities. The authors present 2 cases of this rare variant to underscore the importance of clinicopathologic correlation in diagnosis. To the best of the authors' knowledge, this is the first report of the follicular LyP variant with concurrent mycosis fungoides. In the context of a literature review, diagnostic pitfalls and classification of this variant are discussed.

Anetoderma treated with combined 595-nm pulsed-dye laser and 1550-nm non-ablative fractionated laser.

Anetoderma is a skin disorder characterized by a focal loss of dermal elastic tissue whereby patients present with soft, depressible lesions. We postulated that a series of combination treatment using the 595-nm pulsed dye laser (PDL) and the 1550-nm non-ablative fractionated laser (NAFL) would improve the anetoderma lesions. Our patient with biopsy proven anetoderma received 3 treatments with a combination of 595-nm PDL and 1550-nm NAFL spaced 3 weeks apart. Skin biopsies were performed at baseline and immediately prior to the third treatment. Stains for hematoxylin and eosin and Verhoeff Van Gieson (VVG) were performed. Improvement in lesion color, texture, and overall appearance was noted after the second treatment and continued following the third treatment. Post-treatment VVG staining demonstrated an increase in dermal elastin fibers and a decrease in elastin fiber fragmentation. Thus, the combination of 595-nm PDL and 1550-nm NAFL should be considered as a treatment modality for anetoderma.

Disseminated superficial actinic porokeratosis improved with fractional 1927-nm laser treatments.

Disseminated superficial actinic porokeratosis (DSAP) is an inherited disorder of keratinization readily diagnosed through clinical and histologic examination. While generally benign in nature, the lesions can have profound psychosocial implications for patients. Although no cure exists, a number of treatment modalities, from topical medications to laser and light devices, have been reported with variable success. The authors report two cases of DSAP treated with the 1927-nm thulium fiber fractional laser along with a review of the treatment literature for DSAP. This therapy is convenient and safe with nearly no downtime or morbidity associated with pigment or textural changes.

Patient seeking behaviors and online personas: social media's role in cosmetic dermatology.

BACKGROUND: Social media sites, composed of providers, patients, and their social circles, facilitate health and healthcare delivery. OBJECTIVE: To examine patients' perspective on social media as an information source, communication tool, and referral service through an anonymous survey. In addition, influences on patient Internet personas, an actively constructed online identity, around the time of cosmetic procedures are examined. MATERIALS AND METHODS: Patients completed an anonymous institutional review board-approved survey during their initial cosmetic visit. RESULTS: Patients are highly active on social media using it as a multipurpose tool for physician referral services, support groups, and disease education. Patients gathered dermatology information from multiple sources, including friends, family, social media pages, and other online sources, often sharing their own experiences through social media platforms. Patients indicated a desire for provider educational materials on interactive media pages. Most preferred material written by a physician, but some indicated a preference for both physician and lay material. Online images highlighting dissatisfying skin features were influential to select patients, prompting manipulation of online personas and evaluation for aesthetic procedures. LIMITATIONS: Although the study examines cosmetic patient perspectives, data highlight valuable trends for all dermatologists. CONCLUSION: Social media can improve patient education, collaboration, recruitment, and online professional image, leading to healthier patient-centered care.

Davida Teller Award Lecture 2013: the importance of prediction and anticipation in the control of smooth pursuit eye movements.

The ability of smooth pursuit eye movements to anticipate the future motion of targets has been known since the pioneering work of Dodge, Travis, and Fox (1930) and Westheimer (1954). This article reviews aspects of anticipatory smooth eye movements, focusing on the roles of the different internal or external cues that initiate anticipatory pursuit.We present new results showing that the anticipatory smooth eye movements evoked by different cues differ substantially, even when the cues are equivalent in the information conveyed about the direction of future target motion. Cues that convey an easily interpretable visualization of the motion path produce faster anticipatory smooth eye movements than the other cues tested, including symbols associated arbitrarily with the path, and the same target motion tested repeatedly over a block of trials. The differences among the cues may be understood within a common predictive framework in which the cues differ in the level of subjective certainty they provide about the future path. Pursuit may be driven by a combined signal in which immediate sensory motion, and the predictions about future motion generated by sets of cues, are weighted according to their respective levels of certainty. Anticipatory smooth eye movements, an overt indicator of expectations and predictions, may not be operating in isolation, but may be part of a global process in which the brain analyzes available cues, formulates predictions, and uses them to control perceptual, motor, and cognitive processes.