Richter Syndrome Presenting as Subcutaneous Nodules and a Dermal Plaque.

ABSTRACT: Richter syndrome (RS) describes a phenomenon in which a patient with chronic lymphocytic leukemia (CLL) develops an aggressive lymphoma, most commonly diffuse large B-cell lymphoma (DLBCL). Reports of cutaneous RS remain exceedingly rare. We report a 61-year-old woman with relapsed/refractory CLL presenting with several subcutaneous nodules on her arms and legs and a single dermal plaque on her abdomen. Skin biopsy revealed a diagnosis of DLBCL, ABC-type, and her clinical status rapidly deteriorated following diagnosis. We review the variety of clinical presentations of cutaneous RS, its association with CLL, risk factors for RS development in CLL patients, and the distinctive histopathologic and immunophenotypic features of DLBCL. We hope to highlight the importance of prompt skin biopsy in patients with CLL presenting with progressive skin lesions and increase awareness of this aggressive clinical syndrome.

Use of Clinical Practice Guideline to Improve Management of Osteoarticular Infections in Children.

OBJECTIVES: Osteoarticular infections (OAIs) in children pose significant risks if incorrectly managed. We introduced a clinical practice guideline (CPG) to decrease use of broad-spectrum and intravenous (IV) antibiotics for OAI treatment. The primary aims of our project were to decrease the percent of patients with empirical broad cephalosporin use to 10% and decrease IV antibiotic therapy on discharge to 20% while increasing narrow-spectrum oral antibiotic use to 80% within 24 months. METHODS: We used quality improvement methodology to study patients diagnosed with OAIs. Interventions included multidisciplinary workgroup planning, CPG implementation, education, information technology, and stakeholder feedback. Outcome measures were the percentage of patients prescribed empirical broad-spectrum cephalosporins, percent discharged on IV antibiotics, and percent discharged on narrow-spectrum oral antibiotics. Process measures included percent of patients hospitalized on medicine service and infectious diseases consultation. Balancing measures included rates of adverse drug reactions, disease complications, length of stay, and readmission within 90 days. The impact of the interventions was assessed with run and control charts. RESULTS: A total of 330 patients were included over 96 months. The percentage of patients with empirical broad cephalosporin coverage decreased from 47% to 10%, percent discharged on IV antibiotics decreased from 75% to 11%, and percent discharged on narrow-spectrum oral antibiotics increased from 24% to 84%. Adverse drug reactions decreased from 31% to 10%. Rates of complications, readmissions, and length of stay were unchanged. CONCLUSIONS: Through development and implementation of a CPG for OAI management, we demonstrated decreased use of empirical broad-spectrum antibiotics and improved definitive antibiotic management.

Health-related articles on Syria before and after the start of armed conflict: a scoping review for The Lancet-American University of Beirut Commission on Syria.

INTRODUCTION: Armed conflict may influence the size and scope of research in Arab countries. We aimed to assess the impact of the 2011 Syrian conflict on health articles about Syria published in indexed journals. METHODS: We conducted a scoping review on Syrian health-related articles using seven electronic databases. We included clinical, biomedical, public health, or health system topics published between 1991 and 2017. We excluded animal studies and studies conducted on Syrian refugees. We used descriptive and social network analyses to assess the differences in rates, types, topics of articles, and authorship before and after 2011, the start of the Syrian conflict. RESULTS: Of 1138 articles, 826 (72.6%) were published after 2011. Articles published after 2011 were less likely to be primary research; had a greater proportion reporting on mental health (4.6% vs. 10.0%), accidents and injuries (2.3% vs. 18.8%), and conflict and health (1.7% vs. 7.8%) (all p < 0.05); and a lower proportion reporting on child and maternal health (8.1 to 3.6%, p = 0.019). The proportion of research articles reporting no funding increased from 1.1 to 14.6% (p < 0.01). While international collaborations increased over time, the number of articles with no authors affiliated to Syrian institutions overtook those with at least one author affiliation to a Syrian institution for the first time in 2015. CONCLUSION: To our knowledge, this is the first study to examine the impact of armed conflict on health scholarship in Syria. The Syrian conflict was associated with a change in the rates, types, and topics of the health-related articles, and authors' affiliations. Our findings have implications for the prioritization of research funding, development of inclusive research collaborations, and promoting the ethics of conducting research in complex humanitarian settings.

Minimally Invasive Facial Cosmetic Procedures for the Millennial Aesthetic Patient.

Millennials, defined as the generation of individuals born between 1981 and 1996, have emerged as one of the leading patient demographics seeking minimally invasive cosmetic procedures. Worldwide, millennials are more likely to consider preventative treatments compared to any other age-group. The three most popular minimally invasive facial procedures in this demographic include botulinum toxin, dermal fillers (eg, hyaluronic acid, calcium hydroxylapatite, facial fat-fillers), and microdermabrasion. Given their impact on the expanding aesthetic medicine market and their favorable disposition towards cosmetic procedures, it is necessary for dermatologists and cosmetic providers to understand their motivations and perspectives. While some research studies have elicited the opinions of millennials on social issues, education, and technology, there is a paucity of literature on millennials' impressions, opinions, and perceptions of aesthetic procedures. As a generation that has been reshaping the culture of healthcare delivery and encouraging the innovation of products and procedures with their unique values and perspectives, accounting for their beliefs and fostering a better understanding of their experiences will promote an elevation in the quality of their care.

Fusiform Gyrus Dysfunction is Associated with Perceptual Processing Efficiency to Emotional Faces in Adolescent Depression: A Model-Based Approach.

While the extant literature has focused on major depressive disorder (MDD) as being characterized by abnormalities in processing affective stimuli (e.g., facial expressions), little is known regarding which specific aspects of cognition influence the evaluation of affective stimuli, and what are the underlying neural correlates. To investigate these issues, we assessed 26 adolescents diagnosed with MDD and 37 well-matched healthy controls (HCL) who completed an emotion identification task of dynamically morphing faces during functional magnetic resonance imaging (fMRI). We analyzed the behavioral data using a sequential sampling model of response time (RT) commonly used to elucidate aspects of cognition in binary perceptual decision making tasks: the Linear Ballistic Accumulator (LBA) model. Using a hierarchical Bayesian estimation method, we obtained group-level and individual-level estimates of LBA parameters on the facial emotion identification task. While the MDD and HCL groups did not differ in mean RT, accuracy, or group-level estimates of perceptual processing efficiency (i.e., drift rate parameter of the LBA), the MDD group showed significantly reduced responses in left fusiform gyrus compared to the HCL group during the facial emotion identification task. Furthermore, within the MDD group, fMRI signal in the left fusiform gyrus during affective face processing was significantly associated with greater individual-level estimates of perceptual processing efficiency. Our results therefore suggest that affective processing biases in adolescents with MDD are characterized by greater perceptual processing efficiency of affective visual information in sensory brain regions responsible for the early processing of visual information. The theoretical, methodological, and clinical implications of our results are discussed.

Altered insular activation and increased insular functional connectivity during sad and happy face processing in adolescent major depressive disorder.

BACKGROUND: Major depressive disorder (MDD) is a leading cause of disability worldwide and occurs commonly first during adolescence. The insular cortex (IC) plays an important role in integrating emotion processing with interoception and has been implicated recently in the pathophysiology of adult and adolescent MDD. However, no studies have yet specifically examined the IC in adolescent MDD during processing of faces in the sad-happy continuum. Thus, the aim of the present study is to investigate the IC during sad and happy face processing in adolescents with MDD compared to healthy controls (HCL). METHODS: Thirty-one adolescents (22 female) with MDD and 36 (23 female) HCL underwent a well-validated emotional processing fMRI paradigm that included sad and happy face stimuli. RESULTS: The MDD group showed significantly less differential activation of the anterior/middle insular cortex (AMIC) in response to sad versus happy faces compared to the HCL group. AMIC also showed greater functional connectivity with right fusiform gyrus, left middle frontal gyrus, and right amygdala/parahippocampal gyrus in the MDD compared to HCL group. Moreover, differential activation to sad and happy faces in AMIC correlated negatively with depression severity within the MDD group. LIMITATIONS: Small age-range and cross-sectional nature precluded assessment of development of the AMIC in adolescent depression. CONCLUSIONS: Given the role of the IC in integrating bodily stimuli with conscious cognitive and emotional processes, our findings of aberrant AMIC function in adolescent MDD provide a neuroscientific rationale for targeting the AMIC in the development of new treatment modalities.

Standardization of the NEO-PI-3 in the Greek general population.

BACKGROUND: The revised NEO Personality Inventory (NEO-PI-3) includes 240 items corresponding to the Big Five personality traits (Extraversion, Agreeableness, Conscientiousness, Neuroticism, and Openness to Experience) and subordinate dimensions (facets). It is suitable for use with adolescents and adults (12 years or older). The aim of the current study was to validate the Greek translation of the NEO-PI-3 in the general Greek population. MATERIAL AND METHODS: The study sample included 734 subjects from the general Greek population of whom 59.4% were females and 40.6% males aged 40.80 ± 11.48. The NEO-PI-3 was translated into Greek and back-translated into English, and the accuracy of the translation was confirmed and established. The statistical analysis included descriptive statistics, confirmatory factorial analysis (CFA), the calculation of Cronbach's alpha, and the calculation of Pearson product-moment correlations. Sociodemographics groups were compared by ANOVA. RESULTS: Most facets had Cronbach's alpha above 0.60. Confirmatory factor analysis showed acceptable loading of the facets on their own hypothesized factors and very good estimations of Cronbach's alphas for the hypothesized factors, so it was partially supportive of the five-factor structure of the NEO-PI-3.The factors extracted with Procrustes rotation analysis can be considered reasonably homologous to the factors of the American normative sample. Correlations between dimensions were as expected and similar to those reported in the literature. DISCUSSION: The literature suggests that overall, the psychometric properties of NEO-PI-3 scales have been found to generalize across ages, cultures, and methods of measurement. In accord with this, the results of the current study confirm the reliability of the Greek translation and adaptation of the NEO-PI-3. The inventory has comparable psychometric properties in its Greek version in comparison to the original and other national translations, and it is suitable for clinical as well as research use.