Unusual presentations of chronic graft versus host disease.

Skin is commonly affected by graft versus host disease (GVHD), a complication of bone marrow transplantation (BMT). One-third of hematopoietic cell transplantation recipients develop acute eruption classically described as folliculocentric, maculopapular, or morbilliform, in contrast to the more common chronic presentations of sclerotic, poikilodermic, or lichenoid dermatitides. With the wider use of non-myeloablative (reduced-intensity) transplant therapy, various atypical presentations can occur, representing a diagnostic challenge. Herein, we report an unusual case of chronic GVHD manifested by two distinct clinical and histopathological features lacking the classical presentation. Five months after her BMT, the patient presented with a papulosquamous eruption on her neck, trunk, and arms showing a psoriasiform histopathological pattern of chronic GVHD. She also demonstrated multiple small flesh-colored papules on her distal extremities showing a solitary syringotropic pattern of GVHD, demonstrated by interface dermatitis involving the superficial eccrine duct, as the only diagnostic histopathological feature of GVHD. This report, with review of literature, highlights the uncommon psoriasiform GVHD and the novel description of isolated syringotropic chronic GVHD.

Anti-PL-7, anti-Ro/SSA, anti-Mi-2, and anti-TIF1-γ correlate with specific patterns of histopathologic features in dermatomyositis: An analysis of 39 skin biopsy specimens from 25 patients.

BACKGROUND: In dermatomyositis (DM), myositis-specific and myositis-associated antibodies have been correlated with clinical features. It is unknown if histopathologic findings in lesional skin biopsies correlate with serologic subtypes of DM. METHODS: A retrospective chart review of patients with DM was performed. Patients with myositis antibodies and DM lesional skin biopsies were included in the study. Skin biopsies were reviewed by blinded dermatopathologists for 20 histopathologic features. RESULTS: There was a statistically significant (p < 0.05) association between anti-PL-7 serology and decreased degree of vacuolar degeneration, necrotic keratinocytes, and thickening of the epidermal basement membrane. Anti-aminoacyl tRNA synthetase (anti-ARS) antibodies had the same significant negative association with degree of vacuolar degeneration, necrotic keratinocytes, and thickening of the epidermal basement membrane. A similar pattern was seen with an anti-cytoplasmic serology; where there was a significant association with an increased degree of vacuolar degeneration and necrotic keratinocytes, and a nonsignificant trend of minimally thickened epidermal basement membrane. There was a statistically significant association between anti-Ro/SSA serology and increased degree of vacuolar degeneration. Anti-TIF1-γ serology was significantly associated with the increased presence of necrotic keratinocytes and pigment incontinence, and displayed a pattern of increased neutrophils. There was a significant association between anti-Mi-2 antibodies and pigment incontinence, as well as between myositis-specific antibodies and pigment incontinence. A statistically significant positive association was found between nuclear antibodies and degree of vacuolar degeneration, thickened epidermal basement membrane, pigment incontinence, and epidermal atrophy. CONCLUSION: In patients with DM, some specific serotypes, including anti-PL-7, anti-Ro/SSA, anti-Mi-2, and anti-TIF1-γ, may have characteristic histopathologic features.

Adjunctive hyperbaric oxygen treatment for challenging pyoderma gangrenosum cases.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare, difficult-to-treat neutrophilic ulcerative cutaneous condition that severely impacts those affected. Treatment options for PG are limited, and disease remission is not guaranteed. Hyperbaric oxygen treatment is a potential therapeutic option for treating various ulcerative conditions not frequently utilized for PG. CASE REPORT: We present a case of a patient with treatment-resistant PG who achieved remission with adjunctive HBOT, and then later had difficulty achieving remission without HBOT during a future flare. DISCUSSION: HBOT should be more readily considered as a treatment option for those with PG.

The Role of the Microbiome in Gastroentero-Pancreatic Neuroendocrine Neoplasms (GEP-NENs).

Gut microbiome balance plays a key role in human health and maintains gut barrier integrity. Dysbiosis, referring to impaired gut microbiome, is linked to a variety of diseases, including cancers, through modulation of the inflammatory process. Most studies concentrated on adenocarcinoma of different sites with very limited information on gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs). In this study, we have analyzed the gut microbiome (both fungal and bacterial communities) in patients with metastatic GEP-NENs. Fecal samples were collected and compared with matched healthy control samples using logistic regression distances utilizing R package MatchIt (version 4.2.0, Daniel E. Ho, Stanford, CA, USA). We examined differences in microbiome profiles between GEP-NENs and control samples using small subunit (SSU) rRNA (16S), ITS1, ITS4 genomic regions for their ability to accurately characterize bacterial and fungal communities. We correlated the results with different behavioral and dietary habits, and tumor features including differentiation, grade, primary site, and therapeutic response. All tests are two-sided and p-values ≤ 0.05 were considered statistically significant. Gut samples of 34 patients (12 males, 22 females, median age 64 years) with metastatic GEP-NENs (22 small bowel, 10 pancreatic, 1 gall bladder, and 1 unknown primary) were analyzed. Twenty-nine patients had well differentiated GEP-neuroendocrine tumors (GEP-NETs), (G1 = 14, G2 = 12, G3 = 3) and five patients had poorly differentiated GEP-neuroendocrine carcinomas (GEP-NECs). Patients with GEP-NENs had significantly decreased bacterial species and increased fungi (notably Candida species, Ascomycota, and species belonging to saccharomycetes) compared to controls. Patients with GEP-NECs had significantly enriched populations of specific bacteria and fungi (such as Enterobacter hormaechei, Bacteroides fragilis and Trichosporon asahii) compared to those with GEP-NETs (p = 0.048, 0.0022 and 0.034, respectively). In addition, higher grade GEP-NETs were associated with significantly higher Bacteroides fragilis (p = 0.022), and Eggerthella lenta (p = 0.00018) species compared to lower grade tumors. There were substantial differences associated with dietary habits and therapeutic responses. This is the first study to analyze the role of the microbiome environment in patients with GEP-NENs. There were significant differences between GEP-NETs and GEP-NECs, supporting the role of the gut microbiome in the pathogenesis of these two distinct entities.

Gastrointestinal Microbiome and Mycobiome Changes during Autologous Transplantation for Multiple Myeloma: Results of a Prospective Pilot Study.

Microbiome dysbiosis has been associated with adverse outcomes of hematopoietic cell transplantation (HCT). We hypothesized that exposure to high-dose melphalan and antimicrobials in patients undergoing autologous HCT for plasma cell disorders results in oral and gastrointestinal microbial dysbiosis, which in turn is associated with regimen-related toxicities. We conducted a prospective study describing the longitudinal changes in oral and gastrointestinal bacteriome and mycobiome in this patient population. Our findings show that microbiome composition present at baseline is associated with the incidence and severity of post-transplantation nausea, vomiting, and culture-negative neutropenic fever, as well as with the rate of neutrophil engraftment. We also have evidence of an association between the microbial communities at count nadir and the development of regimen-related gastrointestinal toxicities commonly observed after exposure to high-dose melphalan. Although bacteriome diversity largely recovers within 1 month after transplantation, we observed a continuous decrease in oral and gastrointestinal mycobiome diversity, suggesting that the mycobiome requires a longer time to recover compared with the bacteriome.

Therapeutic options and postoperative wound complications after extremity soft tissue sarcoma resection and postoperative external beam radiotherapy.

Soft tissue sarcomas occur most commonly in the lower and upper extremities. The standard treatment is limb salvage surgery combined with radiotherapy. Postoperative radiotherapy is associated with wound complications. This systematic review aims to summarise the available evidence and review the literature of the last 10 years regarding postoperative wound complications in patients who had limb salvage surgical excision followed by direct closure vs flap coverage together with postoperative radiotherapy and to define the optimal timeframe for adjuvant radiotherapy after soft tissue sarcomas resection and flap reconstruction. A literature search was performed using PubMed. The following keywords were searched: limb salvage, limb-sparing, flaps, radiation therapy, radiation, irradiation, adjuvant radiotherapy, postoperative radiotherapy, radiation effects, wound healing, surgical wound infection, surgical wound dehiscence, wound healing, soft tissue sarcoma and neoplasms. In total, 1045 papers were retrieved. Thirty-seven articles were finally selected after screening of abstracts and applying dates and language filters and inclusion and exclusion criteria. Plastic surgery provides a vast number of reconstructive flap procedures that are directly linked to decreasing wound complications, especially with the expectant postoperative radiotherapy. This adjuvant radiotherapy is better administered in the first 3-6 weeks after reconstruction to allow timely wound healing and avoid local recurrence.

The Emerging Pathogen Candida auris: Growth Phenotype, Virulence Factors, Activity of Antifungals, and Effect of SCY-078, a Novel Glucan Synthesis Inhibitor, on Growth Morphology and Biofilm Formation.

Candidaauris, a new multidrug-resistant Candida spp. which is associated with invasive infection and high rates of mortality, has recently emerged. Here, we determined the virulence factors (germination, adherence, biofilm formation, phospholipase and proteinase production) of 16 C. auris isolates and their susceptibilities to 11 drugs belonging to different antifungal classes, including a novel orally bioavailable 1,3-ß-d-glucan synthesis inhibitor (SCY-078). We also examined the effect of SCY-078 on the growth, ultrastructure, and biofilm-forming abilities of C. auris Our data showed that while the tested strains did not germinate, they did produce phospholipase and proteinase in a strain-dependent manner and had a significantly reduced ability to adhere and form biofilms compared to that of Candida albicans (P = 0.01). C. auris isolates demonstrated reduced susceptibility to fluconazole and amphotericin B, while, in general, they were susceptible to the remaining drugs tested. SCY-078 had an MIC90 of 1 mg/liter against C. auris and caused complete inhibition of the growth of C. auris and C. albicans Scanning electron microscopy analysis showed that SCY-078 interrupted C. auris cell division, with the organism forming abnormal fused fungal cells. Additionally, SCY-078 possessed potent antibiofilm activity, wherein treated biofilms demonstrated significantly reduced metabolic activity and a significantly reduced thickness compared to the untreated control (P < 0.05 for both comparisons). Our study shows that C. auris expresses several virulence determinants (albeit to a lesser extent than C. albicans) and is resistant to fluconazole and amphotericin B. SCY-078, the new orally bioavailable antifungal, had potent antifungal/antibiofilm activity against C. auris, indicating that further evaluation of this antifungal is warranted.

Assessment of Medical Students' Knowledge of Ocular First Aid During Trauma: A Cross-Sectional Study From King Abdulaziz University.

Background Ocular trauma is defined as an eye injury of diverse types and subtypes, all of which can threaten vision. Hence, a precise first-aid approach is crucial to salvage the eyes and prevent blindness. Therefore, this study was designed to assess the level of knowledge among medical students at King Abdulaziz University (KAU) and identify factors that affect knowledge regarding ocular first aid in cases of trauma. Methodology A cross-sectional approach was used, targeting KAU medical students. First, students were asked to voluntarily respond to a previously used questionnaire that contained demographic data, including gender, marital status, socioeconomic status, academic year, and city of residence, followed by a history of ocular trauma. Then, questions were asked to assess their knowledge regarding different types of ocular trauma and proper first aid. Results A total of 310 participants responded to the questionnaire. Participants included both sexes, with 169 (50.8%) being males. Only 89 (26.7%) participants had a history of managing ocular injury. Knowledge levels were divided into good 76 (27%) and poor 201 (73%). Third-year students had the highest percentage of poor knowledge, whereas sixth-year students had the highest level of knowledge. The source of knowledge was mainly from studies. Conclusions The ocular first-aid knowledge level was predominantly poor, accounting for 201 (73%) of all responses. Thus, steps to enhance knowledge should be taken.

The impact of prices and pricing units on residual and organic waste: Evidence from Wallonia, Belgium.

Waste pricing is important to encourage households to reduce their waste and to increase sorting and recycling. Pricing instruments include differentiated prices for the waste fractions collected and the choice of an appropriate pricing unit (volume, weight, levy). In this paper, we test the effectiveness of those different instruments using an original and complete dataset from Wallonia (the southern region of Belgium), covering 10 years and all the 262 municipalities of the region. Our approach is to estimate the sensitivity of households' production of residual and organic waste to prices i.e., the price elasticities, using sophisticated econometric techniques to control for the endogeneity of prices. For residual waste, we show a significant own-price elasticity, which is higher when organic waste is not collected at the curbside. For organic waste, we found an important and significant cross-price elasticity, but a limited own-price elasticity. Hence, the privileged instrument to encourage waste reduction and sorting should be the price of residual waste. Finally, we show that the weight-based pricing system contributes substantially to the reduction of residual waste.

Skin and gut microbial associations with squamous cell carcinoma in solid organ transplant recipients.

Solid organ transplant recipients (SOTRs) are burdened with a significantly higher risk of squamous cell carcinoma (SCC) compared to the general population. Accumulating evidence suggests the potential influence of microbial dysbiosis on transplant outcomes. Based on these observations, we sought to identify differences in the cutaneous and gut microbiomes of SOTRs with and without a history of SCC. This case-control study collected and analyzed non-lesional skin and fecal samples of 20 SOTRs > 18 years old with either ≥ 4 diagnoses of SCC since most recent transplant (n = 10) or 0 diagnoses of SCC (n = 10). The skin and gut microbiomes were investigated with Next-Generation Sequencing, and analysis of variance (ANOVA) followed by Tukey pairwise comparison procedure was used to test for differences in taxonomic relative abundances and microbial diversity indices between the two cohorts. Analyses of the skin microbiome showed increased bacterial and reduced fungal diversity in SOTRs with a history of SCC compared to SOTRs without a history of SCC (bacterial median Shannon diversity index (SDI) = 3.636 and 3.154, p < 0.05; fungal SDI = 4.474 and 6.174, p < 0.05, respectively). Analyses of the gut microbiome showed reduced bacterial and fungal diversity in the SCC history cohort compared to the SCC history-negative cohort (bacterial SDI = 2.620 and 3.300, p < 0.05; fungal SDI = 3.490 and 3.812, p < 0.05, respectively). The results of this pilot study thus show a trend toward the bacterial and fungal communities of the gut and skin being distinct in SOTRs with a history of SCC compared to SOTRs without a history of SCC. It furthermore demonstrates the potential for microbial markers to be used in the prognostication of squamous cell carcinoma risk in solid organ transplant recipients.

Barriers to Using Breast Cancer Screening Methods Among Adult Females in Jeddah, Saudi Arabia: A Cross-Sectional Study.

Introduction Breast cancer (BC) is one of the most common cancers worldwide and it considerably increases morbidity and mortality globally. Screening methods, such as self-examination, clinical examination, and mammography, can help in early detection and treatment, which will help in improving survival rates and reducing mortality. While regular screening of the breast is essential to detect the earliest stages of breast cancer, not all women adhere to regular breast screening. Methods A cross-sectional study was conducted in Jeddah, Saudi Arabia, between December 2021 to July 2022. using an online self-administered questionnaire. The total number of responses (n = 328), Data was analyzed using SPSS 25. Results In this study, out of the 328 respondents, 18.9% reported undergoing regular mammography, 14.3% reported having regular clinical breast examinations, and 38.1% reported practicing regular breast self-examinations.. In addition, the participants' most known warning signs of BC were a lump under their armpit (69.1%). the most perceived barrier to breast self-examination (BSE) was Doing a breast examination will make her worry about what is wrong with her breast (47%). whereas the most barrier to clinical breast examination (CBE) was embarrassment (45.9%). On the other hand, the main barriers that prevented women from having mammograms were embarrassment (36%) and pain (32.6%). Conclusion The most perceived barrier to BSE was women's concern, while embarrassment and painful procedures were significant barriers to performing mammography and CBE. Therefore, adult females in Jeddah need educational programs to improve their knowledge and increase public awareness of breast cancer screening for early detection.

Electrolyte imbalance in infectious disease patients at King Abdulaziz Hospital, Jeddah.

Objectives: Infectious diseases are the common cause of morbidity and mortality among humans. Electrolyte imbalance occurs frequently in patients with infectious diseases. This study aims to identify electrolyte imbalances in hospitalised patients with infectious diseases. Methods: Two hundred and eighty-three patients with age mean 36.48 ± 18.86 years, consisting of 127 (53.4%) males, 111 (46.6%) females, enrolled in a retrospective cohort study carried out at the King Abdulaziz University Hospital, Jeddah, KSA from September to December 2020. All hospitalised patients with infectious diseases were included. Demographic data, comorbidity, and diagnosis were collected from patients' sheets. Serum levels of electrolytes (chloride, potassium, sodium), urea, and creatinine were collected at admission (period 1), during hospital stay (period 2), and at discharge (period 3). Levels were compared during different periods. Results: Most infectious diseases were viral infections (63.4%), while comorbidity was diabetes mellitus (7.1%). Serum chloride elevated from period 1 to period 3 (P = 0.046). Sodium elevated between period 1 and both period 2 and period 3 (P < 0.001). Urea decreased between period 1 and both period 2 (P = 0.018) and period 3 (P < 0.001). Creatinine decreased between period 1 and both period 2 and period 3 (P < 0.001) and between period 2 and period 3 (P < 0.001). Patients with decreased chloride and sodium levels were mostly in the 1st period, while those with decreased potassium levels were mostly in the period 2. Conclusion: Prevalence of electrolyte imbalance in hospitalised patients with an infectious disease at the King Abdulaziz University Hospital, Jeddah was high, especially at admission and during the hospital stay.

Incidence of Coronary Artery Disease in King Abdulaziz University Hospital, Jeddah, Saudi Arabia, 2019-2020: A Retrospective Cohort Study.

Background Coronary artery disease (CAD) remains a significant cause of death and morbidity in people globally despite advances in treatment. Prevention of CAD risk factors is crucial to reducing its prevalence. We conducted this study to determine the incidence of CAD from 2019 to 2020 in King Abdulaziz University Hospital (KAUH), Jeddah, Kingdom of Saudi Arabia (KSA), and its major risk factors among this population. Method This retrospective study involved all patients diagnosed with CAD at KAUH in 2019 and 2020. We analyzed validated hospital data to determine the incidence of CAD and identify the risk factors among participants. The incidence of CAD was calculated based on the total number of patients admitted to KAUH by gender, age group, and nationality (Saudi/non-Saudi). Result The study included 1,364 patients with a mean age of 49 years. Most patients were men (n=1,050; 77%), with fewer women (n=314; 23%), and 71.2% were non-Saudi. The incidence of CAD in 2019 was 220.98 per 10,000, and the incidence in 2020 was 3,030.52 per 10,000. However, the incidence for 2020 was confounded by the coronavirus disease 2019 pandemic-related restrictions affecting hospital admissions. The most common diagnosis was acute transmural myocardial infarction, and patients aged <60 years had a significantly high incidence of hypertension, high total cholesterol levels, low low-density lipoprotein levels, and high triglyceride levels. Patients ≥60 years had a significantly high incidence of chronic kidney disease, low hemoglobin levels, history of ischemic heart disease, and intensive care unit or critical care unit admission. Conclusion The study demonstrated a significant rise in CAD incidence associated with advanced age and male sex. Further prevention and control of these risk factors would be essential to decrease the incidence of CAD. A national community-based prevention effort should be implemented to avoid the expected CAD epidemic in KSA.

The Correlation Between Wearing Face Masks and Skin Damage in Adults During the COVID-19 Pandemic: A Cross-Sectional Study in Jeddah, Saudi Arabia.

Background The impact of COVID-19 on the world is rapidly spreading among countries. According to WHO, wearing face masks was recommended to prevent its spread. After regular use of face masks, some people have experienced common skin disorders such as facial acne, rash, and eczema. This paper aims to cite the prevalence and potential risk of wearing a face mask on the skin by exploring some of the rationales that have been established in the literature. Methodology A cross-sectional study was carried out in Jeddah, Saudi Arabia in November 2021. A self-administered online questionnaire was distributed among 389 participants from the adult public to find the correlation between face mask wearing and skin damage during the COVID-19 pandemic. Statistical analysis was conducted using the IBM SPSS statics for windows, version 25.0 (IBM Corp., Armonk, USA) to evaluate and test the hypothesis. Results The study included 389 participants; 63.8% of them were female and 36.2% were male. The main result of this study was that there was a statistically significant association between the duration and frequency of wearing a face mask and developing skin damage. 58.1% of the participants were using face masks for more than 4 hours. Furthermore, 22% and 59.1% of the male and female participants, respectively, said they noticed adverse skin reactions on their faces after using a face mask. Conclusion Our study revealed that 46% of the participants noticed adverse skin reactions on the face by wearing a face mask. Females had a significantly higher chance of developing skin irritation than males.

Impact of Altered Gut Microbiota and Its Metabolites in Cystic Fibrosis.

Cystic fibrosis (CF) is the most common lethal, multisystemic genetic disorder in Caucasians. Mutations in the gene encoding the cystic fibrosis transmembrane regulator (CFTR) protein are responsible for impairment of epithelial anionic transport, leading to impaired fluid regulation and pH imbalance across multiple organs. Gastrointestinal (GI) manifestations in CF may begin in utero and continue throughout the life, resulting in a chronic state of an altered intestinal milieu. Inherent dysfunction of CFTR leads to dysbiosis of the gut. This state of dysbiosis is further perpetuated by acquired factors such as use of antibiotics for recurrent pulmonary exacerbations. Since the gastrointestinal microbiome and their metabolites play a vital role in nutrition, metabolic, inflammatory, and immune functions, the gut dysbiosis will in turn impact various manifestations of CF-both GI and extra-GI. This review focuses on the consequences of gut dysbiosis and its metabolic implications on CF disease and possible ways to restore homeostasis.

Acute Kidney Injury as a Risk Factor for Cerebrovascular Disease Outcome among Patients Presenting with Stroke in King Abdulaziz University Hospital, Jeddah, Saudi Arabia: A Retrospective Cohort Study.

Patients suffering from stroke may develop different complications including acute kidney injury (AKI). AKI affects mortality among the stroke patients. The association between stroke and AKI despite extensive research has been not completely understood. The study aimed to determine an AKI as an independent poor risk factor of cerebrovascular disease outcome among the stroke patients. Our objectives were to estimate AKI incidence among stroke patients at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia, between 2013 and 2017 and assess the major risk factors related to AKI among stroke patients. The research population was sourced from the publicly available KAUH records from 2013 to 2017. The total number of stroke cases was 717 with a mean age of 63.94 ± 15.70 years. As many as 83.5% of cases had no AKI and 16.5% were suffered from AKI among total stroke patients studied. Furthermore, 74.1% of stroke patients were alive compared to 25.9% reported dead. The study concluded that AKI incidence is higher in stroke patients after admission immediately or during hospitalization. As such, the renal function file could be used as an early indicator upon stroke patients' admission to health-care facilities. Prevention and control of AKI seem to be very important among patients with stroke.

Knowledge and attitude towards hydrocephalus among healthcare providers and the general population in Saudi Arabia.

BACKGROUND: Hydrocephalus is a worldwide disorder characterized by abnormal flow or rarely excessive production of cerebrospinal fluid, leading to the widening of the cerebral ventricles system due to the accumulation of the cerebrospinal fluid in the brain. Previous researches have shown that knowledge about the disorder is limited among healthcare providers and the population, affecting attitudes toward patients, as well as patient outcomes. AIM: To investigate healthcare providers and population's knowledge and attitudes towards hydrocephalus in Saudi Arabia. METHODOLOGY: A descriptive cross-sectional study was conducted through an electronic questionnaire. The survey was self-constructed in Arabic and English by the research team and inspired by other awareness questionnaires and validated before use by three experts. RESULTS: There were 444 participants in this study, aged between 17 and 73 years with a mean age of 32.60 ± 10.98. Most of the participants were from the general population (74.8%). More than half of the participants had a bachelor's degree (60.1%). 38.4% of healthcare providers had negative knowledge while 61.6% had positive knowledge. In addition, 82.5% of the general population had negative knowledge, although 17.5% had positive knowledge. Moreover, it was observed that 17.0% of the healthcare providers had a bad attitude while 83.0% had a good attitude. In addition, 60.2% of the general population had a bad attitude, whereas 39.8% had a good attitude. CONCLUSION: This study revealed that the level of knowledge and attitude towards hydrocephalus among healthcare providers was good on both aspects, while it was poor among the general population.

Fasting and Its Impact on Skin Anatomy, Physiology, and Physiopathology: A Comprehensive Review of the Literature.

Skin serves as the first protective line and barrier of the body. Like many other organs, skin can be affected by several disorders in response to external factors such as pathogens, ultraviolet light, and pollution, as well as endogenous alterations related to aging and/or oxidative stress disturbance. Researchers have reported new insights into how skin cells are altered in response to caloric restriction diets in mammals. One of the most well-known caloric restriction diets is the Ramadan intermittent fasting, which is a radical change in the diet plan of practitioners for the period of one lunar month. Ramadan fasting represents the fourth of the five pillars of the Islamic creed. Even though infirm individuals are waived to take part in this religious duty, patients with various health problems, including those with different skin disorders, might choose to share this event with peers and family members. No standardized protocols or guidelines exist, however, to advise their physicians on the proper management of their patients' condition during fasting. With an increasing Muslim population living in Western countries, this topic has started to draw substantial attention, not only of Middle-Eastern physicians, but also of clinicians in the West. For this purpose, we carried out a comprehensive overview on the topic. Our main findings are that: (1) there is a strong need for evidence-based suggestions and guidance. Literature on the impact of the Ramadan fasting, as well as of other kinds of fasting, on skin diseases is scarce and of poor quality, as well as the information available from the Internet; (2) patients willing to fast should be advised about the importance of taking proper treatments or consider alternative options including administration of trans-dermal/topical drugs, as they are permitted during daylight hours. Further, non-compliance has important, clinical and economic implications for an effective patient management.

A Survey of Knowledge, Attitudes, and Practices of Providers and Staff at Al-Zahraa University Hospital Regarding the Baby-Friendly Hospital Initiative and the International Code of Marketing Breast Milk Substitutes.

Four hundred eight providers and staff members who care for breastfeeding mothers and babies at Al-Zahraa University Hospital, Cairo, Egypt were randomly selected to assess their knowledge, attitudes, and practices regarding the Baby-Friendly Hospital Initiative. The majority of the participants scored above 50% on the knowledge and attitude questions, however, on the practice questions only 45.3% scored above 50%, similar to the result obtained 10 years prior. The results indicate that most attention should be focused on developing practice guidelines and monitoring outcomes since knowledge and attitude were found to be adequate. We would recommend self-appraisal of staff as a first step to others whose hospitals are in the process of implementing the Baby-Friendly Hospital Initiative.

Neutrophilic Dermatoses and Their Implication in Pathophysiology of Asthma and Other Respiratory Comorbidities: A Narrative Review.

Neutrophilic dermatoses (ND) are a polymorphous group of noncontagious dermatological disorders that share the common histological feature of a sterile cutaneous infiltration of mature neutrophils. Clinical manifestations can vary from nodules, pustules, and bulla to erosions and ulcerations. The etiopathogenesis of neutrophilic dermatoses has continuously evolved. Accumulating genetic, clinical, and histological evidence point to NDs being classified in the spectrum of autoinflammatory conditions. However, unlike the monogenic autoinflammatory syndromes where a clear multiple change in the inflammasome structure/function is demonstrated, NDs display several proinflammatory abnormalities, mainly driven by IL-1, IL-17, and tumor necrosis factor-alpha (TNF-a). Additionally, because of the frequent association with extracutaneous manifestations where neutrophils seem to play a crucial role, it was plausible also to consider NDs as a cutaneous presentation of a systemic neutrophilic condition. Neutrophilic dermatoses are more frequently recognized in association with respiratory disorders than by chance alone. The combination of the two, particularly in the context of their overlapping immune responses mediated primarily by neutrophils, raises the likelihood of a common neutrophilic systemic disease or an aberrant innate immunity disorder. Associated respiratory conditions can serve as a trigger or may develop or be exacerbated secondary to the uncontrolled skin disorder. Physicians should be aware of the possible pulmonary comorbidities and apply this knowledge in the three steps of patients' management, work-up, diagnosis, and treatment. In this review, we attempt to unravel the pathophysiological mechanisms of this association and also present some evidence for the role of targeted therapy in the treatment of both conditions.