Electromagnetic tracking of flexible robotic catheters enables "assisted navigation" and brings automation to endovascular navigation in an in vitro study.

OBJECTIVE: Combining three-dimensional (3D) catheter control with electromagnetic (EM) tracking-based navigation significantly reduced fluoroscopy time and improved robotic catheter movement quality in a previous in vitro pilot study. The aim of this study was to expound on previous results and to expand the value of EM tracking with a novel feature, assistednavigation, allowing automatic catheter orientation and semiautomatic vessel cannulation. METHODS: Eighteen users navigated a robotic catheter in an aortic aneurysm phantom using an EM guidewire and a modified 9F robotic catheter with EM sensors at the tip of both leader and sheath. All users cannulated two targets, the left renal artery and posterior gate, using four visualization modes: (1) Standard fluoroscopy (control). (2) 2D biplane fluoroscopy showing real-time virtual catheter localization and orientation from EM tracking. (3) 2D biplane fluoroscopy with novel EM assisted navigation allowing the user to define the target vessel. The robotic catheter orients itself automatically toward the target; the user then only needs to advance the guidewire following this predefined optimized path to catheterize the vessel. Then, while advancing the catheter over the wire, the assisted navigation automatically modifies catheter bending and rotation in order to ensure smooth progression, avoiding loss of wire access. (4) Virtual 3D representation of the phantom showing real-time virtual catheter localization and orientation. Standard fluoroscopy was always available; cannulation and fluoroscopy times were noted for every mode and target cannulation. Quality of catheter movement was assessed by measuring the number of submovements of the catheter using the 3D coordinates of the EM sensors. A t-test was used to compare the standard fluoroscopy mode against EM tracking modes. RESULTS: EM tracking significantly reduced the mean fluoroscopy time (P < .001) and the number of submovements (P < .02) for both cannulation tasks. For the posterior gate, mean cannulation time was also significantly reduced when using EM tracking (P < .001). The use of novel EM assisted navigation feature (mode 3) showed further reduced cannulation time for the posterior gate (P = .002) and improved quality of catheter movement for the left renal artery cannulation (P = .021). CONCLUSIONS: These results confirmed the findings of a prior study that highlighted the value of combining 3D robotic catheter control and 3D navigation to improve safety and efficiency of endovascular procedures. The novel EM assisted navigation feature augments the robotic master/slave concept with automated catheter orientation toward the target and shows promising results in reducing procedure time and improving catheter motion quality.

A Retrospective Study of 3,000 Indian Patients with Vitiligo Treated with Phototherapy or Topical Monotherapy.

BACKGROUND: Vitiligo-affected individuals, especially patients with darker skin tones, can suffer from negative psychosocial impacts due to unpredictable development of the condition and perceived cosmetic concerns. However, given that spontaneous repigmentation can be gained in vitiligo, many patients ask for treatment due to these cosmetic concerns. In the literature, only a few studies have been documented focusing on the outcome of various treatment modalities for vitiligo. OBJECTIVE: This article highlights the retrospective response of various treatment modalities in Indian patients with vitiligo. METHODS: A retrospective chart review was performed from July 2017 to August 2018 at our private dermatology clinic. A total of 3,000 patients were enrolled in this observational study. Patient characteristics and details of phototherapy (psoralen and ultraviolet A, narrow-band ultraviolet B, excimer laser) were noted as per a predefined format. The clinical response was evaluated as a marked response, defined as repigmentation in more than 75% of the initial lesional area. RESULTS: Of those included in this retrospective analysis, 1,996 patients received phototherapy and 1,004 patients were treated with topical monotherapy. Patients treated with phototherapy only and those treated with a combination of phototherapy and topical agents showed significantly higher clinical response rates relative to patients treated with topical monotherapy only (marked response rate: 47.8% vs. 8.7%; P<0.001 and 23.4% vs. 8.7%; P<0.001). Disease subtype predominately affected the treatment response. CONCLUSION: In Indian patients with vitiligo, phototherapy appears to be an effective treatment option for both focal and vitiligo vulgaris. Due to its reliability and minimal side effects, it can be considered a preferable treatment modality for vitiligo.

Pyoderma gangrenosum with an underlying ulcerative colitis associated with bone tuberculosis.

Pyoderma gangrenosum is a rare noninfective neutrophilic dermatosis, characterized by progressive painful ulceration. It is frequently associated with systemic disorders like inflammatory bowel disease, rheumatoid arthritis and myeloproliferative diseases. However, its association with infectious diseases in particular with tuberculosis is extremely rare. Diagnosis is based on the history of an underlying disease, a typical clinical presentation, histopathology and exclusion of other diseases leading to ulcerations of similar appearance. Immunosuppression with corticosteroids remains the mainstay of treatment. We report a case of a 49-year-old male with long-standing ulcerative colitis, associated with tuberculosis of hip, who presented with nonhealing ulcers over the lower extremity.

Kojic Acid vis-a-vis its Combinations with Hydroquinone and Betamethasone Valerate in Melasma: A Randomized, Single Blind, Comparative Study of Efficacy and Safety.

BACKGROUND: Melasma is a relatively common, acquired symmetric hypermelanosis characterized by irregular light to gray-brown macules involving sun-exposed areas. Kojic acid, with its depigmenting potential due to tyrosinase inhibition and suppression of melanogenesis, has become a vital component of the dermatologists' armamentarium against melasma. AIM: To study and compare the efficacy of kojic acid 1% alone, vis-a-vis its separate combinations with 2% hydroquinone or 0.1% betamethasone valerate and a combination of all these three agents with respect to the duration of symptoms and level of pigmentation in the therapy of melasma. MATERIALS AND METHODS: Eighty patients from a single tertiary care center objectively assessed by calculating the melasma area severity index (MASI) and randomized (simple randomization) into four parallel groups (A, B, C, and D) of 20 each were prescribed once daily local application at night, (participants blinded regarding the difference in identity of interventions), as follows: Group A - kojic acid 1% cream. Group B - kojic acid 1% and hydroquinone 2% cream. Group C - kojic acid 1% and betamethasone valerate 0.1% cream. Group D - kojic acid 1%, hydroquinone 2%, and betamethasone valerate 0.1% cream. Strict photoprotection and use of a SPF 15 sunscreen was advised during the day. Patients were evaluated every 2 weeks and a fall in MASI score was calculated at the end of the study period of 12 weeks by the same investigator. RESULTS: The response was compared according to percentage decrease in MASI score. Efficacy was evaluated among the groups at the end of 3 months using bivariate analysis and calculated by using the paired 't' test. The clinical efficacy of group B was the highest followed closely by group D and group A, that of group C being the lowest. CONCLUSION: Kojic acid in synergy with hydroquinone is a superior depigmenting agent as compared with other combinations.

Zosteriform skin metastases: clue to an undiagnosed breast cancer.

Cancer metastases represent the most devastating aspect of malignancy, since the mortality of cancer patients is mainly related to the metastatic behavior of the primary neoplasm. Skin metastases are usually late events in the course of tumor progression. Excluding melanoma, the most common tumor to metastasize to the skin is breast cancer. Patients who develop cutaneous metastases rarely present with a zosteriform distribution. Herein, we present a 60-year-old female, an undiagnosed case of breast cancer, with zosteriform metastases along her right T2-T3 dermatome.