Serum triamcinolone levels during intensive, inpatient wet-dressing therapy.

BACKGROUND: Wet dressings combined with topical corticosteroids are beneficial for patients with generalized and refractory dermatosis; however, to our knowledge, serum levels after topical corticosteroid absorption during intensive therapy have not been reported previously. AIM: To examine serum levels of triamcinolone acetonide (TAC) after topical corticosteroid application during intensive wet-dressing therapy. METHODS: We performed a retrospective study of adult patients admitted for inpatient wet-dressing therapy from 7 November 2015 to 24 June 2016. Data were collected on sex, age, body surface area, TAC serum levels, number of wet-dressing changes after 24 and 48 h, and type of wet dressing. RESULTS: In total, 29 patients (14 men, 15 women) were assessed. Median [interquartile range (IQR)] age was 57 years (51.5-67.0 years) and involved body surface area was 1.98 m2 (1.88-2.15) m2 . Before the 24-hour blood draw, patients had received 1-3 dressing changes. Median (IQR) TAC level at 24 h was 0.33 µg/dL (0.20-0.58 µg/dL), with no significant difference noted between the number of dressing changes and TAC serum level. At 48 h, results of a serum TAC test were available for 22 patients with 2-6 dressing changes. Mean (IQR) serum level was 0.30 µg/dL (0.30-0.87 µg/dL). For each additional dressing change, there was an estimated 0.21 µg/dL increase in TAC serum level (95% CI 0.11-0.31; P < 0.001). TAC serum level was not significantly associated with sex, age, body surface area or dressing type. CONCLUSIONS: Intensive, inpatient wet-dressing therapy is associated with detectable TAC serum levels. However, we suspect that topical TAC has a primarily local therapeutic effect on the skin.

Treatment of acne with spironolactone: a retrospective review of 395 adult patients at Mayo Clinic, 2007-2017.

BACKGROUND: Few large studies have assessed spironolactone treatment of adult female acne. OBJECTIVES: To explore the role of spironolactone in the treatment of adult female acne. METHODS: We performed a retrospective case series assessing the efficacy of spironolactone treatment of a cohort of women evaluated at Mayo Clinic in Rochester, Minnesota, from 2007 through 2017. RESULTS: In total, 395 patients (median age, 32 years) received a median spironolactone dose of 100 mg daily. Approximately two-thirds of patients (66.1%) had a complete response; 85.1% had a complete response or a partial response greater than 50%. Median times to initial response and maximum response were 3 and 5 months. Efficacy was observed across all severity subtypes of acne, including those with papulopustular and nodulocystic acne. Patients received long-term treatment with spironolactone (median duration, 13 months) and had few adverse effects. CONCLUSIONS: Spironolactone is a safe and effective treatment of acne for women.

Human dimethylarginine dimethylaminohydrolase 1 inhibition by proton pump inhibitors and the cardiovascular risk marker asymmetric dimethylarginine: in vitro and in vivo significance.

Proton pump inhibitor (PPI)-induced inhibition of dimethylarginine dimethylaminohydrolase 1 (DDAH1), with consequent accumulation of the nitric oxide synthase inhibitor asymmetric dimethylarginine (ADMA), might explain the increased cardiovascular risk with PPI use. However, uncertainty exists regarding whether clinical PPI concentrations significantly inhibit DDAH1 under linear initial rate conditions, and whether PPI-induced DDAH1 inhibition significantly increases ADMA in humans. DDAH1 inhibition by esomeprazole, omeprazole, pantoprazole, lansoprazole and rabeprazole was determined by quantifying DDAH1-mediated L-citrulline formation in vitro. Plasma ADMA was measured in PPI users (n = 134) and non-users (n = 489) in the Hunter Community Study (HCS). At clinical PPI concentrations (0.1-10 µmol/L), DDAH1 retained >80% activity vs. baseline. A significant, reversible, time-dependent inhibition was observed with lansoprazole (66% activity at 240 min, P = 0.034) and rabeprazole (25% activity at 240 min, P < 0.001). In regression analysis, PPI use was not associated with ADMA in HCS participants (beta 0.012, 95% CI -0.001 to 0.025, P = 0.077). Furthermore, there were no differences in ADMA between specific PPIs (P = 0.748). At clinical concentrations, PPIs are weak, reversible, DDAH1 inhibitors in vitro. The lack of significant associations between PPIs and ADMA in HCS participants questions the significance of DDAH1 inhibition as a mechanism explaining the increased cardiovascular risk reported with PPI use.

Network meta-analysis of antibiotic prophylaxis for prevention of surgical-site infection after groin hernia surgery.

BACKGROUND: First-generation cephalosporins (such as cefazolin) are recommended as antibiotic prophylaxis in groin hernia repair, but other broad-spectrum antibiotics have also been prescribed in clinical practice. This was a systematic review and network meta-analysis to compare the efficacy of different antibiotic classes for prevention of surgical-site infection (SSI) after hernia repair. METHODS: RCTs were identified that compared efficacy of antibiotic prophylaxis on SSI after inguinal or femoral hernia repair from PubMed and Scopus databases up to March 2016. Data were extracted independently by two reviewers. Network meta-analysis was applied to assess treatment efficacy. The probability of being the best antibiotic prophylaxis was estimated using surface under the cumulative ranking curve (SUCRA) analysis. RESULTS: Fifteen RCTs (5159 patients) met the inclusion criteria. Interventions were first-generation (7 RCTs, 1237 patients) and second-generation (2 RCTs, 532) cephalosporins, ß-lactam/ß-lactamase inhibitors (6 RCTs, 619) and fluoroquinolones (2 RCTs, 581), with placebo as the most common comparator (14 RCTs, 2190). A network meta-analysis showed that ß-lactam/ß-lactamase inhibitors and first-generation cephalosporins were significantly superior to placebo, with a pooled risk ratio of 0·44 (95 per cent c.i. 0·25 to 0·75) and 0·62 (0·42 to 0·92) respectively. However, none of the antibiotic classes was significantly different from the others. SUCRA results indicated that ß-lactam/ß-lactamase inhibitors and first-generation cephalosporins were ranked first and second respectively for best prophylaxis. CONCLUSION: ß-Lactam/ß-lactamase inhibitors followed by first-generation cephalosporins ranked as the most effective SSI prophylaxis for adult patients undergoing groin hernia repair.

Autoantibodies are not predictive markers for the development of depressive symptoms in a population-based cohort of older adults.

BACKGROUND: Autoantibodies have been implicated in the etiologic pathway of depressive disorders. Here, we determine the association between the presence of a panel of autoantibodies at baseline and change in depression symptom score over 5-year follow-up in a cohort of healthy elderly Australians. METHODS: Serum samples from 2049 randomly selected subjects enrolled in the Hunter Community Study (HCS) aged 55-85 years were assayed for a range of autoimmune markers (anti-nuclear autoantibodies, extractable nuclear antigen autoantibodies, anti-neutrophil cytoplasmic autoantibodies, thyroid peroxidase autoantibodies, tissue transglutaminase autoantibodies, anti-cardiolipin autoantibodies, rheumatoid factor and cyclic citrullinated peptide autoantibodies) at baseline. Depression symptom score was assessed using the Centre for Epidemiological Study (CES-D) scale at baseline and 5 years later. RESULTS: Autoantibody prevalence varied amongst our sample with ANA being the most prevalent; positive in 16% and borderline in 36% of study population. No evidence for a relationship was found between change in CES-D score over time and any autoimmune marker. Statins and high cholesterol were significantly associated with change in CES-D score over time in univariate analysis; however, these were probably confounded since they failed to remain significant following multivariable analysis. CONCLUSIONS: Autoantibodies were not associated with change in CES-D score over time. These findings point to an absence of autoimmune mechanisms in the general population or in moderate cases of depression.

Materials science. Materials that couple sensing, actuation, computation, and communication.

Tightly integrating sensing, actuation, and computation into composites could enable a new generation of truly smart material systems that can change their appearance and shape autonomously. Applications for such materials include airfoils that change their aerodynamic profile, vehicles with camouflage abilities, bridges that detect and repair damage, or robotic skins and prosthetics with a realistic sense of touch. Although integrating sensors and actuators into composites is becoming increasingly common, the opportunities afforded by embedded computation have only been marginally explored. Here, the key challenge is the gap between the continuous physics of materials and the discrete mathematics of computation. Bridging this gap requires a fundamental understanding of the constituents of such robotic materials and the distributed algorithms and controls that make these structures smart.

The association between dietary patterns and type 2 diabetes: a systematic review and meta-analysis of cohort studies.

BACKGROUND: Observational studies suggest that dietary pattern intake plays an important role in the development of type 2 diabetes. A meta-analysis was performed of existing cohort studies on the association between dietary patterns and the risk of type 2 diabetes. METHODS: Pertinent studies were identified by searching MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PROQUEST, MEDNAR and the Joanna Briggs Institute Library of Systematic Reviews, as well as the reference lists of all identified studies up to September 2012. A random-effects meta-analysis was performed to pool relative risk (RR) estimates from individual studies to assess the relationship between dietary pattern intake and the risk of type 2 diabetes. Statistical heterogeneity was assessed using I(2) and sensitivity analyses were conducted. Publication bias was evaluated by visual inspection of funnel plots and was formally assessed using Egger's test. RESULTS: There were fifteen cohort studies that met the inclusion criteria. There was evidence of a reduction in the risk of type 2 diabetes in the highest adherence compared to the lowest adherence to healthy dietary patterns [RR = 0.79, 95% confidence interval (CI) = 0.74-0.86, P < 0.005]. An increase in the risk of type 2 diabetes was evident for the highest adherence compared to the lowest adherence to unhealthy dietary patterns (RR = 1.44, 95% CI = 1.33-1.57, P < 0.005). CONCLUSIONS: The results of this systematic review and meta-analysis indicate that dietary patterns may be associated with the risk of type 2 diabetes.

Efficacy of Mitomycin C for postoperative endoscopic sinus surgery: a systematic review and meta-analysis.

BACKGROUND: Mitomycin C has recently been used to prevent nasal synechiae and sinus ostium stenosis after endoscopic sinus surgery. OBJECTIVE OF REVIEW: To compare nasal synechiae rate between topical Mitomycin C and saline or no treatment. TYPE OF REVIEW: Systematic review and meta-analysis. DATA SOURCES: MEDLINE, SCOPUS, and Cochrane Register of Controlled Trials databases were used to identify studies up to January 2013. EVALUATION METHOD: Data were independently extracted by two reviewers (PN and KT). Studies which compared topical Mitomycin C with control where the outcomes of interest were nasal synechiae or sinus ostium stenosis were included. Baseline study characteristics, quality of study, numbers of patients between treatment and control groups, outcomes, and adverse events were extracted. A multivariate meta-analysis was separately applied for each outcome (nasal synechiae and maxillary sinus ostium stenosis). RESULTS: Among 11 included studies, most studies used Mitomycin C dose of 0.4-0.5 mg/mL 1-5 mL in the middle meatus for 5 min duration. Eight studies reported synechiae with 281 and 281 nasal cavities received Mitomycin C and saline, respectively. For outcome of nasal synechiae, a multivariate meta-analysis suggested that Mitomycin C was associated with a 66% (RR = 0.34, 95% CI: 0.18-0.65) lower risk of nasal synechiae with moderate heterogeneity (I(2) = 43%, 95% CI: 0-77%). Subgroup analyses by age and history of revision could reduce the degree of heterogeneity. Mitomycin C benefits were found in subgroups of age ≤ 40 years (RR = 0.27, 95% CI: 0.05-1.50) and patients without any history of revision (RR = 0.19, 95% CI: 0.06-0.58). Five studies with 134 and 140 nasal cavities for Mitomycin C and saline were included in pooling of maxillary sinus ostium stenosis. Mitomycin C was associated with 74% (RR = 0.26, 95% CI: 0.12-0.54) lower risk of maxillary sinus ostium stenosis when compared with saline with low heterogeneity (I(2) = 5%, 95% CI: 0-85%). There was no evidence of publication bias for both poolings. CONCLUSION: Applying Mitomycin C topically after endoscopic sinus surgery could reduce the risk of nasal synechiae and maxillary sinus ostium stenosis in short term by 66% and 74%, respectively. The treatment effects may be more beneficial in patients aged 40 years or younger or in patients without history of revision. However, our results were based on pooling trials with questionable methodological quality. Further trials with good research methodology and long-term follow-up should be conducted to confirm our results.

Experience with the dermatology inpatient hospital service for adults: Mayo Clinic, 2000-2010.

BACKGROUND: There is a paucity of medical literature describing the role of dermatology inpatient hospital services for patients with severe dermatologic disease. A diminishing number of US hospitals have a dedicated dermatology inpatient service run by dermatologists. OBJECTIVES: To describe the role of a dermatology-run inpatient service in treatment of severe dermatologic disease from 2000 to 2010 at our institution. METHODS: We studied demographic characteristics, indications for admission and length of stay for the adult (age, >18 years) dermatology inpatient hospital service over the most recent decade. We compared data from the first 5.5 years with the subsequent 5.5 years and with previously published data. RESULTS: A total of 1732 patients had 2216 inpatient admissions to the adult service from 2000 to 2010. The mean (SD) age was 61.3 (17.7) years (age range 18-100 years). Median duration of admission was 3 days interquartile range (IQR), 2-5 days. The most common indications for admission were dermatitis (44.2%), psoriasis (17.4%) and cutaneous T-cell lymphoma (9.2%). We compared admissions from 2000 to mid-2005 (n = 1260) to admissions from mid-2005 to 2010 (n = 956). Statistically significant changes included median length of stay (decreased from 4 days [IQR, 3-6 days] to 3 days [IQR, 2-4 days] P < 0.01), admissions for psoriasis (decreased from 20.7% to 13.0%; P < .01) and admissions for dermatitis (increased from 41.6% to 47.6%; P < .01). CONCLUSION: The number of patients admitted and the median length of stay decreased between the 2 periods. Indications for admission have changed significantly across the two time periods.

Effect of perennial ryegrass (Lolium perenne L.) cultivars on the milk yield of grazing dairy cows.

The objective of this experiment was to investigate the effect of four perennial ryegrass cultivars: Bealey, Astonenergy, Spelga and AberMagic on the milk yield and milk composition of grazing dairy cows. Two 4 × 4 latin square experiments were completed, one during the reproductive and the other during the vegetative growth phase of the cultivars. Thirty-two Holstein-Friesian dairy cows were divided into four groups, with each group assigned 17 days on each cultivar during both experiments. Within each observation period, milk yield and milk composition, sward morphology and pasture chemical composition were measured. During the reproductive growth phase, organic matter digestibility (OMD) was greater for Bealey and Astonenergy (P < 0.001; +1.6%). AberMagic contained a higher stem proportion (P < 0.01; +0.06) and a longer sheath height (P < 0.001; +1.9 cm). Consequently, cows grazing AberMagic recorded a lower milk yield (P < 0.001; -1.5 kg/day) and a lower milk solids yield (P < 0.001; -0.13 kg/day). During the vegetative growth phase, OMD was greater (P < 0.001; +1.1%) for Bealey, whereas the differences between the cultivars in terms of sward structure were smaller and did not appear to influence animal performance. As a result, cows grazing Bealey recorded a higher milk yield (P < 0.001; +0.9 kg/day) and a higher milk solids yield (P < 0.01; +0.08 kg/day). It was concluded that grass cultivar did influence milk yield due to variations in sward structure and chemical composition.

Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy.

BACKGROUND: Laparoscopic appendicectomy has gained wide acceptance as an alternative to open appendicectomy during pregnancy. However, data regarding the safety and optimal surgical approach to appendicitis in pregnancy are still controversial. METHODS: This was a systematic review and meta-analysis of studies comparing laparoscopic and open appendicectomy in pregnancy identified using PubMed and Scopus search engines from January 1990 to July 2011. Two reviewers independently extracted data on fetal loss, preterm delivery, wound infection, duration of operation, hospital stay, Apgar score and birth weight between laparoscopic and open appendicectomy groups. RESULTS: Eleven studies with a total of 3415 women (599 in laparoscopic and 2816 in open group) were included in the analysis. Fetal loss was statistically significantly worse in those who underwent laparoscopy compared with open appendicectomy; the pooled relative risk (RR) was 1·91 (95 per cent confidence interval (c.i.) 1·31 to 2·77) without heterogeneity. The pooled RR for preterm labour was 1·44 (0·68 to 3·06), but this risk was not statistically significant. The mean difference in length of hospital stay was - 0·49 (-1·76 to - 0·78) days, but this was not clinically significant. No significant difference was found for wound infection, birth weight, duration of operation or Apgar score. CONCLUSION: The available low-grade evidence suggests that laparoscopic appendicectomy in pregnant women might be associated with a greater risk of fetal loss.

Pneumococcal vaccination may induce anti-oxidized low-density lipoprotein antibodies that have potentially protective effects against cardiovascular disease.

Many animal and human studies have found an inverse association between anti-oxidized low-density lipoprotein (oxLDL) antibodies (anti-oxLDL) and atherosclerotic burden. Furthermore, anti-oxLDL antibodies have been shown to cause regression of atherosclerotic plaque in mice. Animal studies indicate that the 23-valent pneumococcal vaccine may induce the production of these potentially protective anti-oxLDL antibodies, and human epidemiological studies support their potentially beneficial effect in reducing cardiovascular events. Here we describe the association between self-reported pneumococcal vaccination, vaccination verified by linkage to health records, and anti-pneumococcal antibody titers, and anti-ox-LDL titers in a group of 116 older people. We found a bimodal distribution of anti-oxLDL antibodies, and a significant association between pneumococcal IgG and anti-oxLDL antibody titers that remained after multivariate adjustment for potential confounders (p=0.04). There was no significant association between self-reported vaccination or vaccination verified by health record linkage and ox-LDL titers, which may be due to reporting error or variability in response to the vaccine. These results support a mechanistic link between pneumococcal vaccination and a potential protective effect on cardiovascular disease, and indicate that self-reported or verified vaccine status may not be sufficient to detect this association.

Current state of medical-advice-seeking behaviour for symptoms of colorectal cancer: determinants of failure and delay in medical consultation.

AIM: There are few data on the factors associated with healthcare-seeking behaviour for symptoms of colorectal cancer. This study describes the determinants of failure and delay in seeking medical advice for rectal bleeding and change in bowel habit. METHOD: In total, 1592 persons (56-88 years) were randomly selected from the Hunter Community Study and mailed a questionnaire. RESULTS: In all, 18% (60/332) of respondents experiencing rectal bleeding and 20% (39/195) reporting change in bowel habit had never consulted a doctor. The rate of delay (>1 month) for each symptom was 18% and 37%. The reasons for delay included the assumption that the symptoms were not serious or that they were benign. Triggers for seeking medical advice varied. Healthcare-seeking behaviour for rectal bleeding had not significantly improved compared with a previous community-based study. CONCLUSION: The seriousness of symptoms, importance of early detection and prompt medical consultation must be articulated in health messages to at-risk persons.

Disease severity and therapy as predictors of cardiovascular risk in psoriasis: a population-based cohort study.

BACKGROUND: Previous studies suggest an increased risk of cardiovascular disease in psoriasis, but the relative contributions of traditional risk factors and markers of disease severity are unclear. We examined the effect of psoriasis disease characteristics on cardiovascular risk after adjusting for traditional cardiovascular risk factors. METHODS: Study populations included (a) case-cohort sample of 771 patients nested within a population-based psoriasis incidence cohort, and (b) cohort of 1905 patients with incident and prevalent psoriasis patients. Both cohorts were followed-up to ascertain disease and treatment characteristics, traditional cardiovascular risk factors and cardiovascular outcomes. Cox proportional hazards regression models were used to identify predictors of cardiovascular outcomes. RESULTS: After adjusting for traditional risk factors, increasing number of psoriasis-affected body sites at disease onset (HR: 1.53 per additional site, 95% CI: 1.20, 1.95) was significantly associated with an increased risk of cardiovascular outcomes. Phototherapy (HR: 3.76, 95% CI: 2.45, 5.77) and systemic therapy (HR: 2.17, 95% CI: 1.50, 3.13) were associated with a higher risk of cardiovascular outcomes in univariate analyses, but these relatively strong associations disappeared after adjusting for cardiovascular risk factors. CONCLUSIONS: Increasing number of psoriasis-affected body sites may be a severity indicator in psoriasis and is associated with an increased cardiovascular risk. Due to low number of patients exposed to systemic therapy, this study had limited power to examine the effect of treatment on cardiovascular risk. Strong associations with phototherapy and systemic therapy suggest that the cardiovascular risk in psoriasis is confined to patients with severe disease.

Virtual patients: an effective educational intervention to improve paediatric basic specialist trainee education in the management of suspected child abuse?

Child abuse is a particularly difficult subject to teach at both undergraduate and postgraduate level. Most doctors are dissatisfied with their training in child abuse recognition and management. We developed an interactive video based Virtual Patient to provide formal training for paediatric Basic Specialist Trainees in the recognition of suspected child abuse. The Virtual Patient case revolves around the management of suspected physical abuse in a seven month old child, who initially presents to the Emergency Department with viral upper respiratory tract symptoms. This Virtual Patient was used to facilitate a case discussion with Basic Specialist Trainees. A questionnaire was developed to determine their perception of the value of the Virtual Patient as an educational tool. Twenty five Basic Specialist Trainees completed the questionnaire. Upon completion of the case, 23/25 (92%) participants reported greater self confidence in their ability to recognize cases of suspected child abuse and 24/25 (96%) of participants reported greater self confidence in their ability to report cases of suspected child abuse. Basic Specialist Trainees perceived the Virtual Patient to be a useful educational tool. Virtual Patients may have a role to play in enhancing postgraduate training in the recognition of suspected child abuse.