Photodynamic therapy for the prevention and treatment of actinic keratosis/squamous cell carcinoma in solid organ transplant recipients: a systematic review and meta-analysis.

Solid organ transplant recipients (sOTR) are at an increased risk of developing cutaneous cancers, especially squamous cell carcinoma (SCC). Photodynamic therapy (PDT) for the prevention and treatment of actinic keratosis (AK)/SCC in sOTR is increasingly prescribed given the increase in solid organ transplantations performed worldwide. PDT has added advantages of superior cosmetic outcomes and good safety profile compared to conventional surgical methods and other topical therapies. We aim to evaluate the role of PDT in the prevention and treatment of AK/SCC in sOTRs. The Cochrane Library, PubMed and EMBASE database were searched. Articles reporting PDT outcomes amongst sOTR with or without AK/SCC at baseline were selected. We classified the studies into two categories: (i) PDT as prevention measure and (ii) treatment of AK/SCC in sOTR. Primary outcome for the prevention category was 3-year incidence of AK/SCC and complete response (CR) of lesions after PDT exposure in the treatment category. Secondary outcomes were cosmesis and adverse reaction in both categories. Pooled results were expressed as risk difference (RD) with corresponding 95% confidence interval (95% CI). Twelve out of 641 articles met our eligibility criteria, out of which four RCTs reported the preventive effect of AK/SCC and another five RCTs reported the treatment effect of PDT in sOTR. One RCT did not report absolute number of lesions at baseline/end of study for results to be pooled in the quantitative analysis. The remaining three studies were cohort studies reporting treatment and preventive effect of PDT in sOTR. PDT group had a lower incidence as a preventive measure with pooled RD of 0.14 (95% CI 0.08-0.19). The CR in PDT was higher in the treatment group with a pooled RD of 0.77 (95% CI 0.6-0.94) and 0.50 (95% CI 0.22-0.79) in predivided lesional areas and number of lesions, respectively. In conclusion, PDT is efficacious for prevention and treatment of AK/SCC in sOTRs.

An overview of lower limb cellulitis in an acute medical ward-a few lessons we can learn.

Lower limb cellulitis is a common cause for hospital admissions. In this retrospective study, we assessed the characteristics and outcome of patients admitted in an acute medical unit. The mean duration of treatment was 10.48 days, with 95.5% receiving antibiotics for more than 5 days. Mean length of stay (LOS) was 5.19 days. 12-month readmission rate was higher in patients with diabetes, chronic kidney disease (CKD) and previous stroke. Diabetes, CKD, previous stroke, and elevated procalcitonin levels were independently associated with prolonged admission (>3 days).

Painful skin lesions and squamous cell carcinoma predict overall mortality risk in organ transplant recipients: a cohort study.

BACKGROUND: Organ transplant recipients (OTRs) have a highly increased risk of cutaneous squamous cell carcinomas (SCCs). Sensation of pain in cutaneous tumours is a powerful patient-reported warning signal for invasive SCCs in OTRs. OBJECTIVES: To investigate the impact of painful vs. painless skin lesions and SCC vs. other skin lesions on the overall mortality risk in OTRs. METHODS: We followed 410 OTRs from 10 different centres across Europe and North America between 2008 and 2015. These patients had been enrolled in an earlier study to define clinically meaningful patient-reported warning signals predicting the presence of SCC, and had been included if they had a lesion requiring histological diagnosis. Cumulative incidences of overall mortality were calculated using Kaplan-Meier survival analysis, and risk factors were analysed with Cox proportional hazard analysis. RESULTS: There was an increased overall mortality risk in OTRs who reported painful vs. painless skin lesions, with a hazard ratio (HR) of 1·6 [95% confidence interval (CI) 0·97-2·7], adjusted for age, sex and other relevant factors. There was also an increased overall mortality risk in OTRs diagnosed with SCC compared with other skin lesions, with an adjusted HR of 1·7 (95% CI 1·0-2·8). Mortality due to internal malignancies and systemic infections appeared to prevail in OTRs with SCC. CONCLUSIONS: We suggest that OTRs have an increased overall mortality risk if they develop painful skin lesions or are diagnosed with cutaneous SCC.

A study of topical methyl-aminolaevulinate red-light photodynamic therapy in the treatment of actinic keratosis in Chinese patients: a Singaporean experience.

BACKGROUND: The incidence of skin cancers has been increasing in Singapore, owing to the country's location near the equator and its ageing population. Topical photodynamic therapy (PDT) is a treatment method employing light and a topical photosensitizer to treat actinic keratosis (AK). Most published data to date on PDT have been drawn from studies of patient with Fitzpatrick skin phototypes I and II. AIM: To evaluate the effectiveness of PDT in the treatment of AK in patients with skin phototype IV in Singapore. METHODS: This was a retrospective analysis of 13 East Asian patients with AK treated with PDT at the National Skin Centre, Singapore, from 2006 to 2013. RESULTS: The overall clearance rate of AK at 3 months was 81.8% (9 of 11 patients; the other 2 were lost to follow-up). Mild to moderate pain during therapy was a common adverse event. CONCLUSIONS: PDT is a useful treatment method for AK in East Asian patients with skin phototype IV. Further larger prospective studies will be needed to evaluate its overall efficacy in East Asian patients.

Pernicious anaemia presenting as hyperpigmentation.

An adult East Asian woman presented with sudden onset of hyperpigmented macules on her oral mucosal surfaces, palms and soles, in association with hypoguesia and loss of weight. This was found to be associated with underlying severe vitamin B12 deficiency secondary to pernicious anaemia.

Factitious panniculitis masquerading as pyoderma gangrenosum.

We report a case of factitious panniculitis masquerading as florid pyoderma gangrenosum in a 35-year-old woman. At presentation, she had tender, ecchymotic plaques over the lower trunk and limbs, and several biopsies showed active lobular panniculitis. However, the extensive ulceration that ensued was clinically persuasive for pyoderma gangrenosum. We elected to treat the inflammatory element symptomatically with a range of topical and systemic medications including clobetasol propionate, tacrolimus 0.1% ointment, prednisolone, dapsone, cyclosporin A and mycophenolate mofetil, none of which effected an improvement. The possibility of a factitious aetiology had been suspected from the outset, and when signs of clinical depression emerged, antidepressant therapy was initiated and the ulcers were encased in fibreglass casts. Within a short period, healing commenced and slowly progressed with scar formation. In retrospect, we consider the diagnosis to have been factitious panniculitis on the basis of strong circumstantial evidence and the disparity between the histological and clinical features.

Role of intraoperative transesophageal echocardiography in determining aortic annulus diameter in homograft insertion.

The sizing of aortic valve (AV) homografts for optimum function requires an accurate measurement of the aortic annulus. Typically, this measurement is obtained directly with sizers in the open aorta. We describe the use of intraoperative transesophageal echocardiography (IOTEE) to measure the aortic annulus and select the appropriate AV homograft before cardiopulmonary bypass and aortic cross-clamping. Thirty-two patients underwent AV homograft insertion between March 1993 and March 1996 and had IOTEE. There were 13 women and 19 men. Mean age was 58 +/- 14 years. IOTEE measurements were satisfactory in sizing in all patients, and no extraordinary surgical measures were necessary to insert the AV homografts. Early postoperative follow-up showed trivial or mild regurgitation of all homografts. Prebypass IOTEE is reliable in guiding the selection of optimal AV homografts.

Alterations of GABA metabolism and seizure susceptibility in the substantia nigra of the kindled rat acclimating to changes in osmotic state.

Seizure susceptibility and GABA metabolism were altered in the substantia nigra [SN] of adult male Sprague Dawley rats when these animals were acclimating to an altered plasma osmolality. Changes in GABA metabolism were measured in vivo in SN of the freely moving rat. Suitable precautions were taken to avoid any post-mortem flux of glutamate to GABA and to correct for the underestimation of GABA build up in SN due to the finite diffusion rate of gamma-vinyl GABA [GVG] after stereotaxic injection of small amounts into one side of the brain. Control experiments provided evidence that changes in osmolality, within a normal physiological range, did not affect significantly gamma-aminobutyric acid transaminase [GABA-T]. Also kindling via the medial septum [MS], in the absence of electrical stimulation did not alter GABA metabolism in SN, thus providing a stable baseline for studies of osmotic effects. Hyperosmolality was associated with a rise in seizure thresholds, with a marked reduction of the rate of GABA synthesis in SN, and with a substantial increase in turnover time of the GABA pool. Hypoosmolality, of a degree known to be associated with mild cerebral edema and swelling localized to astrocytes, markedly reduced seizure threshold, and reduced GABA pool size in SN, but did not alter the rate of GABA synthesis significantly. These results demonstrate by new and independent means the relationship between GABA metabolism in the SN and seizure susceptibility in vivo.

Changes of amino acid gradients in brain tissues induced by microwave irradiation and other means.

Focused microwave irradiation to the head (FMI) has been used extensively by neurochemists for rapid inactivation of enzymatic activity in brain tissues and the preservation, for in vitro analysis, of in vivo substrate concentrations. Periodically the suitability of this technique for regional studies has been questioned. Evidence has now been obtained, on the basis of altered concentration gradients for GABA and taurine from the Substantia Nigra (SN) to an Adjacent Dorsal Area (ADJ), that FMI not only inactivates enzymes, but also facilitates rapid diffusion of small molecules from areas of high concentrations to adjacent areas of lower concentration. To a lesser extent, the implantation of plastic injection cannulas also decreased these concentration gradients. These results offer clear evidence that FMI is ill suited and unreliable for studies designed to map and compare the "in vivo" regional concentrations of diffusible organic molecules (such as amino acids) in brain tissues. Any invasive technique that compromises membrane barriers is likely to produce smaller similar effects.