Detection of significant liver fibrosis in Chinese psoriasis patients receiving methotrexate: a comparison between transient elastography and liver histology.

INTRODUCTION: Methotrexate (MTX) is effective for treating psoriasis and psoriatic arthritis, but its potential hepatoxicity remains a concern. Liver biopsy, the gold standard for detecting MTX-induced liver injury, is invasive and carries considerable risk. Transient elastography (TE) offers a non-invasive alternative for detecting advanced liver fibrosis. This study investigated the performance of TE in detecting MTX-induced liver fibrosis among Chinese psoriasis patients, compared with liver biopsy. METHODS: This study included adult patients with clinical psoriasis. Liver stiffness measurement using TE was performed in patients receiving MTX. Exclusion criteria were known liver cirrhosis, positive viral hepatitis carrier status, or conditions influencing TE performance. Liver biopsy was performed when liver stiffness was ≥7.1 kilopascals (kPa) or when the total cumulative dose (TCD) of MTX was ≥3.5 g. RESULTS: A total of 228 patients were screened; among 34 patients who met the inclusion criteria, nine (26.5%) had significant liver fibrosis (Roenigk grade ≥3a). The area under the receiver operating characteristic curve was 0.76 (95% confidence interval=0.59-0.93; P=0.021), indicating that TE had satisfactory performance in detecting liver fibrosis. A cut-off value of 7.1 kPa of liver stiffness yielded 100% sensitivity and 68% specificity. Liver fibrosis was not correlated with the TCD of MTX or the duration of MTX use; it was significantly correlated with obesity and diabetes status (body mass index ≥30 kg/m2, waist circumference ≥138 cm, and glycated haemoglobin level ≥7.8%). CONCLUSION: Transient elastography is reliable and superior to the TCD for detecting liver fibrosis in Chinese psoriasis patients receiving MTX. Liver biopsy should be reserved for high-risk patients or patients with liver stiffness ≥11.7 kPa on TE.

Cutaneous manifestations, viral load, and prognosis among hospitalised patients with COVID-19: a cohort study.

INTRODUCTION: Various cutaneous manifestations have been reported as symptoms of coronavirus disease 2019 (COVID-19), which may facilitate early clinical diagnosis and management. This study explored the incidence of cutaneous manifestations among hospitalised patients with COVID-19 and investigated its relationships with viral load, co-morbidities, and outcomes. METHODS: This retrospective study included adult patients admitted to a tertiary hospital for COVID-19 from July to September 2020. Clinical information, co-morbidities, viral load (cycle threshold [Ct] value), and outcomes were analysed. RESULTS: In total, 219 patients with confirmed COVID-19 were included. Twenty patients presented with new onset of rash. The incidence of new rash was 9.1% (95% confidence interval=6.25%-14.4%). The most common manifestations were maculopapular exanthem (n=6, 42.9%, median Ct value: 24.8), followed by livedo reticularis (n=4, 28.6%, median Ct value: 21.3), varicella-like lesions (n=2, 14.3%, median Ct value: 19.3), urticaria (n=1, 7.1%, median Ct value: 14.4), and acral chilblain and petechiae (n=1, 7.1%, median Ct value: 33.1). The median Ct values for patients with and without rash were 22.9 and 24.1, respectively (P=0.58). There were no significant differences in mortality or hospital stay between patients with and without rash. Patients with rash were more likely to display fever on admission (P<0.01). Regardless of cutaneous manifestations, patients with older age, hypertension, and chronic kidney disease stage ≥3 had significantly higher viral load and mortality (P<0.05). CONCLUSION: This study revealed no associations between cutaneous manifestation and viral load or clinical outcomes. Older patients with multiple co-morbidities have risks of high viral load and mortality; they should be closely monitored.

Does Secretory Clearance Follow Glomerular Filtration Rate in Chronic Kidney Diseases? Reconsidering the Intact Nephron Hypothesis.

Drug-dose modification in chronic kidney disease (CKD) utilizes glomerular filtration rate (GFR) with the implicit assumption that multiple renal excretory processes decline in parallel as CKD progresses. We compiled published pharmacokinetic data to evaluate if GFR predicts renal clearance changes as a function of CKD severity. For each drug, we calculated ratio of renal clearance to filtration clearance (Rnf). Of 21 drugs with Rnf >0.74 in subjects with GFR >90 mL/min (implying filtration and secretion), 13 displayed significant change in Rnf vs. GFR (slope of linear regression statistically different from zero), which indicates failure of GFR to predict changes in secretory clearance. The dependence was positive (n = 3; group A) or negative (n = 10; group B). Eight drugs showed no correlation (group C). Investigated drugs were small molecules, mostly hydrophilic, and ionizable, with some characterized as renal transporter substrates. In conclusion, dosing adjustments in CKD require refinement; in addition to GFR, biomarkers of tubular function are needed for secreted drugs.

A Single-Port Robotic Platform for Laparoscopic Surgery with a Large Central Channel for Additional Instrument.

A new approach to a surgical robotic platform for single incision laparoscopic or natural orifice transluminal endoscopic surgery is presented in this paper This platform allows insertion of up to four instruments including the robotic arms and the camera through a single cannula at the same footprint. After insertion of all instruments, a large central channel of 15 mm diameter is kept clear for the passage of additional laparoscopic instruments, such as passage or retrieval of suture needles, and/or suction irrigators which greatly facilitates the performance of complex surgical procedures. Phantom and animal trials have been performed to evaluate the insertion and retrieval sequences. These important features were made possible by internally-motorized robotic arms with 7 degrees of freedom and with no external mechanical device connections. The whole platform, together with the 3 degrees of freedom from the swivel system that support the cannula, has altogether 10 degrees of freedom to allow the operation of complex surgeries and access to all quadrants of the abdominal cavity. This new single-port robotic platform paves a new development direction for future non-invasive surgery.

Chronic Kidney Disease Alters Vitamin A Homeostasis via Effects on Hepatic RBP4 Protein Expression and Metabolic Enzymes.

Vitamin A, via retinoic acid (RA), is a critical micronutrient. Normally, plasma concentrations are tightly regulated. Concentrations of vitamin A metabolites (13cis-RA, atRA) and relationships between RBP4 and retinoids have never been fully evaluated in adult patients with CKD. We measured retinoid and RBP4 concentrations in plasma and urine from 55 adult patients with CKD and 21 matched healthy subjects. RBP4 and retinol levels were increased approximately twofold in patients with CKD, with a negative correlation between plasma retinol and eGFR (p = 0.006) and plasma RBP4 and eGFR (p = 0.0007). RBP4 renal clearance was higher in patients with CKD than healthy subjects but not associated with eGFR. Circulating concentrations of atRA increased and concentrations of 13cis-RA decreased in subjects with CKD with no change in RA-to-retinol ratio. Increases in circulating retinol, RBP4, and atRA may be due to increased hepatic RBP4 synthesis, retinyl ester hydrolysis, and/or hepatic secretion of RBP4-retinol.

Organ Impairment-Drug-Drug Interaction Database: A Tool for Evaluating the Impact of Renal or Hepatic Impairment and Pharmacologic Inhibition on the Systemic Exposure of Drugs.

The organ impairment and drug-drug interaction (OI-DDI) database is the first rigorously assembled database of pharmacokinetic drug exposure data from publicly available renal and hepatic impairment studies presented together with the maximum change in drug exposure from drug interaction inhibition studies. The database was used to conduct a systematic comparison of the effect of renal/hepatic impairment and pharmacologic inhibition on drug exposure. Additional applications are feasible with the public availability of this database.

An unusual cause of acromegaly.

We report a rare case of acromegaly due to a growth hormone releasing hormone-secreting bronchial carcinoid tumour. A 40-year-old man initially presented with acromegalic features, and was subsequently found to have a large lung mass in the right lower zone on chest X-ray. Right lower lobectomy was performed, and the tumour was confirmed to be a bronchial carcinoid tumour on histology. Resection of the tumour led to normalisation of serum insulin-like growth factor 1 level and growth hormone responses to an oral glucose tolerance test.

Evaluating the safety and efficacy of the 1,440-nm laser in the treatment of photodamage in Asian skin.

BACKGROUND AND OBJECTIVE: As the demand for diminished procedure-associated downtime continues to increase, nonablative fractional laser resurfacing is becoming a more popular intervention in the progression of photoaging. Patients with pigmented skin and a mild degree of photodamage may be particularly suited for a less intensive laser treatment. In this study, we have evaluated the safety and efficacy of a low energy, low density 1,440-nm fractional laser in the treatment of multiple signs of photoaging including dyspigmentation, wrinkling, tissue laxity, enlarged pores, and skin roughness in Asians. STUDY DESIGN/MATERIALS AND METHODS: Ten Chinese subjects with Fitzpatrick skin types III-V and visible signs of photodamage participated in this study. Patients received four treatments at 2-week intervals with a 1,440-nm diode-based fractional laser. Photographs were taken at baseline, 2 weeks after each of the first three treatments and 4 weeks after the final treatment. Images were evaluated independently by two physicians. Clinical improvement and adverse events were analyzed. Discomfort, heat sensation and overall patient satisfaction associated with the procedure were also quantified. RESULTS: In this prospective single-arm study, signs of photoaging were examined after treatment with the 1,440-nm laser. Here we show that a series of four treatments with this device produced a mild improvement in skin texture, pigmentation, and wrinkling. Changes in pore size and skin laxity failed to reach statistical significance. Immediate after-effects of the procedure included erythema and edema which were transient and left no permanent sequela. A significant proportion of patients reported some degree of discomfort during the procedure despite use of a topical anesthetic. One patient developed a discrete, localized area of post-inflammatory hyperpigmentation which completely resolved by the final follow up visit. CONCLUSION: The low energy, low density nonablative 1,440-nm fractional laser produces a mild improvement in select signs of photodamage after four treatments without any long-term adverse effects.

Hydralazine-induced toxic epidermal necrolysis in a patient on continuous ambulatory peritoneal dialysis.

WHAT IS KNOWN AND OBJECTIVE: Hydralazine is an effective antihypertensive drug which acts by vasodilatation. It is well known to cause drug-induced lupus erythematosus. Nevertheless, the overall safety profile is good and cutaneous adverse effects are uncommon. To the best of our knowledge, hydralazine has never been reported to cause Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). CASE SUMMARY: We herein report the first case of hydralazine-induced TEN in a patient with end-staged renal failure. Despite meticulous wound management and intensive medical care, the patient died of a sudden cardiac arrest on day 10 of admission. WHAT IS NEW AND CONCLUSION: We speculate that patients with renal failure may be predisposed to a higher risk of allergy to drug entities that are rarely associated. Physicians should be aware that hydralazine can be a potential cause for severe allergic reaction such as SJS or TEN, particularly in the setting of poor renal excretory function. Patient education and cautious monitoring by physicians are essential for early diagnosis and hence successful management of the life-threatening condition.

Relationship between parathyroid hormone and subclinical myocardial dysfunction in patients with severe psoriasis.

BACKGROUND: Psoriasis is associated with an increased risk of cardiovascular disease although the mechanism remains unclear. Recent studies have shown that such patients have a high prevalence of vitamin D (vit-D) deficiency and elevated parathyroid hormone (PTH) level. We hypothesized that vit-D deficiency and/or elevated PTH in psoriasis may contribute to left ventricular (LV) dysfunction. METHODS: Seventy-four patients with severe psoriasis with no known cardiovascular disease and 53 age- and gender-matched controls were recruited. All patients underwent detailed transthoracic echocardiography, including speckle tracking derived strains, and plasma levels of 25-hydoxyvitamin D (25-OHD), PTH and cardiac biomarkers including high sensitive C-reactive protein (hs-CRP), high sensitive troponin I (hs-TNI) and brain natriuretic peptide (BNP) were measured. RESULTS: Despite similar systolic and diastolic LV function, patients with severe psoriasis had impaired LV global longitudinal (-18.1 ± 2.6 vs.-19.6 ± 2.9%, P < 0.01) and circumferential strain (-18.7 ± 3.6 vs. -20.8 ± 4.3%, P < 0.01) compared with controls. Patients with severe psoriasis also had a significantly higher PTH (49.9 ± 18.0 vs. 40.5 ± 15.4 pmol/mL, P < 0.01) and hs-CRP (5.7 ± 6.9 vs. 1.9 ± 2.5 pg/mL, P < 0.01), but similar levels of 25-OHD, hs-TNI and BNP (all P > 0.05) compared with controls. Importantly, PTH level was negatively correlated with LV global longitudinal strain (R = -0.30, P < 0.01); and higher PTH level was independently associated with impaired global LV longitudinal strain (R = -0.33, P = 0.04), independent of cardiovascular risk factors, vit-D status and serum biomarkers. CONCLUSIONS: Severe psoriasis patients had an elevated PTH level and suffered from subclinical LV systolic dysfunction as detected by impaired global LV longitudinal strain. Importantly, a higher PTH level was independently associated with impaired global LV longitudinal strain.

A retrospective study of the management of Chinese melasma patients using a 1927 nm fractional thulium fiber laser.

BACKGROUND: A new fractional photothermolysis device is used in our retrospective study to treat melasma in Chinese patients. OBJECTIVES: To evaluate the efficacy and safety of the 1927 nm fractional thulium fiber laser in the treatment of melasma in Chinese patients. METHODS: Eleven melasma patients who received treatment between November 2009 and May 2010 were included. Photographic images at baseline and follow-up were assessed for clinical efficacy and complications by two independent and blinded physicians. Questionnaires were also completed by patients. RESULTS: Significant MASI improvements were seen at 1 week, 1 month and 2 months, but not at 3 months. Patients' degree of satisfaction was high. Significant improvement in skin texture and pore size was seen for up to 2 months and improvement in wrinkles for up to a month. There was no change in skin laxity. Main adverse effects seen were erythema, edema, and crusting in the early days. One patient developed PIH. CONCLUSION: The novel 1927 nm fractional thulium fiber laser is safe and effective in the management of melasma in Chinese patients for up to 2 months. It is also useful in photo-rejuvenation. Complications were limited to erythema and edema in the early days, and transient PIH.

Prevalence and extent of subclinical atherosclerosis in patients with psoriasis.

OBJECTIVE: Patients with psoriasis are prone to premature atherosclerosis and increased risk of cardiovascular disease events. However, the prevalence and extent of atherosclerosis in patients with psoriasis are unknown. DESIGN: A cross-sectional study. SETTING AND SUBJECTS: The prevalence and extent of coronary and carotid atherosclerosis were compared in 70 patients with psoriasis (46 ± 9 years, 71% male) without known cardiovascular disease or joint involvement and 51 age- and gender-matched healthy control subjects (45 ± 7 years, 71% male). Systemic inflammation was assessed by the level of high-sensitivity C-reactive protein (hs-CRP). Coronary atherosclerosis was determined by the coronary calcification score (CCS) measured by multi-detector computed tomography. Carotid atherosclerosis was assessed by high-resolution ultrasound-derived carotid intima-media thickness (cIMT). RESULTS: Patients with psoriasis had a higher prevalence of coronary atherosclerosis (CCS > 0; 28.6% vs. 3.9%, P < 0.01), and a higher degree of coronary atherosclerosis estimated by the mean CCS (67.4 ± 349.2 vs. 0.5 ± 3.0, P < 0.05) compared with controls. Similarly, cIMT was significantly greater in patients with psoriasis than in control subjects (0.73 ± 0.11 mm vs. 0.67 ± 0.08 mm, P < 0.01). Multiple logistic regression revealed that psoriasis [odd ratio (OR): 10.54, 95% confidence interval (CI) 1.89-58.67, P < 0.01] and serum total cholesterol level (OR 2.10, 95% CI 1.01-4.37) were associated with the presence of coronary atherosclerosis (CCS > 0). By contrast, only age was independently associated with increased cIMT. Amongst participants with no traditional cardiovascular disease risk factors, hs-CRP level was higher in patients with psoriasis than in controls. CONCLUSION: The present results demonstrate early-onset, diffuse arterial atherosclerosis in coronary and carotid arteries in patients with psoriasis, but not in age- and gender-matched control subjects. Low-grade inflammation could explain the presence of premature atherosclerosis in patients with psoriasis.

A retrospective analysis of the management of freckles and lentigines using four different pigment lasers on Asian skin.

BACKGROUND: The risk of post-inflammatory hyperpigmentation (PIH) is increased during freckles and lentigines treatment in Asians. OBJECTIVE: To determine the effectiveness and safety of using 595-nm long pulsed dye laser (LPDL), 755-nm LP Alexandrite laser, 532-nm QS Nd:YAG laser and 532-nm LP potassium-titanyl-phosphate (KTP) laser for the treatment of freckles or lentigines in Asian patients. METHODS: This is a retrospective study of 40 Chinese patients, who were divided into four groups based on treatment modality using four different pigment lasers. Each patient attended between 1 and 4 treatments (mean of 1.8), at 4-6 weeks intervals, depending on clinical response. Lesional clearance and PIH were assessed by two independent clinicians. RESULTS: Statistically significant improvement of global and focal facial pigmentation was found after treatment with LPDL, QS Nd:YAG and LP KTP lasers. No significant improvement was found after LP Alexandrite laser. PIH risk was 20% after LP Alexandrite treatment, 10% with QS Nd:YAG, and absent after LPDL and LP KTP treatment. CONCLUSION: A long pulse laser and small spot size appear to reduce the risks of lentigines treatment in darker skin types.

Association between HLA-B*58:01 allele and severe cutaneous adverse reactions with allopurinol in Han Chinese in Hong Kong.

BACKGROUND: Allopurinol has been reported as a common cause of severe cutaneous adverse reactions (SCARs). Recent studies in various populations suggest that HLA-B*58:01 is a strong genetic marker for allopurinol-induced SCAR, especially in populations with a high frequency of HLA-B*58:01. OBJECTIVES: To confirm the association link between HLA-B*58:01 and hypersensitivity reactions attributed to allopurinol use in Han Chinese patients in Hong Kong. METHODS: We performed a case-control study to investigate whether the HLA-B*58:01 allele predisposes to allopurinol-induced SCAR in Han Chinese patients in Hong Kong. The HLA-B*58:01 genotyping was performed in 20 patients with allopurinol-induced SCAR or erythema multiforme major (EMM; n = 1) and in 30 patients tolerant to allopurinol. RESULTS: All of the 19 patients with allopurinol-induced SCAR examined but not the patient with EMM carried HLA-B*58:01 whereas only four (13%) of the control patients had this allele. The positive rate of the HLA-B*58:01 was significantly higher in the cases than in the allopurinol-tolerant control group [odds ratio (OR) 123·5, 95% confidence interval (CI) 12·8-1195·1; P < 1 × 10(-4) ] and was even higher after removal of the patient with EMM (OR 229·7, 95% CI 11·7-4520·4). The sensitivity and specificity of the HLA-B*58:01 allele for prediction of allopurinol-induced SCAR were 100% and 86·7%, respectively. CONCLUSIONS: This study confirmed the strong association between the HLA-B*58:01 and allopurinol-induced SCAR in Hong Kong Han Chinese patients. A screening test for the HLA-B*58:01 allele should effectively reduce the risk for allopurinol-induced SCAR in Chinese populations.

Non-invasive measures of tissue autofluorescence are increased in Type 1 diabetes complications and correlate with a non-invasive measure of vascular dysfunction.

OBJECTIVE: To determine if ocular and skin autofluorescence, reflecting advanced glycation end-products, and vascular stiffness correlate in non-diabetic and Type 1 diabetic subjects and if levels differ by diabetes status. RESEARCH DESIGN AND METHODS: Patients with Type 1 diabetes (n = 69, 19 with and 50 without vascular complications) and 60 subjects without diabetes (control) had ocular and skin autofluorescence and pulse-wave analysis performed in the fasted state. Correlations between measures within groups used the Pearson or Spearman correlation-coefficient and measures between groups were compared by ANOVA. RESULTS: Lens and skin autofluorescence correlated in control (r = 0.58, P = 0.0001) and in Type 1 diabetes (r = 0.53, P = 0.001). Corneal autofluorescence correlated with lens (r = 0.53, r = 0.52, P = 0.0001) and skin autofluorescence (r = 0.34, P = 0.01 and r = 0.49, P = 0.00001) in control and Type 1 diabetes respectively. In Type 1 diabetes, small and large artery elasticity correlated inversely and systemic vascular resistance correlated positively with skin autofluorescence (all P = 0.001), and with lens and corneal autofluorescence (all P < 0.03). In Type 1 diabetes tissue advanced glycation end-products correlated with C-reactive protein and inversely with the estimated glucose disposal rate and with circulating advanced glycation end-product levels. Relative to non-diabetic subjects, lens, corneal and skin fluorescence were increased (all P < 0.001) and small artery elasticity was decreased in diabetes (P = 0.04). Lens, corneal and skin autofluorescence were greater (all P = 0.0001) in patients with Type 1 diabetes with complications compared to those without complications, but small artery elasticity did not differ significantly. CONCLUSIONS: Ocular and skin autofluorescence and vascular stiffness correlate in non-diabetic and Type 1 diabetes subjects and are increased in Type 1 diabetes. Tissue advanced glycation end-products correlate with vascular risk factors, including circulating advanced glycation end-products.

The significance of chloride in the inhibitory action of disodium cromoglycate on immunologically-stimulated rat peritoneal mast cells.

BACKGROUND: The microelectrode array (MEA) was used to investigate the pharmacological relevance of chloride (Cl-) ions in antigen-dependent mast cell activation and the inhibitory effect of disodium cromoglycate (DSCG) on mast cell activation. METHODS: The movements of ions across the cellular membrane and the potential relationship between Cl- channels and DSCG during immunological activation were investigated using the MEA. The results were then subsequently compared with the amount of histamine released from anti-IgE activated peritoneal mast cells. RESULTS: The inclusion of charybdotoxin (ChTX) in Cl--free buffer showed that the measured field potentials during antigen-stimulated peritoneal mast cell were a combination of Cl- influx and K+ efflux. The delayed onset time of Cl- influx indicated the presence of a delayed outwardly-rectifying Cl- current in the antigen-stimulated peritoneal mast cells. The use of 5-nitro-2-(3-phenylpropylamino) benzoic acid demonstrated that the activated mast cell membrane potential can be stabilised, thereby reducing the amount of histamine released from the anti-IgE activated mast cells. The correlation between the results of the histamine release assay and the electrophysiological measurements demonstrated the importance of Cl- to anti-IgE dependent mast cell activation. The inhibitory effect of DSCG on anti-IgE activated cells, however, did not correlate with the presumed influx of Cl-. CONCLUSIONS: The MEA data suggest that Cl- influx is crucial to IgE-dependent mast cell degranulation. GENERAL SIGNIFICANCE: While the MEA cannot yield information about single channel properties, it is convenient to use and can provide information on the global changes in electrophysiological responses of non-excitable cells.

What are the learning outcomes of a short postgraduate training course in dermatology for primary care doctors?

BACKGROUND: There are increasing expectations on primary care doctors to shoulder a bigger share of care for patients with common dermatological problems in the community. This study examined the learning outcomes of a short postgraduate course in dermatology for primary care doctors. METHODS: A self-reported questionnaire developed by the research team was sent to the Course graduates. A retrospective design was adopted to compare their clinical practice characteristics before and after the Course. Differences in the ratings were analysed using the nonparametric Wilcoxon signed rank test to evaluate the effectiveness of the Course in various aspects. RESULTS: Sixty-nine graduates replied with a response rate of 42.9% (69/161). Most were confident of diagnosing (91.2%) and managing (88.4%) common dermatological problems after the Course, compared to 61.8% and 58.0% respectively before the Course. Most had also modified their approach and increased their attention to patients with dermatological problems. The number of patients with dermatological problems seen by the graduates per day showed significant increase after the Course, while the average percentage of referrals to dermatologists dropped from 31.9% to 23.5%. The proportion of graduates interested in following up patients with chronic dermatological problems increased from 60.3% to 77.9%. CONCLUSIONS: Graduates of the Course reported improved confidence, attitudes and skills in treating common dermatological problems. They also reported to handle more patients with common dermatological problems in their practice and refer fewer patients.

A comparison of Q-switched and long-pulsed alexandrite laser for the treatment of freckles and lentigines in oriental patients.

BACKGROUND: Q-switched (QS) lasers are effective in the treatment of freckles and lentigines in Type I and II skin, with minimal adverse effects. Long pulsed (LP) lasers have been proposed to be more suitable for treatment of darker skin types. OBJECTIVES: To investigate the efficacy and adverse effects of using QS or LP Alexandrite laser for the treatment of freckles and lentigines in Oriental patients. METHODS: A prospective split-face study of 20 Chinese patients who were randomly assigned to undergo a single QS (50 nanosecond) or LP (100 microseconds) laser treatment to either side of their face was carried out. Two blinded physicians assessed clinical efficacy using visual analogue scales of pre- and post-treatment photographs. Subjective assessment was evaluated using questionnaires which detailed the degree of pain, erythema and edema sustained during treatment, and improvement and satisfaction levels at 4, 8, and 12 weeks. RESULTS: There was statistically significant improvement in pigmentation (P < 0.05) in both groups throughout the study, with no statistical difference found between the groups. Postinflammatory hyperpigmentation was more frequently found after QS treatment (22%), compared to LP treatment (6%). Majority of patients reported moderate to marked improvement in pigmentation throughout the study with both pulse widths, and correspondingly high levels of satisfaction rates. More severe pain, erythema and edema were experienced during QS Alexandrite treatment. CONCLUSION: LP Alexandrite is quick and effective, and carries a lower risk of adverse effects than QS Alexandrite, for the removal of freckles and lentigines in darker skin types.

Parenteral vitamin B12 in macrocytic hemodialysis patients reduced MMA levels but did not change mean red cell volume or hemoglobin.

AIMS: Unexplained macrocytic anemia was common in our hemodialysis (HD) unit. Vitamin B12 requirements may be higher in HD patients; therefore, patients may be deficient despite "normal" serum levels. We studied vitamin B12 status and the effect of parenteral vitamin B12 administration in macrocytic HD patients. A normocytic group was included for comparison. MATERIALS AND METHODS: Prospective cohort study of 62 HD patients (34 macrocytic, 28 normocytic) from November 2008 to March 2009. Patients were on stable doses of darbepoetin and iron replete. Vitamin B12 1,000 µg IV was given once weekly for 4 weeks and follow-up was 12 weeks. Methylmalonic acid (MMA) level was used as an indicator of vitamin B12 status. MCV and hemoglobin were also examined for an effect of B12 administration. RESULTS: At baseline: all patients had serum B12 levels > 200 pmol/l; 97% had serum folate levels > 55 nmol/l; there was no difference in serum B12 levels between groups (504 vs. 571 pmol/l, p = 0.18); MMA was higher in the macrocytic group (0.56 vs. 0.48 µmol/l, p = 0.048) and hemoglobin (Hg) was lower (119 vs. 125 g/l, p = 0.03); median darbepoetin dose was equivalent (20 µg/week). Following IV vitamin B12, the macrocytic group had a greater and more sustained reduction in MMA (-0.064 vs. -0.0066 µmol/l/wk, p = 0.004). There was no improvement in hemoglobin (Hg), reticulocyte count or MCV in either group. Median darbepoetin dose was unchanged. CONCLUSIONS: IV vitamin B12 led to a sustained decline in MMA levels in macrocytic patients, suggesting functional vitamin B12 deficiency at baseline. However, there were no significant changes in Hg or darbepoetin dose.