Impact of Tilt-Down Positioning Compared With Left Lateral Positioning on Ease of Colonoscope Insertion During Colonoscopy.

GOALS: The aim of this study was to evaluate the efficacy of tilt-down (TD) versus left lateral (LL) positioning in speed and ease of colonoscope insertion in women with risk factors for difficult colonoscopy. BACKGROUND: Risk factors for difficult colonoscopy in women include pelvic surgery, diverticulosis, and thin body habitus. STUDY: Female patients with body mass index (BMI) under 25, diverticulosis and history of pelvic surgery were randomized to TD or LL positioning. Five colonoscopists performed all studies at a single center. Time to splenic flexure and cecum, type and amount of medication administered, Boston Bowel Prep Score (BBPS), adverse events, and findings were recorded. The Mann-Whitney U test was used to evaluate the primary endpoint. RESULTS: A total of 150 women were enrolled (81 TD, 69 LL). The mean age was 60.1 (SD 10.5) and the mean BMI was 23.9 (SD 3.5). In total 98 (65.3%) women had prior pelvic surgery, 94 (62.7%) had BMI <25 and 60 (40.0%) had diverticulosis. There was no statistically significant difference in time to the splenic flexure overall but insertion to the splenic flexure was significantly faster in the TD position as compared with the LL position in patients with diverticulosis (124 s for TD, 160 s for LL, P=0.022). In a linear regression analysis, lower BMI, diverticulosis and lower BBPS were significantly associated with a longer insertion time to the splenic flexure. There were no adverse events. CONCLUSION: TD positioning represents a straightforward maneuver to facilitate advancement through the sigmoid colon and may be beneficial in women with diverticular disease.

Diagnostic concordance of clinical diagnosis, tissue culture, and histopathology testing for skin and soft tissue infections: A single-center retrospective study.

BACKGROUND: Tissue culture and histopathology are the conventional diagnostic modalities for skin and soft tissue infections (SSTIs), but few studies have investigated their concordance. OBJECTIVE: Determine concordance between histopathology and tissue culture in the diagnosis of suspected SSTIs. METHODS: Single-center retrospective study of 355 cases with suspected SSTIs identified from the dermatology inpatient consultation log January 2014-July 2017. RESULTS: Overall concordance between histopathology testing and tissue culture results was high (76.1%). Concordance was high for cases defined as no evidence of infection, fungal infection and mycobacterial infection by histopathology (77.8%, 74.2%, and 80.0%) and tissue culture (92.1%, 67.7%, and 83.3%). Concordance was lower for suspected SSTIs with bacterial infection by histopathology (61.9%) and tissue culture (28.4%). Concordance rates were not significantly affected by age, sex, race, antimicrobial agent use, immunologic status, or biopsy size. LIMITATIONS: Retrospective and single-institution nature of the study. CONCLUSION: This study demonstrated a high concordance between histopathology and tissue culture in SSTIs with no clinical evidence of infection and suspected fungal and mycobacterial SSTIs, though concordance was lower for suspected SSTIs with evidence of bacterial infection. Clinicians should not be deterred from relying on initial histopathological results based on patients' immunosuppressed status, antimicrobial agent use, age, or biopsy tissue size.

Melanoma in individuals with neurofibromatosis type 1: a retrospective study.

BACKGROUND: Neurofibromatosis type 1 (NF1) is a cancer syndrome associated with many different cancer types. There are limited studies examining melanoma risk in this population. OBJECTIVE: To identify melanoma cases in NF1 patients and compare melanoma incidence rates relative to a general population sample. METHODS: A retrospective single institution case review of 857 NF1 patients (seen from 7/1997 to 7/2017) was conducted. We calculated age- and calendar period-adjusted standardized incidence ratios (SIRs) for white patients >20 years old overall (N=282) and for females (N=156) at their last visit date. We obtained general population melanoma reference rates from the Surveillance, Epidemiology, and End Results (SEER) 9 database. RESULTS: Among 857 patients, 52.2% were female, 54% were <20 (mean±sd=10.9±4.6) years old, and 46% were >20 (40.4±14.9) years old at their last visit date. One white female patient had a malignant melanoma diagnosed at 47 years old. The adjusted SIR was 0.97 (95% CI 0.05-4.78) overall (N=282) and 1.62 (95% CI 0.08-7.98) for females (N=156). CONCLUSIONS: We did not find statistical evidence for an increased melanoma risk in adults with NF1. However, additional large studies are warranted to clarify whether melanoma risk is increased in NF1 patients.

Dermatologic considerations in pediatric transplant recipients.

PURPOSE OF REVIEW: The pediatric transplant patient population is growing as the number of solid organ transplants and indications for hematopoietic stem cell transplant increase. Understanding cutaneous sequelae of pediatric transplant and treatment strategies to manage these outcomes is vital to the care of these patients. RECENT FINDINGS: Important work in the past year enhances our understanding of the cutaneous implications of pediatric transplantation, including further work in areas of malignancy, infection, and graft versus host disease as well as newly reported risks. SUMMARY: This review highlights recent developments in the recognition and management of dermatological complications of pediatric transplant that will be useful for the practicing pediatrician or dermatologist.

Mood changes with methotrexate therapy for dermatologic disease.

Neurotoxicity and cognitive effects of low-dose methotrexate for rheumatologic disease have often been described, but the neuropsychiatric effects of low-dose methotrexate for cutaneous disease have been underreported in the dermatology literature. We describe two children who experienced mood changes with methotrexate treatment for lichen sclerosus with morphea overlap and psoriasis, with rapid resolution of these symptoms after methotrexate cessation. We also detail possible mechanisms underlying psychiatric changes with methotrexate therapy.

EUS-guided drainage of peripancreatic fluid collections with lumen-apposing metal stents and plastic double-pigtail stents: comparison of efficacy and adverse event rates.

BACKGROUND AND AIMS: Transmural drainage with double-pigtail plastic stents (DPPSs) was the mainstay of endoscopic therapy for symptomatic peripancreatic fluid collections (PPFCs) until the introduction of lumen-apposing covered self-expanding metal stents (LAMSs). Currently, there are limited data regarding the efficacy and adverse event rate of LAMSs compared with DPPSs. METHODS: A retrospective analysis of EUS-guided PPFC drainage at a single tertiary care center between 2008 and 2015 was performed. Patients were classified based on drainage method: DPPSs and LAMSs. Adverse event rates, unplanned endoscopic procedures/necrosectomies, and PPFC resolution within 6 months were recorded. Significant bleeding was defined as necessitating transfusion or requiring endoscopic treatment/radiographic embolization. Subsequent endoscopic procedures were defined as unplanned procedures; stent removals were excluded. RESULTS: A total of 103 patients met inclusion criteria (84 DPPSs, 19 LAMSs). PPFCs were classified as walled-off necrosis (WON) in 23 (14 DPPSs, 9 LAMSs). There were significantly more bleeding episodes in the LAMS group (4 [19%]: 2 splenic artery pseudo-aneurysms, 1 collateral vessel bleed, 1 intracavitary variceal bleed; P = .0003) than in the DPPS group (1 (1%]: stent erosion into the gastric wall). One perforation occurred in the DPPS group. Unplanned repeat endoscopy was more frequent in the LAMS group (10% vs 26%, P = .07). Among retreated LAMS patients in with WON, 5 (56%) had obstruction by necrotic debris. In patients for whom follow-up was available, 67 of 70 (96%) with DPPSs and 16 of 17 (94%) with LAMSs had resolution of PPFCs within 6 months (P = .78). CONCLUSIONS: DPPSs and LAMSs are effective methods for treatment of PPFCs. In our cohort, use of LAMSs was associated with significantly higher rates of procedure-related bleeding and greater need for repeat endoscopic intervention.

Inhibitors of Arg-Gly-Asp-Binding Integrins Reduce Development of Pancreatic Fibrosis in Mice.

BACKGROUND & AIMS: Pancreatic stellate cells (PSCs) regulate the development of chronic pancreatitis (CP) and are activated by the cytokine transforming growth factor ß (TGFB). Integrins of the αv family promote TGFB signaling in mice, probably by interacting with the Arg-Gly-Asp (RGD) sequence of the TGFB latency-associated peptide, which frees TGFB to bind its cellular receptors. However, little is known about the role of integrins in the development of CP. We investigated the effects of small-molecule integrin inhibitors in a mouse model of CP. METHODS: We induced CP in C57BL/6 female mice by repeated cerulein administration. An active RGD peptidomimetic compound (Center for World Health and Medicine [CWHM]-12) was delivered by continuous infusion, starting 3 days before or 5 days after cerulein administration began. Pancreata were collected and parenchymal atrophy, fibrosis, and activation of PSCs were assessed by histologic, gene, and protein expression analyses. We measured CWHM-12 effects on activation of TGFB in co-culture assays in which rat PSC cells (large T immortalized cells [LTC-14]) activate expression of a TGFB-sensitive promoter in reporter cells. RESULTS: Pancreatic tissues of mice expressed messenger RNAs encoding subunits of RGD-binding integrins. Cerulein administration increased expression of these integrins, altered pancreatic cell morphology, and induced fibrosis. The integrin inhibitor CWHM-12 decreased acinar cell atrophy and loss, and substantially reduced fibrosis, activation of PSCs, and expression of genes regulated by TGFB. CWHM-12 also reduced established fibrosis in mice and blocked activation of TGFB in cultured cells. CONCLUSIONS: Based on studies of a mouse model of CP and cultured PSCs, integrins that bind RGD sequences activate PSCs and promote the development of pancreatic fibrogenesis in mice. Small-molecule antagonists of this interaction might be developed for treatment of pancreatic fibrotic diseases.