Acute relapse after initiation of Siponimod in a patient with secondary progressive MS.

Sphingosine 1-phosphate (S1P) is a signaling molecule that binds to five G protein-coupled receptors (Proc Natl Acad Sci USA 108:751-756, 2011). Modulation of these receptors has been associated with pleiotropic biological effects in the immune, cardiovascular, and central nervous systems (CNS). The functional S1P receptor antagonist fingolimod was the first member of this class of pharmacotherapeutics to be approved for treatment of relapsing multiple sclerosis (MS). Siponimod is currently in clinical trial in patients with secondary progressive (SP) MS, a clinical trial for which there is an unmet need for disease-modifying agents. 10 weeks into the trial, the patient awoke with blurry vision in his left eye, and was subsequently diagnosed with an acute optic neuritis. Despite discontinuation of siponimod and treatment with pulse corticosteroids, the patient did not regain visual function in the affected eye. This is the first report of disease reactivation shortly after initiating siponimod in a patient with SPMS. This case illustrates that the known changes in lymphocyte numbers and composition in the CNS associated with S1P receptor antagonism during the SPMS disease stage may have adverse outcomes in some patients during treatment initiation, and that close clinical and paraclinical monitoring is advised.

Prevention of scar spread on trunk excisions: a rater-blinded randomized controlled trial.

IMPORTANCE: Wounds that heal under tension lead to wider and more conspicuous scars and result in decreased long-term patient satisfaction. We hypothesized that prolonged intradermal suture lifetime can decrease scar spread in wounds under tension. OBJECTIVE: To determine whether prolonged intradermal support would help decrease scar spread. DESIGN Prospective, randomized, controlled, rater-blinded, split-scar trial. SETTING: Outpatient dermatology clinic at Dallas Veterans Affairs Hospital, Dallas, Texas. PATIENTS: Patients presenting with skin cancer on the trunk were considered for the trial. We included 25 distinct surgical sites on a total of 22 patients. INTERVENTION: After excision, the wounds were closed with polyglactin 910 and poly-4 hydroxybutyrate (P4HB) sutures in opposite halves of the same wound. MAIN OUTCOME MEASURES: Quantitative scar spread at 12 months and qualitative assessment using a visual analog scale and Hollander Wound Evaluation Scale. RESULTS: We found a statistically significant difference in scar width between the 2 suture materials, with a mean difference of 2.3 (95% CI, 1.0-3.6) mm (P < .001) favoring P4HB. A clinically significant difference on the visual analog and Hollander Wound Evaluation scales was not identified. Suture reactions were more common with P4HB. CONCLUSIONS AND RELEVANCE: Prolonged intradermal suture support leads to significantly decreased scar spread. However, the use of a longer-acting absorbable suture increases the rate of suture reaction noted at 3 months. Further studies into less reactive, longer-acting biomaterials are needed. In clinical practice, excisions in high-tension areas that are classically known to spread over time can benefit from longer-acting intradermal sutures. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00938691.

Prevalence of antigliadin antibodies in patients with psoriasis is not elevated compared with controls.

BACKGROUND: Antigliadin antibodies (AGAs) are markers of celiac sprue but may have autoimmune implications in the absence of gastrointestinal disease. There is anecdotal evidence to suggest that gluten sensitivity may play a role in psoriasis, and patients with psoriasis in Europe have been reported to improve on a gluten-free diet. OBJECTIVE: To assess whether patients with psoriasis in the US have an increased prevalence of elevated AGAs. METHOD: A US sample of patients with psoriasis (n=100), patients with psoriasis and psoriatic arthritis (n=100), and age-matched control individuals without any personal or family history of autoimmune disorders (n=100) were tested for IgG and IgA AGAs. RESULTS: No difference in the prevalence of abnormal AGAs among patients with psoriasis (14%), combined psoriasis and psoriatic arthritis (18%), and control individuals (19%) was observed. No significant correlations between AGA positivity and psoriasis severity, joint involvement, or age of onset of psoriasis or arthritis were observed. CONCLUSION: We found no support for the results of prior studies showing that elevated AGAs occur with increased frequency in patients with psoriasis. Furthermore, the relatively high prevalence of abnormal AGAs in our control population suggests these antibodies may not be associated with autoimmune disease.

Clinical e-mail in an academic dermatology setting.

BACKGROUND: Use of e-mail among patients and physicians is limited by reservations over issues such as medicolegal aspects, reimbursement, and time-management. OBJECTIVE: Our purpose was to identify the content of patient-related e-mails in an academic dermatology practice and determine whether clinical questions could be answered by e-mail. METHODS: The first 100 e-mails received each year that related to patients from January 1, 2000 to June 1, 2005 (plus any messages received in e-mail threads started in the original 100) were studied (N = 614). E-mails were sent by patients, potential patients, or physicians in reference to a patient. E-mails were divided into 8 categories on the basis of content. E-mails were subdivided as relating to new (patients who had never been seen in-person) or established patients. All clinical questions were categorized as to whether they were answered by e-mail. The average number of e-mails received per e-mail thread was tallied. RESULTS: E-mails were distributed as follows: clinical question from a physician (20%), clinical question from a patient (17%), appointment request (18%), request for referral to another physician (7%), prescription refill (3%), research inquiry (2%), thank-you correspondence (31%), other (17%). Percentages do not equal 100 because some e-mails contained more than one subject. Clinical questions were more likely to be answered when posed by physicians (100%) than patients (70%; P = .001), and when from established (79%) versus new patients (60%; P = .02). There were fewer e-mails per thread for queries from physicians (1.6 messages received) versus patients (2.2; P < .001) and for established (1.6) versus new patients (2.2; P < .001). LIMITATIONS: This study was limited to the experience of one dermatologist in an academic setting. CONCLUSION: E-mail broadens communication between patients and their dermatologist. E-mail may facilitate consultation with other physicians and management of patients with chronic disease. "Thank-you" responses engage a substantial amount of e-mail resources.

Laparoscopic vs open surgical approach for intussusception requiring operative intervention.

PURPOSE: Laparoscopy has recently been used to treat intussusception that cannot be reduced radiologically. The effectiveness and practical nature of this approach has been questioned. METHODS: This study retrospectively analyzed the authors' experience with this laparoscopic approach and compared this to the conventional open laparotomy procedure. RESULTS: Sixteen patients were treated via laparoscopy, with 2 of these requiring conversions to an open procedure (12.5%). Twenty-five patients underwent an open reduction. Operative time was not significantly different (P = .698) between the laparoscopic (49.56 +/- 26.40 minutes) and open groups (45.00 +/- 24.74). Length of stay, however, was significantly reduced (P = .005) in the laparoscopic group (3.00 +/- 1.31 days) compared to the open group (4.52 +/- 1.98). Total hospital charges were lower in the laparoscopic group ($8171 +/- 2595) compared to the open group ($11,672 +/- 5466); this difference was not significant (P = .088). There were no significant differences in intra- or postoperative complication rates (P = .637) between the 2 approaches. CONCLUSIONS: Although there remains a group who will require a conversion to an open procedure, the laparoscopic approach should be considered a safe and effective option for all children who do not respond to a radiological reduction.

Mechanical properties of acellular peripheral nerve.

BACKGROUND: Acellular nerve has been used in experimental models as a peripheral nerve substitute. Our objective was to determine the difference in tensile strength between fresh and chemically treated acellularized peripheral nerve. MATERIALS AND METHODS: F344 rat sciatic nerves were either fresh or acellularized and tested either whole (Part A) or transected and repaired (Part B). For all constructs, the mean ultimate stress, mean ultimate strain, Young's modulus, and total mechanical work to fracture were calculated. The average ultimate strains for Groups A-1 and A-2 were 0.480 +/- 0.117 and 0.810 +/- 0.114, respectively. The Young's moduli in Groups A-1 and A-2 were 576 +/- 160 and 580 +/- 150 kPa, respectively. In Groups A-1 and A-2, the normalized work to failure was 0.35 +/- 0.14 and 1.11 +/- 0.38 N. The specimens in Group B-1 withstood an average ultimate stress of 780 +/- 280 kPa. The specimens in Group B-2 withstood an average ultimate stress of 405 +/- 20 kPa. RESULTS: The average ultimate strains for Groups B-1 and B-2 were 0.319 +/- 0.087 and 0.266 +/- 0.019, respectively. The Young's moduli in Groups B-1 and B-2 were 4,030 +/- 1360 and 2,290 +/- 280 kPa, respectively. The normalized work to failure in Groups B-1 and B-2 was calculated as 0.22 +/- 0.04 and 0.11 +/- 0.02 N. CONCLUSIONS: Although adequately robust for reconstructive procedures, the acellular peripheral nerve had decreased tensile strength compared with fresh nerve either when tested whole or when transected and repaired.