Unintended insulin delivery using Omnipod DASH during a high-altitude flight.

Insulin pumps are an important tool in the management of type I diabetes mellitus. Omnipod DASH is a tubeless insulin pump that delivers insulin through customisable basal rate and bolus amounts. There is no data available to date on how this insulin pump delivery system is influenced by changes in atmospheric pressure during flight at high altitudes. We report a case of a 55-year-old woman who developed symptomatic hypoglycaemia while using this pump during flight in a non-pressurised cabin. This report demonstrates the risk of insulin pump therapy at high altitudes. Flight emergencies involving rapid depressurisation may lead to catastrophic hypoglycaemia. Caution should be exercised when using insulin pump therapy during flights and manual insulin delivery should be considered.

Application of Intralesion Ultrasound-Guided Laser Ablation for Plantar Foot Mass Involving Arteriovenous Fistula: A Case Report.

Penetrating and blunt trauma to the plantar aspect of the foot are common. Both penetrating and blunt trauma may be associated with an injury to the blood vessels, which may go undetected clinically. A minor puncture, blunt trauma and repeated blunt trauma can injure small arteries leading to an arteriovenous fistula (AVF). The arterial rupture leads to a system of veins creating a small AVF and appearing clinically as a blue colored, painful lesion. A case of such an injury is presented where the clinical examination, magnetic resonance arteriogram and point of service ultrasound with duplex imaging was used to diagnose the AVF. The AVF was treated in the clinic with a percutaneous ultrasound-guided laser procedure. The laser procedure was effective and there was minimal post procedural morbidity.

Skin-brain axis signaling mediates behavioral changes after skin wounding.

Patients with chronic wounds often have associated cognitive dysfunction and depression with an as yet unknown mechanism for this association. To address the possible causality of skin wounding inducing these changes, behavior and cognitive functions of female C57BL/6 mice with an excisional skin wound were compared to unwounded animals. At six days post wounding, animals exhibited anxiety-like behaviors, impaired recognition memory, and impaired coping behavior. Wounded animals also had concomitant increased hippocampal expression of Tnfa, the pattern recognition receptor (PRR) Nod2, the glucocorticoid receptors GR/Nr3c1 and Nr3c2. Prefrontal cortex serotonin and dopamine turnover were increased on day six post-wounding. In contrast to the central nervous system (CNS) findings, day six post -wounding serum catecholamines did not differ between wounded and unwounded animals, nor did levels of the stress hormone corticosterone, TNFα, or TGFß. Serum IL6 levels were, however elevated in the wounded animals. These findings provide evidence of skin-to-brain signaling, mediated either by elevated serum IL6 or a direct neuronal signaling from the periphery to the CNS, independent of systemic mediators. Wounding in the periphery is associated with an altered expression of inflammatory mediators and PRR genes in the hippocampus, which may be responsible for the observed behavioral deficits.

Granuloma annulare-like eruption in chronic lymphocytic leukemia.

We report a patient with new-onset ulcerated granuloma annulare with concomitant involvement of B-cell leukemia. A granuloma annulare-like eruption with concomitant B cell chronic lymphocytic leukemia involvement in the skin is extremely rare, as only three cases have been previously reported in the literature to our knowledge. Given the rarity of ulceration in conventional granuloma annulare, it is possible this finding may serve as a diagnostic clue for underlying malignancy.

Beta-adrenergic antagonist for the healing of chronic diabetic foot ulcers: study protocol for a prospective, randomized, double-blinded, controlled and parallel-group study.

BACKGROUND: Diabetic foot ulcers (DFUs) are the most common cause of leg amputations and their management is extremely challenging. Despite many advances and expensive therapies, there has been little success in improving outcomes of DFUs. In prior work our laboratory has examined the effects of beta-adrenergic antagonists (ßAAs) on skin and skin-derived cells. We have shown that ßAAs enhance the rate of keratinocyte migration, promote angiogenesis, and hasten wound healing in scratch wounds in vitro, in animal wound models, and in anecdotally reported cases of chronic wounds that healed successfully after topical application of the ßAA timolol. Thus, we propose to test timolol directly on DFUs to determine if it improves healing above the current standard of care (SOC). This study will examine the efficacy and safety of topically applied beta-antagonist Timoptic-XE® (timolol maleate ophthalmic gel forming solution) in subjects with DFUs. METHODS/DESIGN: This is a phase two, randomized, double-blinded, controlled, and parallel-group clinical trial with two treatment arms, SOC plus topical Timoptic-XE® and SOC plus a non-biologically active gel (hydrogel, as placebo drug). Study subjects with a DFU will be selected from the Veterans Affairs Northern California Health Care System (VANCHCS). Study duration is up to 31 weeks, with three phases (screening phase for two weeks, active phase for up to 12 weeks, with an additional second consecutive confirmatory visit after 2 weeks, and follow-up phase comprising monthly visits for 4 months). Subjects will apply daily either the topical study drug or the placebo on the foot ulcer for 12 weeks or until healed, whichever comes first. Measurements of wound size and other data will be collected at baseline, followed by weekly visits for 12 weeks, and then a monthly follow-up period. DISCUSSION: This is a clinical translation study, moving the investigators' pre-clinical laboratory research into a translational study in which we will analyze clinical outcomes to assess for safety and estimate the efficacy of a topical beta-antagonist in healing of DFUs. The results from this trial may establish new treatment paradigms and safety profile for DFU treatment. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03282981. Registered on June 14th, 2018.

Microbiome-skin-brain axis: A novel paradigm for cutaneous wounds.

Chronic wounds cause a significant burden on society financially, medically, and psychologically. Unfortunately, patients with nonhealing wounds often suffer from comorbidities that further compound their disability. Given the high rate of depressive symptoms experienced by patients with chronic wounds, further studies are needed to investigate the potentially linked pathophysiological changes in wounds and depression in order to improve patient care. The English literature on wound healing, inflammatory and microbial changes in chronic wounds and depression, and antiinflammatory and probiotic therapy was reviewed on PubMed. Chronic wound conditions and depression were demonstrated to share common pathologic features of dysregulated inflammation and altered microbiome, indicating a possible relationship. Furthermore, alternative treatment strategies such as immune-targeted and probiotic therapy showed promising potential by addressing both pathophysiological pathways. However, many existing studies are limited to a small study population, a cross-sectional design that does not establish temporality, or a wide range of confounding variables in the context of a highly complex and multifactorial disease process. Therefore, additional preclinical studies in suitable wound models, as well as larger clinical cohort studies and trials are necessary to elucidate the relationship between wound microbiome, healing, and depression, and ultimately guide the most effective therapeutic and management plan for chronic wound patients.

Ultrasound as a diagnostic and interventional aid at point-of-care in dermatology clinic: a case report.

Ultrasound is currently underutilized in dermatology practice. However, ultrasound provides clinicians with precise and unique information on cutaneous and subcutaneous lesions, while minimizing costs and complications related to more common and invasive diagnostic methods. We report a patient who presented with a tender subcutaneous mass that was diagnosed and treated using point-of-care ultrasound-guidance at the dermatology clinic. Ultrasound revealed features consistent with a ganglion cyst, which was subsequently injected with triamcinolone acetonide under ultrasound-guidance with the resolution of symptoms upon follow-up one month later. Our study demonstrates the utility of ultrasound as an effective, time-efficient diagnostic and interventional aid that can modify dermatology practice.

Interleukin-17: Potential Target for Chronic Wounds.

Chronic wounds exhibit persistent inflammation with markedly delayed healing. The significant burden of chronic wounds, which are often resistant to standard therapy, prompts further research on novel therapies. Since the interleukin-17 family has been implicated as a group of proinflammatory cytokines in immune-mediated diseases in the gut and connective tissue, as well as inflammatory skin conditions, we consider here if it may contribute to the pathogenesis of chronic wounds. In this review, we discuss the interleukin-17 family's signaling pathways and role in tissue repair. A PubMed review of the English literature on interleukin-17, wound healing, chronic wounds, and inflammatory skin conditions was conducted. Interleukin-17 family signaling is reviewed in the context of tissue repair, and preclinical and clinical studies examining its role in the skin and other organ systems are critically reviewed. The published work supports a pathologic role for interleukin-17 family members in chronic wounds, though this needs to be more conclusively proven. Clinical studies using monoclonal interleukin-17 antibodies to improve healing of chronic skin wounds have not yet been performed, and only a few studies have examined interleukin-17 family expression in chronic skin wounds. Furthermore, different interleukin-17 family members could be playing selective roles in the repair process. These studies suggest a therapeutic role for targeting interleukin-17A to promote wound healing; therefore, interleukin-17A may be a target worthy of pursuing in the near future.

Radiation induced lichen planus - an uncommon side effect.

Cutaneous lichen planus is classically characterized by violaceous, pruritic, planar papules and plaques, most commonly affecting the extremities. Lichen planus following radiation therapy is extremely rare and lichen planus following radiation therapy for prostate carcinoma has not been previously reported in the literature. We report a 66-year-old man who presented to the dermatology clinic with a symmetric pruritic eruption affecting the pelvic and gluteal region within two months of radiation therapy targeting the prostate and pelvic lymph nodes for prostate adenocarcinoma. The patient did not have a prior history of lichen planus. Physical examination demonstrated well demarcated, violaceous papules and plaques in a circumferential band-like distribution on the bilateral gluteal, lumbosacral, and pelvic region. In addition, he had a few discrete lesions on the calves and dorsal feet. Punch biopsy revealed an acanthotic epidermis with "saw-tooth" rete ridges and a lichenoid inflammatory infiltrate. A diagnosis of hypertrophic lichen planus was made, reinforcing the importance for clinicians to recognize radiation therapy as a risk factor for developing lichen planus despite no prior history of lichen planus.

Elephantiasis nostras verrucosa: an atypical presentation following intrapelvic lymphoma.

Elephantiasis nostras verrucosa is a progressively debilitating and disfiguring disease commonly presenting with verrucous, cobblestone-like papules, nodules, or plaques with nonpitting edema in the lower extremities. Histopathology is marked by hyperkeratosis and dermal or subcutaneous fibrosis as a result of chronic lymphedema. Risk factors include obesity, recurrent cellulitis, chronic venous insufficiency, congestive heart failure, scleroderma, radiation, trauma, and tumors. We report a 72-year-old man who presented to the dermatology clinic for an 11-year history of edematous legs, occasionally associated with ulcerations. The findings developed within a year of intrapelvic non-Hodgkin lymphoma and progressed gradually over 10 years after lymphoma remission. Physical examination revealed atypical features including compressible cysts and pitting edema extending from the lower legs to the thighs bilaterally. The patient was noncompliant for the recommended compressive devices and the condition progressively worsened over the course of 7 months of follow-up. Early interdisciplinary management using compressive devices and a lymphatic pump are recommended. Underlying causative factors should be assessed with regular follow-up to optimize treatment outcomes.