Transcriptomic and histological analysis of exposed facial skin areas wrinkled or not and unexposed skin.

BACKGROUND: Skin aging involves genetic, environmental and hormonal factors. Facial wrinkles also depend on muscular activity. Gene expression investigation may be useful for new anti-aging products. METHODS AND RESULTS: To evaluate structure and gene expression differences among exposed and unexposed skin in menopausal women. Cross-sectional study, including 15 menopausal women, 55-65 years, phototype III; photo-exposed, periorbital wrinkles (A1), preauricular, not wrinkled (A2), and unexposed gluteal (A3) areas were described and compared by non-invasive measures, histology, immunohistochemistry and gene expression (RNASeq); participants mean age was 61yo, presenting moderate periorbital wrinkles and light facial photodamage. Higher roughness, wrinkles number and echogenicity were observed in A1 and A2 versus A3. Decreased epidermal thickness and dermal collagen IV were demonstrated in A1 versus A2 and A3. Exposed areas impacted different pathways compared to unexposed. Exposed wrinkled skin (A1) showed impact on cell movement with decreased inflammatory activation state. Pathways related to lipid and aminoacids metabolism were modulated in non-wrinkled exposed (A2) compared to unexposed (A3) skin. CONCLUSIONS: Expected histological findings and gene expression differences among areas were observed. Photoaging in menopausal women may modulate lipid and aminoacids metabolism and decrease inflammatory and keratinization pathways, cellular homeostasis, immune response, fibrogenesis and filament formation. These findings may help development of new therapies for skin health and aging control.

Development of a clinical scale to assess the severity of striae distensae.

BACKGROUND AND OBJECTIVE: There is no validated instrument to assess the clinical severity of striae distensae. Here, we aimed to develop a striae distensae severity scale. MATERIAL AND METHODS: After a Delphi-based consensus, 15 items related to striae severity were assessed in 110 areas (breasts, abdomen, and buttocks) from 45 participants. The items were analyzed through a partial least squares model to select the most important variables. To assess the reliability of the scale, 43 areas were retested. RESULTS: Of the 110 areas evaluated, 34 were breasts, 24 abdomens, and 52 buttocks. Striae were considered mild in 30% of the evaluations, moderate in 33%, severe in 21%, and extremely severe in 16%. The final model was composed by: width of the widest striae, width of the striae with the most frequent pattern, atrophy, number of affected quadrants, distribution (multiple or isolated), hypo or hyperchromia and topography. The scores of the scale demonstrated a high correlation with the clinical classification (rho = 0.77). There was a high agreement in the scores from the reassessed areas (intraclass correlation coefficient = 0.90). CONCLUSION: An objective and reliable scale to assess the clinical severity of striae distensae on the breasts, abdomen, and buttocks was developed.

Reliability across content areas in progress tests assessing medical knowledge: a Brazilian cross-sectional study with implications for medical education assessments.

BACKGROUND: Brazilian medical schools equitably divide their medical education assessments into five content areas: internal medicine, surgery, pediatrics, obstetrics and gynecology, and public health. However, this division does not follow international patterns and may threaten the examinations' reliability and validity. OBJECTIVE: To assess the reliability indices of the content areas of serial, cross-institutional progress test examinations. DESIGN AND SETTINGS: This was an analytical, observational, and cross-sectional study conducted at nine public medical schools (mainly from the state of São Paulo) with progress test examinations conducted between 2017 and 2023. METHODS: The examinations covered the areas of basic sciences, internal medicine, surgery, pediatrics, obstetrics and gynecology, and public health. We calculated reliability indices using Cronbach's α, which indicates the internal consistency of a test. We used simple linear regressions to analyze temporal trends. RESULTS: The results showed that the Cronbach's α for basic sciences and internal medicine presented lower values, whereas gynecology, obstetrics, and public health presented higher values. After changes in the number of items and the exclusion of basic sciences as a separate content area, internal medicine ranked highest in 2023. Individually, all content areas except pediatrics remained stable over time. CONCLUSIONS: Maintaining an equitable division in assessment content may lead to suboptimal results in terms of assessment reliability, especially for internal medicine. Therefore, content sampling of medical knowledge for general assessments should be reappraised.

Morphological and ultrastructural changes in fungal agents after LASER application.

BACKGROUND: Onychomycosis is a fungal nail infection of difficult treatment due to the fungal survival capacity and reduced number of effective therapies. The present study aimed to isolate fungal agents that cause onychomycosis in immunocompetent patients and evaluate how LASER treatments affect the growth and ultrastructure of isolates. METHODS: In total, 21 patients with positive direct microscopic examination (DME) for onychomycosis had nail samples collected for cultivation and phenotypic identification of microorganisms. From these patients, 12 underwent LASER treatment, divided in Group 1 (n = 5) treated with Nd: YAG 1,064 nm, and Group 2 (n = 7) treated with Nd: YAG 1,064 nm + Er: YAG 2,940 nm + topical isoconazole. Transmission Electron Microscopy (TEM) was performed to evaluate ultrastructural changes after treatment. RESULTS: DME, cultivation, and phenotypic identification showed that the most identified fungus was Trichophyton rubrum spp. After LASER therapy, sample cultivation showed alterations in the fungal morphology with reduction of hyphae, conidia, and reproductive structures. Alterations in fungal cell wall structure, cytoplasm density, and organelles were observed by TEM. CONCLUSION: LASER irradiation causes changes in the fungal cells, especially in the number of hyphae and the presence of conidia. In addition, it affects fungal growth and reproduction capacity, which interferes with their infection ability and virulence.

Early chemabrasion for acne scars after treatment with oral isotretinoin.

BACKGROUND: Acne is an inflammatory disease of the pilosebaceous follicles. Oral isotretinoin is the treatment of choice for severe acne. Exaggerated cicatrization related to oral isotretinoin was reported in the 1980s and 1990s. Currently, dermabrasion for acne scar revision is only recommended 6 to 12 months after the completion of oral isotretinoin treatment. OBJECTIVE: To evaluate the evolution of healing from manual chemabrasion of depressed scars resulting from acne conducted within 1 to 3 months after oral isotretinoin treatment. METHODS AND MATERIALS: This was an interventional, prospective study involving 10 patients with depressed facial scars. A medium-depth chemical peel was applied to the entire face. Manual sandpaper dermabrasion was performed to areas of scarring until the appearance of bloody dew. A 6-month reepithelization follow-up was conducted. RESULTS: All of the patients presented with normal cicatrization, and neither hypertrophic scars nor keloids were observed. Depressed acne scar revision was satisfactory. CONCLUSION: Our observations may contribute to the discussion of the negative influence of oral isotretinoin on wound healing. Other studies are necessary to reevaluate the current recommendation of a 6- to 12-month waiting period after oral isotretinoin treatment before performing dermabrasion or fractional ablative laser for acne scar revision.

Compulsory notification of injuries in aesthetic procedures. Impact on patient safety.

The disparity between the number of aesthetic procedures performed worldwide, and the complications described in the literature is remarkable. Doubts regarding the underreporting are reasonable and should be considered. The aim of this study is to demonstrate the scarcity of scientific publications on complications in aesthetic procedures compared to the abundance of these procedures performed worldwide. Based on this knowledge, it will be demonstrated to the health authorities the importance of compulsory notification of complications in aesthetic procedures that require medical attention so that the available data will allow their prevention. The limitation of knowledge regarding complications was demonstrated in the data collection for the preparation of the thesis "Deaths Related to Liposuction in Brazil" presented in 2018 and published in Surgical and Cosmetical Dermatology in 2020. The definition of complication in aesthetic procedures needs to be objective to prevent different and subjective interpretations. With the compulsory notification of complications in aesthetic procedures, it is intended to learn about their causes to develop guidelines for their prevention.

Dermabrasion for acne scars during treatment with oral isotretinoin.

BACKGROUND: Oral isotretinoin is the criterion standard treatment for severe inflammatory acne associated with scar development. Atypical or exaggerated cicatrization related to oral isotretinoin was reported throughout the 1980s and 1990s. Dermabrasion for atrophic acne scar revision is not recommended 6 to 12 months from the end of oral isotretinoin treatment. OBJECTIVE: To evaluate wound healing after localized dermabrasion in patients receiving oral isotretinoin. MATERIALS & METHODS: Interventional, prospective study involving seven patients taking oral isotretinoin to treat acne and with atrophic acne scars on the face. Manual dermabrasion was performed on all patients in an area of approximately 1 cm(2), and a 6-month reepithelization follow-up by clinical evaluation was conducted. RESULTS: All patients presented normal cicatrization evolution; hypertrophic scarring or keloid as a result of localized abrasion was not observed, and atrophic acne scar revision result was excellent. CONCLUSION: The current recommendation to wait 6 to 12 months after treatment with oral isotretinoin for acne scar revision using dermabrasion should be re-evaluated. Abrasion of a small test area may be a useful predictor of wound healing, enabling earlier acne scar treatment using this procedure.

Delayed skin necrosis following hyaluronic acid filler injection: A case report.

Vascular compromise is a rare but serious complication of dermal filler injection. Vessel occlusion tends to have a more immediate onset of symptoms. We report a case of skin necrosis that started with pain, erythema and edema two days after hyaluronic acid filler on the forehead of a 57-year-old woman. The patient was treated with less than 24 hours the onset of symptoms, leaving discreet scar. The current theories that explain skin necrosis caused by HA fillers include angiospasm and embolization. The frontal region has many anastomoses, the embolized proximal vessel initially did not lead to symptoms. However, the HA inside the artery may have traveled over time and reached a terminal distal branch, which generated localized skin damage and pain. The urgent treatment of arterial occlusion and thromboembolism caused by HA injection is intralesional high-dose hyaluronidase.

Herpes Zoster as a Differential Diagnosis for Ischemia after Facial Hyaluronic Acid Filler.

The use of hyaluronic acid (HA) fillers for facial rejuvenation has grown widely and is now one of the most performed noninvasive cosmetic procedures. Viral infections can occur, albeit rarely. This report describes a 65-year-old female patient with significant fat tissue loss in the malar region who developed herpes zoster after receiving HA filler for facial volumization. We performed volumization with a total of 2mL of HA in one session. Two days after the procedure, the patient began feeling mild pain in the malar region bilaterally and in the right side of the nasolabial fold. Upon physical examination, vesicles and erythema were observed. Due to the possibility of herpes zoster virus (HZV) infection, the patient was treated with valacyclovir. Ultrasonography with arterial and venous Doppler study revealed normal blood flow in the angular artery path and adequate positioning of the filler. After seven days of valacyclovir, the patient had complete resolution of the lesions. Herpes virus reactivation can be caused by direct axon damage by the needle, by tissue manipulation, and by inflammatory reaction. Herpes simplex virus (HSV) is the virus most commonly involved and its incidence does not exceed 1.45 percent of the complication cases, and HZV is even rarer. Reactivation of HZV might mimic tissue ischemia. Ultrasonography is a noninvasive, fast, and useful tool to evaluate vascular impairment and the positioning of the filler.

Medicina culinária: relato de experiência de uma disciplina eletiva para alunos de Medicina / Culinary medicine: experience report of an elective course for Medical students

RESUMO Introdução: O aumento global da alimentação não saudável está intimamente ligado a uma tendência de redução na preparação da comida feita em casa. Já existem estudos que mostram uma associação positiva entre o aumento das habilidades culinárias e a redução de risco cardiovascular. Somado a isso, o baixo tempo destinado à educação nutricional no currículo das faculdades de Medicina contrasta com as altas taxas de mortalidade atribuíveis à má alimentação. A medicina culinária (MC) é um campo emergente da medicina, que traz uma nova abordagem educacional, baseada em evidências científicas, cujo objetivo é ensinar o poder que a comida tem sobre a saúde e melhorar os comportamentos alimentares dos profissionais de saúde e, consequentemente, de seus pacientes. Relato da experiência: Desenvolveu-se uma disciplina eletiva de MC na Escola Paulista de Medicina da Universidade Federal de São Paulo (Unifesp) que resultou em um relato de experiência, com abordagem qualitativa, realizado com 18 alunos que participaram de encontros semanais durante cinco semanas de forma 100% online, por meio da plataforma Zoom. Os dados deste estudo foram coletados por meio de portfólios, em que cada estudante descreveu sua experiência com o curso. A avaliação do material foi feita por meio de análise temática. Aplicou-se um questionário que avaliou o Índice de Habilidades Culinárias, desenvolvido e validado segundo a autoeficácia no desempenho das habilidades culinárias e tendo como referencial teórico o Guia alimentar para a população brasileira. Discussão: Existem inúmeros desafios, como a conscientização dos médicos sobre a importância desse assunto, que muitas vezes parece ser mais prático do que técnico, e a subjetividade do tema sobre mudança de comportamento de médicos e pacientes. No entanto, os resultados deste estudo evidenciam que os alunos que realizaram a eletiva acreditam que essa reformulação curricular é extremamente importante e urgente. Conclusão: Observa-se uma tendência mundial de transformação da grade curricular dos profissionais da saúde, e acredita-se que esse processo pode ser iniciado nas faculdades de Medicina por meio de disciplinas eletivas de MC como a que foi implementada na Escola Paulista de Medicina da Unifesp.

ABSTRACT Introduction: The global increase in unhealthy eating is closely linked to a downward trend in food preparation at home. There are studies showing a positive association between increased cooking skills and reduced cardiovascular risk. In addition, the little time devoted to nutrition education in the curriculum of medical schools contrasts with the high mortality rates attributable to poor diet. Culinary Medicine (CM) is an emerging field of Medicine, which brings a new educational approach, based on scientific evidence, whose objective is to teach the power that food has on health and to improve the eating behaviors of healthcare professionals and, consequently, of their patients. Experience report: An elective discipline of CM was developed at Unifesp, which resulted in a descriptive study with a qualitative approach, carried out with 18 students who participated in weekly meetings during 5 weeks of training. The meetings were carried out 100% online, through the Zoom platform. Data from this study were collected through portfolios, in which each student described their experience with the course. The analysis of the material was carried out through thematic analysis. A questionnaire was applied to evaluate the Culinary Skills Index developed and validated according to self-efficacy in the performance of culinary skills and having as theoretical reference the Dietary Guideline for the Brazilian Population. Discussion: There are numerous challenges such as the physicians' awareness about the importance of this approach, which often seems to be more practical than technical, and the subjectivity of the topic on changing the behavior of physicians and patients. However, the results of this study show that the students who took the elective course believe that this curricular reformulation is extremely important and urgent. Conclusion: There is a worldwide transformation trend in the curriculum of healthcare professionals, and it is believed that this process can be initiated in medical schools through elective courses in Culinary Medicine, such as the one implemented at Unifesp.

Reliability across content areas in progress tests assessing medical knowledge: a Brazilian cross-sectional study with implications for medical education assessments

ABSTRACT BACKGROUND: Brazilian medical schools equitably divide their medical education assessments into five content areas: internal medicine, surgery, pediatrics, obstetrics and gynecology, and public health. However, this division does not follow international patterns and may threaten the examinations' reliability and validity. OBJECTIVE: To assess the reliability indices of the content areas of serial, cross-institutional progress test examinations. DESIGN AND SETTINGS: This was an analytical, observational, and cross-sectional study conducted at nine public medical schools (mainly from the state of São Paulo) with progress test examinations conducted between 2017 and 2023. METHODS: The examinations covered the areas of basic sciences, internal medicine, surgery, pediatrics, obstetrics and gynecology, and public health. We calculated reliability indices using Cronbach's α, which indicates the internal consistency of a test. We used simple linear regressions to analyze temporal trends. RESULTS: The results showed that the Cronbach's α for basic sciences and internal medicine presented lower values, whereas gynecology, obstetrics, and public health presented higher values. After changes in the number of items and the exclusion of basic sciences as a separate content area, internal medicine ranked highest in 2023. Individually, all content areas except pediatrics remained stable over time. CONCLUSIONS: Maintaining an equitable division in assessment content may lead to suboptimal results in terms of assessment reliability, especially for internal medicine. Therefore, content sampling of medical knowledge for general assessments should be reappraised.

What do Cochrane systematic reviews say about interventions for treating psoriasis?

CONTEXT AND OBJECTIVE: Psoriasis is a common chronic inflammatory skin disease characterized by abnormal and increased growth of the cells that produce keratin and abnormal functioning of the immune system. We aimed to summarize the evidence available regarding interventions for patients with psoriasis. DESIGN AND SETTING: Review of systematic reviews, developed in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo. METHODS: A systematic search was conducted to identify Cochrane systematic reviews that fulfilled the eligibility criteria. Two authors screened titles and abstracts that had been retrieved through the search strategy. The results from all the Cochrane systematic reviews that were included were summarized and presented in a narrative synthesis. RESULTS: We included six Cochrane systematic reviews assessing interventions for treating psoriasis. The findings from high-quality evidence were that (a) etanercept reduced the psoriasis severity index, compared with placebo and (b) steroids plus vitamin D, compared with vitamin D alone, improved the skin clearance rate, as assessed by investigators, but was associated with a higher proportion of participants who dropped out due to adverse events. For all other comparisons, the quality of the evidence ranged from moderate to very low. CONCLUSION: This review included six Cochrane systematic reviews that provided evidence ranging in quality from unknown to high, regarding management of psoriasis. Further randomized controlled trials are imperative to reduce the uncertainties relating to several treatments that are already used in clinical practice.

Compulsory notification of injuries in aesthetic procedures. Impact on patient safety

Abstract The disparity between the number of aesthetic procedures performed worldwide, and the complications described in the literature is remarkable. Doubts regarding the underreporting are reasonable and should be considered. The aim of this study is to demonstrate the scarcity of scientific publications on complications in aesthetic procedures compared to the abundance of these procedures performed worldwide. Based on this knowledge, it will be demonstrated to the health authorities the importance of compulsory notification of complications in aesthetic procedures that require medical attention so that the available data will allow their prevention. The limitation of knowledge regarding complications was demonstrated in the data collection for the preparation of the thesis ‟Deaths Related to Liposuction in Brazil" presented in 2018 and published in Surgical and Cosmetical Dermatology in 2020. The definition of complication in aesthetic procedures needs to be objective to prevent different and subjective interpretations. With the compulsory notification of complications in aesthetic procedures, it is intended to learn about their causes to develop guidelines for their prevention.

Squamous cell carcinoma arising in a multiple verrucous epidermal nevus.

Verrucous epidermal nevi are hamartomatous lesions of the epidermis that, unlike other epidermal nevi (such as sebaceous nevus or nevus comedonicus), are rarely associated with malignant neoplasms. The majority of squamous cell carcinoma develop in linear or multiple epidermal nevus and rarely in solitary epidermal nevus. In general, the prognosis is favorable. We report a case of well-differentiated invasive squamous cell carcinoma arising from a multiple verrucous epidermal nevus. Although there is no consensus on prophylactic removal of epidermal nevus, its removal and biopsy should be considered if changes occur.