Adverse childhood experiences in children and adolescents with sickle cell disease: A retrospective cohort study.

BACKGROUND: Adverse childhood experiences (ACEs) are linked to poor health outcomes; however, the relationship between ACEs and health outcomes among children and adolescents with sickle cell disease (SCD) has limited documentation in the published literature. PROCEDURE: This retrospective cohort study involved 45 children and 30 adolescents. Participants were screened using the Center for Youth Wellness ACE Questionnaire. Parents completed the questionnaire for children. Adolescents provided self-report. ACEs were treated as continuous and categorical scales: 0-1 verus ≥2 original ACEs (individual and/or familial level); 0-1 versus ≥2 additional ACEs (community level); and 0-3 versus ≥4 expanded ACEs (original + additional). Pain and acute chest syndrome events were compared using Wilcoxon rank-sum tests, and correlated with cumulative ACE scores using Spearman's correlation. Multivariable models were fitted to examine the association between ACEs and pain/acute chest syndrome. RESULTS: The cumulative number of original ACEs positively correlated with acute chest syndrome events (rho = .53, p = .003) and pain (rho = .40, p = .028) among adolescents. Adolescents with ≥2 versus 0-1 original ACEs had a higher number of acute chest syndrome events (4.9 ± 2.6 vs. 1.6 ± 2.2, p = .002); however, this association was confounded by asthma. Acute chest syndrome events and hospitalizations for pain did not differ among child ACE groups. Emergency department (ED) pain visits were higher among children with ≥4 versus 0-3 expanded ACEs (1.6 ± 2.8 vs. 3.3 ± 3.2, p = .042), even after controlling for SCD genotype, asthma, disease-modifying treatment, and follow-up years (p = .027). CONCLUSION: ACEs are linked to increased morbidity among children and adolescents with SCD. Prospective studies are needed to further understand this relationship and test ACE-protective remedies.

Assessing patients' preferences for gender, age, and experience of their urogynecologic provider.

INTRODUCTION AND HYPOTHESIS: Understanding patient preferences regarding provider characteristics is an under-explored area in urogynecology. This study aims to describe patient preferences for urogynecologic care, including provider gender, age, experience, and presence of medical trainees. METHODS: This was a multicenter, cross-sectional, survey-based study assessing patient preferences with a voluntary, self-administered, anonymous questionnaire prior to their first urogynecology consult. A 5-point Likert scale addressing provider gender, age, experience, and presence of trainees was used. Descriptive statistics summarized patient characteristics and provider preferences. Chi-squared (or Fisher's exact) test was used to test for associations. RESULTS: Six hundred fifteen women participated from eight sites including all geographic regions across the US; 70.8% identified as white with mean age of 58.5 ± 14.2 years. Urinary incontinence was the most commonly reported symptom (45.9%); 51.4% saw a female provider. The majority of patients saw a provider 45-60 years old (42.8%) with > 15 years' experience (60.9%). Sixty-five percent of patients preferred a female provider; 10% preferred a male provider. Sixteen percent preferred a provider < 45 years old, 36% preferred 45-60 years old, and 11% of patients preferred a provider > 60 years old. Most patients preferred a provider with 5-15 or > 15 years' experience (49% and 46%, respectively). Eleven percent preferred the presence of trainees while 24% preferred trainee absence. CONCLUSION: Patient preferences regarding urogynecologic providers included female gender and provider age 45-60 years old with > 5 years' experience. Further study is needed to identify qualitative components associated with these preferences.

Duration of therapeutic coma and outcome of refractory status epilepticus.

OBJECTIVE: Examine the association of duration of therapeutic coma (TC) with seizure recurrence, morbidity, and mortality in refractory status epilepticus (RSE). Define an optimal window for TC that provides sustained seizure control and minimizes complications. METHODS: Retrospective, observational cohort study involving patients who presented with RSE to the University of Alabama at Birmingham or the University of California at San Francisco from 2010 to 2016. Relationship of duration of TC with primary and secondary outcomes was evaluated using two-sample t tests, simple linear regression, and chi-square tests. Multivariable linear and logistic regression models were used to identify independent predictors. Predictive ability of TC for seizure recurrence was quantified using a receiver-operating characteristic curve. Youden index was used to determine an optimal cutoff value. RESULTS: Multivariable analysis of clinical and treatment characteristics of 182 patients who were treated predominantly with propofol as anesthetic agent showed that longer duration of the first trial of TC (27.2 vs 15.6 hours) was independently associated with a higher chance of seizure recurrence following the first weaning attempt (P = 0.038) but not with poor functional neurologic outcome upon discharge, in-hospital complications, or mortality. Furthermore, higher doses of anesthetic utilized during the first trial of TC were independently associated with fewer in-hospital complications (P = 0.003) and associated with a shorter duration of mechanical ventilation and total length of stay. Duration of TC was identified as an independent predictor of seizure recurrence with an optimal cutoff point at 35 hours. SIGNIFICANCE: This study suggests that a shorter duration yet deeper TC as treatment for RSE may be more effective and safer than the currently recommended TC duration of 24-48 hours. Prospective and randomized trials should be conducted to validate these assertions.

Severe cutaneous eruptions following the topical use of preparations containing bufexamac: Is it time to reconsider its registration in Australia?

Despite being a well-recognised cause of allergic contact dermatitis with an embargo in many countries around the world, bufexamac is available over the counter in topical preparations in Australia. We present a series of patients who developed severe cutaneous eruptions after the topical application of bufexamac containing preparations to highlight the potential risks of this medication, as well as advocate for the reconsideration of its registration by the Therapeutic Goods Administration in Australia.

Effect of Surface Treatment and Cement on Fracture Load of Traditional Zirconia (3Y), Translucent Zirconia (5Y), and Lithium Disilicate Crowns.

PURPOSE: To determine if surface treatment and cement selection for traditional 3 mol% yttria partially stabilized zirconia (3Y-PSZ), "translucent" 5 mol% yttria-stabilized zirconia (5Y-Z), or lithium disilicate crowns affected their fracture load. MATERIALS AND METHODS: Crowns with 0.8 mm uniform thickness (96, n = 8/group) were milled of 3Y-PSZ (Lava Plus), 5Y-Z (Lava Esthetic), or lithium disilicate (e.max CAD) and sintered/crystallized. Half the crowns were either particle-abraded with 30 µm alumina (zirconias) or etched with 5% hydrofluoric acid (lithium disilicate), and the other half received no surface treatment. Half the crowns from each group were luted with resin-modified glass ionomer (RMGI, RelyX Luting Plus) and half were luted with a resin cement (RelyX Unicem 2) to resin composite dies. Crowns were load cycled (100,000 cycles, 100 N force, 24°C water) and then loaded with a steel indenter until failure. A three-way ANOVA examined the effects of material, cement, and surface treatment on fracture load. Post-hoc comparisons were performed with the Tukey-Krammer method. RESULTS: Fracture load was signficiantly different for materials and cements (p < 0.0001) but not surface treatments (p = 0.77). All lithium disilicate crowns luted with RMGI failed in fatigue loading cycling; 3Y-PSZ and 5Y-Z crowns luted with resin showed a higher fracture load compared with RMGI (p < 0.001). With resin cement, there was no signficant difference in fracture load between 5Y-Z and lithium disiliciate (p = 1) whereas 3Y-PSZ had a higher fracture load (p < 0.0001). CONCLUSIONS: Cement type affected fracture load of crowns but surface treatment did not. The 0.8 mm uniform thick crowns tested benefited from using resin cement regardless of type of ceramic material. Crowns fabricated from 5Y-Z may be particle-abraded if luted with resin cement.

Acute Hemodynamic Effects of Biventricular Pacing After Left Ventricular Assist Device.

BACKGROUND: Despite cardiac resynchronization therapy (CRT), some patients with heart failure progress and undergo left ventricular assist device (LVAD) implantation. Management of CRT after LVAD implantation has not been well studied. The purpose of this study was to determine whether RV pacing or biventricular pacing measurably affects acute hemodynamics in patients with an LVAD and a CRT device. METHODS AND RESULTS: Seven patients with CRT and LVAD underwent right heart catheterization. Pressures and oximetry were measured and LVAD parameters were recorded during 3 different conditions: RV pacing alone, biventricular pacing, and intrinsic atrioventricular conduction. Paired t tests were used to evaluate changes within subjects. There were no significant changes in right atrial pressure, pulmonary arterial pressures, pulmonary capillary wedge pressure, cardiac index, or any LVAD parameter (P > .05). CONCLUSIONS: Our data suggest that CRT probably has no acute hemodynamic effect in patients with LVADs, but further study is needed.

Respiratory oxygen uptake is associated with survival in a cohort of ventilated trauma and burn patients.

BACKGROUND: Little data is available in the literature about the role of end tidal oxygen in critically ill patients. We sought to identify the association between the level of respiratory oxygen and clinical outcomes in critically-ill ventilated trauma and burn patients. METHODS: A retrospective cohort of 55 trauma and burn patients from 2010 to 2016 was collected. Exposures of interest included a) expiratory end tidal oxygen (ETO2) and b) the difference between FiO2 and ETO2 (uptake). Associations of clinical characteristics with ETO2 and oxygen uptake were examined using a Spearman correlation. The relationships between discharge status, demographics, injury type, severity, and clinical characteristics were examined using chi-square (or Fisher's exact) tests and two-sample t-tests. Multivariable analyses using linear and logistic regression were performed to determine whether expiratory end tidal oxygen or oxygen uptake was an independent predictor of clinical outcomes. RESULTS: Mean age for the patients was 46.3±18.2years with 41 (74.6%) male and 34 (61.8%) white. In the cohort, 27 (49.1%) of patients had burns and 28 (50.9%) blunt trauma. Oxygen uptake was negatively correlated with lactic acid, minute ventilation, total ICU days, and ventilator days (p<0.05). Patients who died demonstrated lower oxygen uptake than those alive, oxygen uptake remained significantly associated with discharge status after adjusting for potential confounders (p=0.028). CONCLUSION: A narrowed difference between ETO2 and inspiratory oxygen is associated with increased mortality in a cohort of ventilated trauma and burn patients. Future research is needed to further elucidate the role of respiratory oxygen level in larger, prospective studies.

Retention of CAD/CAM resin composite crowns following different bonding protocols.

PURPOSE: To evaluate the effect of different surface treatments and primers with a CAD/CAM resin composite block on its crown retention. METHODS: 120 human molars were prepared with a 24° total convergence angle, 1.5 mm height, and axial walls in dentin. Surface area was measured by digital microscopy. Crowns were machined from CAD/CAM resin composite blocks. Teeth were randomly allocated to 12 groups (n= 10) based on possible combinations of three surface treatments: [Control, Alumina air abrasion (50-µm Al2O3 at 0.28 MPa) ]; 5% hydrofluoric acid etch (20-second scrub); silane application (with or without Kerr Silane primer); and adhesive application (with or without Optibond XTR Adhesive). Optibond XTR Adhesive was applied to the tooth preparations and crowns were bonded with MaxCem Elite cement. Crowns were fatigued for 100,000 cycles at 100 N in water and debonded in tension (1 mm/minute). Crown retention strength (maximum load/surface area) values were analyzed using a three-way ANOVA with Tukey's post-hoc tests (α= 0.05). RESULTS: Surface treatment, silane and adhesive applications independently affect retention force (P< 0.05). All interactions were not significant (P> 0.05). Alumina airborne abrasion surface treatment, silane and adhesive applications all improve retention strength. Therefore, CAD/CAM resin composite crowns can withstand debonding while undergoing mechanical fatigue. Although all forms of surface treatment and primer application improve bond strength, the highest mean retention strength values were recorded when the crowns were alumina particle abraded and coated with adhesive (with or without silane). CLINICAL SIGNIFICANCE: In order to improve the bonding of resin composite crowns, application of alumina airborne particle abrasion and a coat of adhesive (proceeded by an optional coat of silane) is recommended. If hydrofluoric acid is utilized, the crowns should be treated with a coat of silane followed by adhesive application.

Microleakage around zirconia crown margins after ultrasonic scaling with self-adhesive resin or resin modified glass ionomer cement.

OBJECTIVES: To measure microleakage around zirconia crown margins cemented with self-adhesive resin or resin modified glass ionomer (RMGI) cement after ultrasonic scaling. METHODS: 16 molars were prepared for crowns (margin 0.5 mm coronal of cementum-enamel junction). Preparations were digitally scanned and zirconia crowns milled. Specimens were divided into two groups (n = 8): self-adhesive resin (RelyX Unicem 2) or resin modified glass ionomer (RMGI) (RelyX Luting Plus) cements. After cementation, specimens were ultrasonic scaled with a piezoelectric device (60 s, hand pressure). After thermocycling (20,000 cycles/5-55°C), specimens were immersed in 5 wt% fuchsine dye before sectioning bucco-lingually. Microleakage was examined under 40× light magnification. Statistical comparisons were made using a paired t test and a two-sample t test (α = .05). RESULTS: Ultrasonic scaling did not alter microleakage at the margins of crowns (P = .31). There was no significant difference in microleakage of scaled and untreated margins with the use of different cements (P = .21). The amount of microleakage around margins that were scaled was not significantly different between cements (P = .14). Untreated margins of crowns cemented with RelyX Luting Plus showed a significantly higher microleakage than those cemented with RelyX Unicem 2 (P = .005). CONCLUSIONS: Piezoelectric ultrasonic scaling did not increase microleakage at the margin of zirconia crowns cemented with self-adhesive resin or RMGI cements. CLINICAL SIGNIFICANCE: Piezoelectric ultrasonic scaling around zirconia crowns did not impact marginal microleakage cemented with self-adhesive resin or RMGI cements.

Recurrent ATP2A2 p.(Pro602Leu) mutation differentiates Acrokeratosis verruciformis of Hopf from the allelic condition Darier disease.

Darier disease and Acrokeratosis Verruciformis of Hopf (AKV) are rare disorders of keratinization with autosomal dominant inheritance and very distinct clinical pictures. Both have been shown to be caused by mutations in ATP2A2 (ATPase, Ca++ transporting, cardiac muscle, slow-twitch) a gene encoding one of the SERCA (sarcoplasmic/endoplasmic reticulum calcium ATPase2) intracellular pumps with a crucial role in cell-to-cell adhesion in both skin and heart. While hundreds of different missense and nonsense mutations cause Darier disease, only one missense mutation, p.(Pro602Leu), has been identified in families with AKV. We report a family with AKV due to the p.(Pro602Leu) mutation and discuss implications for this recurrent mutation on knowledge of ATP2A2 structure and function.

Evaluation of Different Polishing Systems and Speeds for Dental Zirconia.

PURPOSE: To evaluate two polishing systems and three polishing speeds on the gloss, roughness, and heat production of yttria stabilized tetragonal zirconia polycrystal (Y-TZP). MATERIALS AND METHODS: A Y-TZP block (Zenostar Zr Translucent) was sectioned into 4-mm-thick sections. Specimens (n = 30 per polishing system) were first wet ground with a fine diamond bur at 200,000 RPM for 15 seconds. The baseline gloss of all specimens was measured in a glossmeter (60° angle) in a direction perpendicular to grinding. Initial surface roughness (Ra ) was determined on an optical profilometer in a direction perpendicular to grinding. The specimens were then polished with either a Dialite ZR Polishing Kit or a CeraMaster Polishing Kit. All grinding and polishing was performed by the same operator calibrated to apply approximately 2 N pressure. The medium grit polisher was used for 30 seconds, repeated for 30 seconds, and then the fine grit polisher was used. After each step, the gloss and roughness of each specimen was remeasured as described previously. Each polishing system was used at 5000, 15,000, and 40,000 RPM (n = 10 for each polish system/speed combination). A group of glazed specimens (n = 10) was evaluated for gloss and roughness as a control. The heat generated for each polishing step was measured with a thermocouple. The gloss and roughness of the specimens were analyzed using a linear mixed model and Tukey-Kramer post-hoc tests. Each step of polishing was compared to the glazed control group with an ANOVA and Dunnett's test. RESULTS: Polishing step, system, and speed were significant (p < 0.05) for gloss and roughness. Examination of system and step interaction was significant for gloss only. Post-hoc analysis revealed that 15,000 RPM produced higher gloss and lower roughness than other speeds. Each progressive step produced an improvement in gloss except for initial 30 seconds with the CeraMaster Coarse (medium polisher; p = 0.34). Roughness was also reduced at each progressive step. No polishing speed/system produced an increase in temperature above 41°C. Both polishing systems were capable of achieving a similar or superior roughness and gloss as the glazed control specimens after the final polishing step at 15,000 RPM. CONCLUSIONS: Fifteen thousand RPM is an optimal polishing speed. Progressing through the polishing sequence significantly improves gloss and roughness and can create similar values as glazed zirconia.

Independent effects of early-life experience and trait aggression on cardiovascular function.

Early-life experience (ELE) can significantly affect life-long health and disease, including cardiovascular function. Specific dimensions of emotionality also modify risk of disease, and aggressive traits along with social inhibition have been established as independent vulnerability factors for the progression of cardiovascular disease. Yet, the biological mechanisms mediating these associations remain poorly understood. The present study utilized the inherently stress-susceptible and socially inhibited Wistar-Kyoto rats to determine the potential influences of ELE and trait aggression (TA) on cardiovascular parameters throughout the lifespan. Pups were exposed to maternal separation (MS), consisting of daily 3-h separations of the entire litter from postnatal day (P)1 to P14. The rats were weaned at P21, and as adults were instrumented for chronic radiotelemetry recordings of blood pressure and heart rate (HR). Adult aggressive behavior was assessed using the resident-intruder test, which demonstrated that TA was independent of MS exposure. MS-exposed animals (irrespective of TA) had significantly lower resting HR accompanied by increases in HR variability. No effects of MS on resting blood pressure were detected. In contrast, TA correlated with increased resting mean, systolic, and diastolic arterial pressures but had no effect on HR. TA rats (relative to nonaggressive animals) also manifested increased wall-to-lumen ratio in the thoracic aorta, increased sensitivity to phenylephrine-induced vascular contractility, and increased norepinephrine content in the heart. Together these data suggest that ELE and TA are independent factors that impact baseline cardiovascular function.

Protocol for Reducing Time to Antibiotics in Pediatric Patients Presenting to an Emergency Department With Fever and Neutropenia: Efficacy and Barriers.

OBJECTIVES: Patients with febrile neutropenia are at high risk of morbidity and mortality from infectious causes. Decreasing time to antibiotic (TTA) administration is associated with improved patient outcomes. We sought to reduce TTA for children presenting to the emergency department with fever and neutropenia. METHODS: In a prospective cohort study with historical comparison, TTA administration was evaluated in patients with neutropenia presenting to the Children's of Alabama Emergency Department. A protocol was established to reduce delays in antibiotic administration and increase the percentage of patients who receive treatment within 60 minutes of presentation. One hundred pre-protocol patient visits between August 2010 and December 2011 were evaluated and 153 post-protocol visits were evaluated between August 2012 and September 2013. We reviewed individual cases to determine barriers to rapid antibiotic administration. RESULTS: Antibiotics were administered in 96.9 ± 57.8 minutes in the pre-protocol patient group, and only 35% of patients received antibiotics within 60 minutes of presentation and 70% received antibiotics within 120 minutes. After implementation of the protocol, TTA for neutropenic patients was decreased to 64.3 ± 28.4 minutes (P < 0.0001) with 51.4% receiving antibiotics within 60 minutes and 93.2% within 120 minutes. CONCLUSIONS: Implementing a standard approach to patients at risk for neutropenia decreased TTA. There are numerous challenges in providing timely antibiotics to children with febrile neutropenia. Identified delays included venous access (time to effect of topical anesthetics, and difficulty obtaining access), physicians waiting on laboratory results, and antibiotic availability.

Postoperative bowel function, symptoms, and habits in women after vaginal reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to characterize postoperative bowel symptoms in women undergoing vaginal prolapse reconstructive surgery randomized to preoperative bowel preparation vs a regular diet. METHODS: Subjects (N = 121) completed two bowel diaries: a 7-day bowel diary immediately before surgery and a 14-day diary postoperatively. Self-reported bowel diary data and symptoms included the time to first bowel movement (BM), daily number of BMs, Bristol Stool Form Scale score, pain, and urgency associated with BM, episodes of fecal incontinence, and use of laxatives. Antiemetic use was abstracted from medical records. Outcomes of groups were compared using Chi-squared/Fisher's exact test or Student's t test as appropriate. RESULTS: Mean time to first postoperative BM was similar in the bowel preparation (n = 60) and control groups (n = 61), 81.2 ± 28.9 vs 78.6 ± 28.2 h, p = 0.85. With the first BM, there were no significant differences between bowel preparation and control groups regarding pain (17.2 vs 27.9 %, p = 0.17), fecal urgency with defecation (56.9 vs 52.5 %, p = 0.63), fecal incontinence (14.0 vs 15.0 %, p = 0.88) and >1 use of laxatives (93.3 vs 96.7 % p = 0.44) respectively. Antiemetic use was similar in both groups (48.3 vs 55.7 % respectively, p = 0.42). CONCLUSIONS: There were no differences in the return of bowel function and other bowel symptoms postoperatively between the randomized groups. Lack of bowel preparation does not have an impact on the risk of painful defecation postoperatively. This information may be used to inform patients regarding expectations for bowel function after vaginal reconstructive surgery.

Depth of cure of bulk fill composites with monowave and polywave curing lights.

PURPOSE: To measure and compare the depth of cure (DOC) of two bulk fill resin composites using a monowave and polywave light curing unit (LCU) according to ISO 4049 and using custom tooth molds. METHODS: The DOC of Tetric Evoceram Bulk Fill and Filtek Bulk Fill Posterior were measured using a monowave LED LCU (Elipar S10) and a polywave LED LCU (Bluephase G2). Metal molds were used to fabricate 10 mm long DOC specimens (n = 10) according to ISO 4049. Uncured composite material was scraped away with a plastic instrument and half the length of remaining composite was measured as the DOC. Custom tooth molds were fabricated by preparing > 10 mm long square- shaped (4 x 4 mm) holes into the mesial/distal surfaces of extracted human molars. Resin composite was placed into one end of the prepared tooth and light polymerized. Uncured resin composite was removed from the opposite side from which the tooth was irradiated and the tooth was sectioned mesio-distally. Half the length of remaining cured composite was measured as the DOC. Data were analyzed by three-way ANOVA (α = 0.05) for factors material, LCU, and mold. RESULTS: The main effect LCU was not significant (P = 0.58). The interaction effect between material x mold was significant (P = 0.0001). The DOC of the composites differed significantly only with the stainless steel mold in which Tetric Evoceram Bulk Fill showed a deeper DOC than Filtek Bulk Fill Posterior (4.03 ± 0.14 vs 3.56 ± 0.38 mm, P < 0.0001).

Inpatient dermatology: pattern of admissions and patients' characteristics in an Australian hospital.

OBJECTIVES: To report the pattern of dermatology admissions and inpatient characteristics at a tertiary Australian hospital and compare the data with international studies. METHODS: The study was conducted at a tertiary referral hospital in New South Wales, Australia. Clinical databases were searched retrospectively to include all inpatient admissions under dermatology from 1 January to 31 December 2011. The medical records were reviewed to gather data on age, sex, ethnicity, length of stay, referral and follow-up source, diagnosis and other consultations obtained during the admission. RESULTS: In all, 97 patients were admitted during the 12-month period, of whom 44% were female and 56% male. The most frequent reasons for admission were dermatitis or eczema and ulcers. The average length of stay was 10 days, with a median of 5 days. A total of 80% of patients had a stay duration of 10 days or less, and 6% were in hospital for more than 30 days. The diagnosis that accounted for the longest length of stay was ulcers. A large proportion of patients required consultation from another medical specialty during their admission with 91 specialist consultations taking place for the study group. CONCLUSIONS: Inpatient treatment plays a fundamental role in the management of complex and severe dermatological disease and comparison of these results to future studies in other dermatology units around Australia and internationally may be a valuable area of further work.

Development and multi-institutional validation of an upgrading risk tool for Gleason 6 prostate cancer.

BACKGROUND: Many patients with low-risk prostate cancer (PC) who are diagnosed with Gleason score 6 at biopsy are ultimately found to harbor higher grade PC (Gleason ≥ 7) at radical prostatectomy. This finding increases risk of recurrence and cancer-specific mortality. Validated clinical tools that are available preoperatively are needed to improve the ability to recognize likelihood of upgrading in patients with low-risk PC. METHODS: More than 30 clinicopathologic parameters were assessed in consecutive patients with Gleason 6 PC upon biopsy who underwent radical prostatectomy. A nomogram for predicting upgrading (Gleason ≥ 7) on final pathology was generated using multivariable logistic regression in a development cohort of 431 patients. External validation was performed in 2 separate cohorts consisting of 1151 patients and 392 patients. Nomogram performance was assessed using receiver operating characteristic curves, calibration, and decision analysis. RESULTS: On multivariable analysis, variables predicting upgrading were prostate-specific antigen density using ultrasound (odds ratio [OR] = 229, P = .003), obesity (OR = 1.90, P = .05), number of positive cores (OR = 1.23, P = .01), and maximum core involvement (OR = 0.02, P = .01). On internal validation, the bootstrap-corrected predictive accuracy was 0.753. External validation revealed a predictive accuracy of 0.677 and 0.672. The nomogram demonstrated excellent calibration in all 3 cohorts and decision curves demonstrated high net benefit across a wide range of threshold probabilities. The nomogram demonstrated areas under the curve of 0.597 to 0.672 for predicting upgrading in subsets of men with very low-risk PC who meet active surveillance criteria (all P < .001), allowing further risk stratification of these individuals. CONCLUSIONS: A nomogram was developed and externally validated that uses preoperative clinical parameters and biopsy findings to predict the risk of pathological upgrading in Gleason 6 patients. This can be used to further inform patients with lower risk PC who are considering treatment or active surveillance.

Acute alveolitis following infliximab therapy for psoriasis.

Infliximab is a high-affinity recombinant chimeric immunoglobulin-1 monoclonal antibody directed against tumour necrosis factor-alpha. It is used to treat a range of inflammatory disorders including psoriatic joint and skin changes. Acute interstitial lung disease is a rare but potentially fatal complication of therapy. We report the case of a 67-year-old man with severe psoriasis who presented with acute alveolitis shortly after his third infusion of infliximab. The infliximab was discontinued and investigations did not reveal an infective cause. His respiratory signs and symptoms improved quickly with corticosteroid therapy. Clinicians should be aware of this uncommon but potentially serious complication.

Serial lipase measurements in pancreatic panniculitis.

Pancreatic panniculitis is a rare cutaneous manifestation of pancreatic disease with only scant case reports available to guide management. In this report, a woman in her 60s developed a painful, erythematous and indurated, nodular rash after an episode of acute pancreatitis postendoscopic retrograde cholangiopancreatography (ERCP). While clinically and radiologically the pancreatitis improved with standard conservative management, the panniculitis remained severely debilitating. Repeat testing of serum pancreatic enzymes revealed persistent and marked elevation. Octreotide was started to inhibit pancreatic enzyme release, and the lesions improved, with resolution of the panniculitis correlating with falling serum pancreatic enzyme levels. Hence, serial pancreatic enzyme testing may have utility in monitoring and management of pancreatic panniculitis.