Focal atrichia: A diagnostic clue in female pattern hair loss.

BACKGROUND: Focal atrichia is a common clinical finding in female pattern hair loss, the specificity and histologic findings of which need further clarification. OBJECTIVE: To determine the frequency of focal atrichia in various types of hair loss and its histologic characteristics in female pattern hair loss. METHODS: Part 1 of the study was a review of 250 consecutive female patients seen with hair loss for the presence of focal atrichia, and part 2 examined paired biopsy specimens from haired areas versus those from areas with focal atrichia in 18 subjects with female pattern hair loss. RESULTS: Focal atrichia was seen in 46 of 104 of women with female pattern hair loss (44%), including 67% of those with the late-onset subtype versus 15% of those with the early-onset subtype, compared with in 3 of 146 of those with other hair disorders (2%). Biopsy findings of focal atrichia in female pattern hair loss showed primarily a more progressive miniaturization process than that of haired areas of the scalp. LIMITATIONS: Some women with female pattern hair loss may have had concomitant chronic telogen effluvium. CONCLUSIONS: When present, focal atrichia is a clinical clue to the diagnosis of female pattern hair loss, particularly the late-onset subtype.

Objective outcome measures: Collecting meaningful data on alopecia areata.

BACKGROUND: Although alopecia areata is a common disorder, it has no US Food and Drug Administration-approved treatment and evidence-based therapeutic data are lacking. OBJECTIVE: To develop guidelines for the diagnosis, evaluation, assessment, response criteria, and end points for alopecia areata. METHODS: Literature review and expert opinion of a group of dermatologists specializing in hair disorders. RESULTS: Standardized methods of assessing and tracking hair loss and growth, including new scoring techniques, response criteria, and end points in alopecia areata are presented. LIMITATIONS: The additional time to perform the assessments is the primary limitation to use of the methodology in clinical practice. CONCLUSION: Use of these measures will facilitate collection of standardized outcome data on therapeutic agents used in alopecia areata both in clinical practice and in clinical trials.

Bivalirudin Anticoagulation for a Pediatric Patient with Heparin-Induced Thrombocytopenia and Thrombosis Requiring Cardiopulmonary Bypass for Ventricular Assist Device Placement.

The direct thrombin inhibitor bivalirudin is an option for anticoagulation in patients with heparin induced thrombocytopenia (HIT) requiring cardiopulmonary bypass (CPB). There are a limited number of reports of pediatric patients in which bivalirudin has been used for anticoagulation for CPB. We present the case of an 11 year old male with acute onset heart failure secondary to idiopathic dilated cardiomyopathy that developed heparin induced thrombocytopenia with thrombosis (HITT). The patient was anticoagulated in the operating room with bivalirudin and placed on CPB for insertion of a HeartWare(®) Ventricular Assist Device (Heartware(®)). Modified techniques were utilized. This included use of the Terumo CDI 500 (Terumo Cardiovascular Systems, Inc.) in-line blood gas monitor which contains a heparin coated arterial shunt sensor. We flushed this sensor with buffered saline preoperatively and noted no significant decrease in platelet count postoperatively. The patient was successfully placed on the ventricular assist device and was subsequently listed for heart transplantation.

Eagle Syndrome: Case Report.

Eagle syndrome (ES) is now defined as both an elongation of the styloid process (SP) and ossification of the stylohyoid ligament (SHL). Because subjective symptomatology is varied or can be absent, imaging is the best approach to diagnosis.

TEG and ROTEM: technology and clinical applications.

Initially described in 1948 by Hertert thromboelastography (TEG) provides a real-time assessment of viscoelastic clot strength in whole blood. Rotational thromboelastometry (ROTEM) evolved from TEG technology and both devices generate output by transducing changes in the viscoelastic strength of a small sample of clotting blood (300 µl) to which a constant rotational force is applied. These point of care devices allow visual assessment of blood coagulation from clot formation, through propagation, and stabilization, until clot dissolution. Computer analysis of the output allows sophisticated clot formation/dissolution kinetics and clot strength data to be generated. Activation of clot formation can be initiated with both intrinsic (kaolin, ellagic acid) and extrinsic (tissue factor) activators. In addition, the independent contributions of platelets and fibrinogen to final clot strength can be assessed using added platelet inhibitors (abciximab and cytochalasin D). Increasingly, ROTEM and TEG analysis is being incorporated in vertical algorithms to diagnose and treat bleeding in high-risk populations such as those undergoing cardiac surgery or suffering from blunt trauma. Some evidence suggests these algorithms might reduce transfusions, but further study is needed to assess patient outcomes.

Global photographic assessment of men aged 18 to 60 years with male pattern hair loss receiving finasteride 1 mg or placebo.

BACKGROUND: Finasteride (1 mg) has been shown to increase vertex hair growth in men aged 18 to 60 years with male pattern hair loss and to increase frontal scalp hair growth in subjects aged 18 to 41 years. OBJECTIVE: A secondary efficacy analysis was conducted to determine effects of finasteride (1 mg) on scalp hair growth in the 4 distinct scalp regions affected by male pattern hair loss. METHODS: Multicenter, double-blind studies randomized patients with vertex hair loss (men aged 18-41 and 41-60 years) to finasteride (1 mg/d) or placebo. Efficacy was evaluated by review of standardized clinical photographs (global photographic assessment) of the vertex, anterior/mid scalp regions, and frontal and temporal hairlines over 24 months relative to baseline. RESULTS: At 24 months, treatment with finasteride resulted in statistically significant (P ≤ .05) hair growth versus placebo in all scalp regions. There was also a significant decrease in hair loss in the younger men treated with finasteride in all areas, but only in the vertex and anterior/mid scalp regions in the older men. A slightly higher incidence of drug-related sexual adverse experiences was reported in the finasteride group than in the placebo group, irrespective of age. LIMITATIONS: These studies enrolled men with vertex pattern hair loss; therefore, the findings may not be extrapolated to men with predominantly anterior/mid scalp, frontal, or temporal hair loss. CONCLUSION: Based on global photographic assessment, finasteride (1 mg) is able to increase hair growth in all areas of the scalp affected by male pattern hair loss.

Post-stroke case fatality within an incident population in rural Tanzania.

BACKGROUND AND PURPOSE: To establish post-stroke case fatality rates within a community based incident stroke population in rural Tanzania. METHODS: Incident stroke cases were identified by the Tanzanian Stroke Incidence Project and followed-up over the next 3-6 years. In order to provide a more complete picture, verbal autopsy (VA) was also used to identify all stroke deaths occurring within the same community and time period, and a date of stroke was identified by interview with a relative or friend. RESULTS: Over 3 years, the Tanzanian Stroke Incidence Project identified 130 cases of incident stroke, of which 31 (23.8%, 95% CI 16.5 to 31.2) died within 28 days and 78 (60.0%, 95% CI 51.6 to 68.4) within 3 years of incident stroke. Over the same time period, an additional 223 deaths from stroke were identified by VA; 64 (28.7%, 95% CI 20.9 to 36.5) had died within 28 days of stroke and 188 (84.3%, 95% CI 78.1 to 90.6) within 3 years. CONCLUSIONS: This is the first published study of post-stroke mortality in sub-Saharan Africa from an incident stroke population. The 28 day case fatality rate is at the lower end of rates reported for other low and middle income countries, even when including those identified by VA, although CIs were wide. Three year case fatality rates are notably higher than seen in most developed world studies. Improving post-stroke care may help to reduce stroke case fatality in sub-Saharan Africa.

Central hair loss in African American women: incidence and potential risk factors.

BACKGROUND: Although central scalp hair loss is a common problem in African American women, data on etiology or incidence are limited. OBJECTIVE: We sought to determine the frequency of various patterns and degree of central scalp hair loss in African American women and to correlate this with information on hair care practices, family history of hair loss, and medical history. METHODS: Five hundred twenty-nine subjects at six different workshops held at four different sites in the central and/or southeast United States participated in this study. The subjects' patterns and degree of central scalp hair loss were independently assessed by both subject and investigator using a standardized photographic scale. Subjects also completed a detailed questionnaire and had standardized photographs taken. Statistical analysis was performed evaluating answers to the questionnaire relative to pattern of central hair loss. RESULTS: Extensive central scalp hair loss was seen in 5.6% of subjects. There was no obvious association of extensive hair loss with relaxer or hot comb use, history of seborrheic dermatitis or reaction to a hair care product, bacterial infection, or male pattern hair loss in fathers of subjects; however, there was an association with a history of tinea capitis. LIMITATIONS: There was no scalp biopsy correlation with clinical pattern of hair loss and further information on specifics of hair care practices is needed. CONCLUSIONS: This central scalp photographic scale and questionnaire provide a valid template by which to further explore potential etiologic factors and relationships to central scalp hair loss in African American women.

Histopathology of alopecia areata, acute and chronic: Why is it important to the clinician?

Alopecia areata (AA) is often easy to diagnose but a scalp biopsy for horizontal sectioning is routine in this research clinic. The characteristic histological feature of AA is the peribulbar and intrabulbar mononuclear cell infiltrate, which occurs in the acute stage of the disease but may be absent in biopsies taken at a later stage. AA evolves through acute, subacute, chronic, and recovery phases. Increased numbers of terminal catagen and telogen hairs are found in the acute and perhaps subacute stages with increased numbers of miniaturized, vellus-like hairs in the subacute and chronic stages. Thus, it is important for clinicians and pathologists to recognize the different phases of AA, so that in the absence of the classic findings of a peribulbar lymphocytic infiltrate, a diagnosis of AA can still confidently be made.

New USEPA water quality criteria by 2012: GOMA concerns and recommendations.

The Gulf of Mexico Alliance (GOMA) was tasked by the five Gulf State Governors to identify major issues affecting the Gulf of Mexico (GoM) and to set priorities for ameliorating these problems. One priority identified by GOMA is the need to improve detection methods for water quality indicators, pathogens and microbial source tracking. The United States Environmental Protection Agency (USEPA) is tasked with revising water quality criteria by 2012; however, the locations traditionally studied by the USEPA are not representative of the GoM and this has raised concern about whether or not the new criteria will be appropriate. This paper outlines a number of concerns, including deadlines associated with the USEPA Consent Decree, which may prevent inclusion of research needed to produce a well-developed set of methods and criteria appropriate for all regulated waters. GOMA makes several recommendations including ensuring that criteria formulation use data that include GoM-specific conditions (e.g. lower bather density, nonpoint sources), that rapid-testing methods be feasible and adequately controlled, and that USEPA maintains investments in water quality research once the new criteria are promulgated in order to assure that outstanding scientific questions are addressed and that scientifically defensible criteria are achieved for the GoM and other regulated waterbodies.

Defining the research agenda to reduce the joint burden of disease from diabetes mellitus and tuberculosis.

The steadily growing epidemic of diabetes mellitus poses a threat for global tuberculosis (TB) control. Previous studies have identified an important association between diabetes mellitus and TB. However, these studies have limitations: very few were carried out in low-income countries, with none in Africa, raising uncertainty about the strength of the diabetes mellitus-TB association in these settings, and many critical questions remain unanswered. An expert meeting was held in November 2009 to discuss where there was sufficient evidence to make firm recommendations about joint management of both diseases, to address research gaps and to develop a research agenda. Ten key research questions were identified, of which 4 were selected as high priority: (i) whether, when and how to screen for TB in patients with diabetes mellitus and vice versa; (ii) the impact of diabetes mellitus and non-diabetes mellitus hyperglycaemia on TB treatment outcomes and deaths, and the development of strategies to improve outcomes; (iii) implementation and evaluation of the tuberculosis 'DOTS' model for diabetes mellitus management; and (iv) the development and evaluation of better point-of-care diagnostic and monitoring tests, including measurements of blood glucose and glycated haemoglobin A(1c) (HbA(1c)) for patients with diabetes mellitus. Implementation of this research agenda will benefit the control of both diseases.

Can Fire and Rescue Services and the National Health Service work together to improve the safety and wellbeing of vulnerable older people? Design of a proof of concept study.

BACKGROUND: Older adults are at increased risk both of falling and of experiencing accidental domestic fire. In addition to advanced age, these adverse events share the risk factors of balance or mobility problems, cognitive impairment and socioeconomic deprivation. For both events, the consequences include significant injury and death, and considerable socioeconomic costs for the individual and informal carers, as well as for emergency services, health and social care agencies.Secondary prevention services for older people who have fallen or who are identifiable as being at high risk of falling include NHS Falls clinics, where a multidisciplinary team offers an individualised multifactorial targeted intervention including strength and balance exercise programmes, medication changes and home hazard modification. A similar preventative approach is employed by most Fire and Rescue Services who conduct Home Fire Safety Visits to assess and, if necessary, remedy domestic fire risk, fit free smoke alarms with instruction for use and maintenance, and plan an escape route. We propose that the similarity of population at risk, location, specific risk factors and the commonality of preventative approaches employed could offer net gains in terms of feasibility, effectiveness and acceptability if activities within these two preventative approaches were to be combined. METHODS/DESIGN: This prospective proof of concept study, currently being conducted in two London boroughs, (Southwark and Lambeth) aims to reduce the incidence of both fires and falls in community-dwelling older adults. It comprises two concurrent 12-month interventions: the integration of 1) fall risk assessments into the Brigade's Home Fire Safety Visit and 2) fire risk assessments into Falls services by inviting older clinic attendees to book a Visit. Our primary objective is to examine the feasibility and effectiveness of these interventions. Furthermore, we are evaluating their acceptability and value to key stakeholders and services users. DISCUSSION: If our approach proves feasible and the risk assessment is both effective and acceptable, we envisage advocating a partnership model of working more broadly to fire and rescue services and health services in Britain, such that effective integration of preventative services for older people becomes routine for an ageing population.

High impact actions: preventing falls and encouraging exercise.

This article, the second in a series on the NHS Institute for Innovation and Improvement's eight high impact actions, reviews the roles played by nurses and local organisations in preventing falls among older people through early intervention and the promotion of active lifestyles.

Factors associated with glycemic control in type 1 diabetes patients in China: A cross-sectional study.

AIMS/INTRODUCTION: Glycemic control in type 1 diabetes can be challenging, and is influenced by many factors. This study aimed to investigate glycemic control and its associated factors in Chinese people with type 1 diabetes. MATERIALS AND METHODS: This cross-sectional study included 779 participants with type 1 diabetes selected from hospital records review, outpatient clinics and inpatient wards. Data were collected through face-to-face interviews, medical records and venous blood samples. Multiple logistic regression analysis was carried out to determine factors associated with glycemic control. RESULTS: Among 779 participants, 49.2% were male. The median age was 24 years (interquartile range 14-36 years). The median age at diagnosis of diabetes was 17 years (interquartile range 10-28 years) and the median duration of diabetes was 4 years (interquartile range 1-8 years). The mean ± standard deviation hemoglobin A1c was 9.1 ± 2.5%. Nearly 80% of participants had inadequate glycemic control (hemoglobin A1c ≥7.0%). Multivariable analysis showed that age at diagnosis of diabetes ≤20 years, living in a rural location, low household income, low intake of fruit and vegetables, low level of physical activity, low adherence to insulin, and low utilization of insulin pump were independent risk factors for poor glycemic control (hemoglobin A1c ≥9.0%). CONCLUSIONS: Inadequate glycaemic control is common among people with type 1 diabetes in China. Efforts should be made to control the modifiable risk factors, which include low intake of fruit and vegetables, low level of physical activity, and low adherence to insulin for the improvement of glycemic control. Appropriate use of insulin pump among type 1 diabetes should be encouraged.

Irregular respiration as a marker of wakefulness during titration of CPAP.

STUDY OBJECTIVES: Regularity of respiration is characteristic of stable sleep without sleep disordered breathing. Appearance of respiratory irregularity may indicate onset of wakefulness. The present study examines whether one can detect transitions from sleep to wakefulness using only the CPAP flow signal and automate this recognition. DESIGN: Prospective study with blinded analysis SETTING: Sleep disorder center, academic institution. PARTICIPANTS: 74 subjects with obstructive sleep apnealhypopnea syndrome (OSAHS) INTERVENTIONS: n/a. MEASUREMENTS AND RESULTS: 74 CPAP titration polysomnograms in patients with OSAHS were examined. First we visually identified characteristic patterns of ventilatory irregularity on the airflow signal and tested their relation to conventional detection of EEG defined wake or arousal. To automate recognition of sleep-wake transitions we then developed an artificial neural network (ANN) whose inputs were parameters derived exclusively from the airflow signal. This ANN was trained to identify the visually detected ventilatory irregularities. Finally, we prospectively determined the accuracy of the ANN detection of wake or arousal against EEG sleep/wake transitions. A visually identified irregular respiratory pattern (IrREG) was highly predictive of appearance of EEG wakefulness (Positive Predictive Value [PPV] = 0.89 to 0.98 across subjects). Furthermore, we were able to automate identification of this irregularity with an ANN which was highly predictive for wakefulness by EEG (PPV 0.66 to 0.86). CONCLUSIONS: Despite not detecting all wakefulness, the high positive predictive value suggests that analysis of the respiration signal alone may be a useful indicator of CNS state with potential utility in the control of CPAP in OSAHS. The present study demonstrates the feasibility of automating the detection of IrREG.

Frontal Fibrosing Alopecia: An Emerging Epidemic.

Since the initial description of frontal fibrosing alopecia (FFA) in 1994, increasingly more cases of FFA have been reported in literature. Although clear epidemiologic data on the incidence and prevalence of FFA is not available, it is intriguing to consider whether FFA should be labeled as an emerging epidemic. A medline trend analysis as well as literature review using keywords "alopecia," "hair loss," and "cicatrical" were performed. Medline trend analysis of published FFA papers from 1905 to 2016 showed that the number of publications referenced in Medline increased from 1 (0.229%) in 1994 to 44 (3.5%) in 2016. The number of patients per published cohort also increased dramatically since the first report of FFA. Over the time period of January 2006-2016, our multi hair-referral centers collaboration study also showed a significant increase in new diagnoses of FFA. At this juncture, the cause for the rapid rise in cases is one of speculation. It is plausible that a cumulative environmental or toxic factor may trigger hair loss in FFA. Once perhaps a "rare type" of cicatricial alopecia, FFA is now being seen in a frequency in excess of what is expected, thus suggestive of an emerging epidemic.

The prevalence of Parkinson's disease in rural Tanzania.

The prevalence of Parkinson's disease (PD) varies worldwide from 7 to 450 per 100,000, and appears low in sub-Saharan Africa (SSA) but few data exist. We conducted a prevalence study of PD in rural Tanzania. A door-to-door study was conducted in the Hai district project area (population 161,071), using a screening questionnaire followed by structured history and examination of positive responders. Diagnosis was based on the UK PD Society Brain Bank Criteria. 33 (23 men) cases of PD were detected, with mean age 74 years (range 38-94). One patient died before the prevalence date. 78% were previously undiagnosed and untreated. Mean duration of symptoms was 5 years, and median Hoehn and Yahr stage 3. Crude prevalence rates were 30/100,000 (men), 11/100,000 (women) and 20/100,000 (combined). The direct age-standardized prevalence rates compared with the UK population were 64/100,000 (men), 20/100,000 (women) and 40/100,000 (combined). These rates are higher than previously reported from SSA, but still lower than the developed world. Many PD patients in SSA may never be diagnosed or treated, with consequent reduction in their life expectancy and quality of life. With the world population ageing PD is predicted to become an increasing problem.

The role of scalp dermoscopy in the diagnosis of alopecia areata incognita.

BACKGROUND: Alopecia areata incognita is a variety of alopecia areata characterized by acute diffuse shedding of telogen hairs without typical patches. OBJECTIVE: We sought to report the clinical, pathological, and dermoscopic features of alopecia areata incognita. METHODS: Seventy patients with alopecia areata incognita were evaluated clinically and with videodermoscopy during the period of 2002 to 2006. Pathology was performed in 50 patients. RESULTS: The presence of numerous, diffuse, round or polycyclic yellow dots, different in size and uniform in color and distribution, was a typical dermoscopic feature in all patients. Short regrowing hairs were also present. The dermoscopic findings were correlated and supported by the histologic features of the scalp specimens. LIMITATIONS: Scalp biopsy was performed only in 50 patients. CONCLUSION: Videodermoscopy is a first step before performing a biopsy. It can help the clinician to find the right place to take the sample, but can also avoid unnecessary biopsies.

Subcutaneous efalizumab is not effective in the treatment of alopecia areata.

BACKGROUND: Alopecia areata (AA) is a T-cell-mediated autoimmune disease. Efalizumab is a T-cell-targeted therapy approved for the treatment of psoriasis. OBJECTIVE: To assess the efficacy and safety of efalizumab in the treatment of moderate-to-severe AA. METHODS: Sixty-two patients were enrolled into this phase II, placebo-controlled trial. The trial consisted of three 12-week periods-a double-blind treatment period, an open-label efalizumab treatment period, and a safety follow-up. RESULTS: There were no statistical differences between treatment groups in percent hair regrowth, quality-of-life measures, or changes in biologic markers of disease severity after 12 or 24 weeks. In both groups, there was an approximately 8% response rate for hair regrowth (at 12 weeks). Efalizumab was well tolerated. LIMITATIONS: Numbers were too small for certain analyses. CONCLUSION: A 3- to 6-month trial of efalizumab was not effective in promoting hair regrowth in this small cohort of patients with moderate-to-severe AA.