Systematic review and meta-analysis of randomized controlled trials on topical interventions for genital lichen sclerosus

BACKGROUND

Lichen sclerosus (LS) is a chronic inflammatory dermatosis that occurs mainly in the anogenital area and causes itching and soreness. Progressive destructive scarring may result in burying of the clitoris in females and phimosis in males. Affected people have an increased risk of genital cancers.

OBJECTIVE

We sought to assess the effects of topical interventions for genital LS.

METHODS

We undertook a systematic review and meta-analysis using the methodology of the Cochrane Collaboration.

RESULTS

We included 7 randomized controlled trials with a total of 249 participants covering 6 treatments. Clobetasol propionate 0.05% was better than placebo in treating genital LS (participant-rated improvement/remission of symptoms: risk ratio 2.85 [95% confidence interval {CI} 1.45-5.61]; investigator-rated global degree of improvement: standardized mean difference [SMD] 5.74 [95% CI 4.26-7.23]) as was mometasone furoate 0.05% (change in clinical grade of phimosis: SMD -1.04 [95% CI -1.77 to -0.31]). We found no evidence supporting the efficacy of topical androgens and progesterone. There were no differences between pimecrolimus and clobetasol propionate in relieving symptoms through change in pruritus (SMD -0.33 [95% CI -0.99 to 0.33]) and burning/pain (SMD 0.03 [95% CI -0.62 to 0.69]). However, pimecrolimus was less effective than clobetasol propionate in improving gross appearance (investigator-rated global degree of improvement: SMD -1.64 [95% CI -2.40 to -0.87]).

LIMITATIONS

Most of the included studies were small.

CONCLUSIONS

The current limited evidence supports the efficacy of clobetasol propionate, mometasone furoate, and pimecrolimus in treating genital LS. Further randomized controlled trials are needed.

Topical interventions for genital lichen sclerosus

BACKGROUND

Lichen sclerosus is a chronic, inflammatory skin condition that most commonly occurs in adult women, although it may also be seen in men and children. It primarily affects the genital area and around the anus, where it causes persistent itching and soreness. Scarring after inflammation may lead to severe damage by fusion of the vulval lips (labia); narrowing of the vaginal opening; and burying of the clitoris in women and girls, as well as tightening of the foreskin in men and boys, if treatments are not started early. Affected people have an increased risk of genital cancers.

OBJECTIVES

To assess the effects of topical interventions for genital lichen sclerosus and adverse effects reported in included trials.

SEARCH METHODS

We searched the following databases up to 16 September 2011: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2007), LILACS (from 1982), CINAHL (from 1981), British Nursing Index and Archive (from 1985), Science Citation Index Expanded (from 1945), BIOSIS Previews (from 1926), Conference Papers Index (from 1982), and Conference Proceedings Citation Index - Science (from 1990). We also searched ongoing trial registries and scanned the bibliographies of included studies, published reviews, and papers that had cited the included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of topical interventions in genital lichen sclerosus.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, extracted data, and assessed the risk of bias. A third author was available for resolving differences of opinion.

MAIN RESULTS

We included 7 RCTs, with a total of 249 participants, covering 6 treatments. Six of these RCTs tested the efficacy of one active intervention against placebo or another active intervention, while the other trial tested three active interventions against placebo.When compared to placebo in one trial, clobetasol propionate 0.05% was effective in treating genital lichen sclerosus in relation to the following outcomes: 'participant-rated improvement or remission of symptoms' (risk ratio (RR) 2.85, 95% confidence interval (CI) 1.45 to 5.61) and 'investigator-rated global degree of improvement' (standardised mean difference (SMD) 5.74, 95% CI 4.26 to 7.23).When mometasone furoate 0.05% was compared to placebo in another trial, there was a significant improvement in the 'investigator-rated change in clinical grade of phimosis' (SMD -1.04, 95% CI -1.77 to -0.31).Both trials found no significant differences in reported adverse drug reactions between the corticosteroid and placebo groups. The data from four trials found no significant benefit for topical testosterone, dihydrotestosterone, and progesterone. When used as maintenance therapy after an initial treatment with topical clobetasol propionate in another trial, topical testosterone worsened the symptoms (P < 0.05), but the placebo did not.One trial found no differences between pimecrolimus and clobetasol propionate in relieving symptoms through change in pruritus (itching) (SMD -0.33, 95% CI -0.99 to 0.33) and burning/pain (SMD 0.03, 95% CI -0.62 to 0.69). However, pimecrolimus was less effective than clobetasol propionate with regard to the 'investigator-rated global degree of improvement' (SMD -1.64, 95% CI -2.40 to -0.87). This trial found no significant differences in reported adverse drug reactions between the pimecrolimus and placebo groups.

AUTHORS' CONCLUSIONS

The current limited evidence demonstrates the efficacy of clobetasol propionate, mometasone furoate, and pimecrolimus in treating genital lichen sclerosus. Further RCTs are needed to determine the optimal potency and regimen of topical corticosteroids, examine other topical interventions, assess the duration of remission or prevention of flares, evaluate the reduction in the risk of genital squamous cell carcinoma or genital intraepithelial neoplasia, and examine the efficacy in improving the quality of the sex lives of people with this condition.

Effect of low doses of long-chain n-3 PUFAs on endothelial function and arterial stiffness: a randomized controlled trial

BACKGROUND

The dietary intake of n-3 (omega-3) long-chain PUFAs (LC-PUFAs) from fish may improve endothelial function and arterial stiffness.

OBJECTIVE

The objective was to test the hypothesis that increasing intakes of n-3 LC-PUFAs-equivalent to the consumption of 1, 2, or 4 portions of oily fish per week-favorably affects endothelial function and arterial stiffness.

DESIGN

A parallel-design, randomized, double-blind study compared daily doses of 0.45, 0.9, and 1.8 g n-3 LC-PUFAs (EPA:DHA ratio of 1.51:1) with placebo (refined olive oil). The primary and secondary outcomes were changes in flow-mediated dilatation (FMD) of the brachial artery, arterial stiffness, and blood pressure. Nonsmoking men (n = 142) and women (n = 225) aged 45-70 y were randomly assigned to treatment for 12 mo; 312 subjects completed the intervention.

RESULTS

Compliance with the intervention was corroborated by significant dose-dependent increases in the proportions of EPA and DHA in erythrocyte lipids and a 16.5% reduction in serum triacylglycerol concentrations with 1.8 g n-3 LC-PUFAs/d. FMD was lower in men than in women (P < 0.0001) and decreased with age (ρ = 0.270, P < 0.001) but was not significantly (P = 0.781) related to n-3 LC-PUFA intake. The mean changes in FMD (95% CIs) compared with placebo were 0.1% (-0.9%, 1.1%), -0.3% (-1.3%, 0.6%), and -0.3% (-1.3%, 0.7%) with daily intakes of 0.45, 0.9, and 1.8 g n-3 LC-PUFAs, respectively. No significant treatment effects were noted for arterial stiffness and central mean or 24-h ambulatory blood pressure.

CONCLUSION

Intakes of n-3 LC-PUFAs ≤1.8 g/d do not improve endothelial function in healthy adults. The trial is registered at controlled-trials.com as ISRCTN66664610.

Language skills following risk-adapted treatment for medulloblastoma

OBJECTIVE

Recent research findings suggested that children treated for medulloblastoma (MB) may experience undiagnosed language difficulties following treatment. The aim of this report was to investigate language skills in an adolescent following treatment for MB.

METHODS

This single case study profiles the language skills of GCG, a female aged 14;1 years, who was treated with risk-adapted cranial radiation therapy (CRT) for MB 4 years prior to language assessment.

RESULTS

Difficulties recalling verbal information of increasing length and complexity and reduced competence with language requiring critical thinking and complex cognitive processing were identified.

CONCLUSION

The findings suggest that prospective language assessment and monitoring should routinely be undertaken in children following treatment for MB, even when less-intense treatments are delivered to reduce adverse neurocognitive outcomes, due to the vulnerability of the developing brain to CRT.

The effectiveness of physiotherapy in cervicogenic headache and concurring temporomandibular dysfunction: a case report

The aim of this case report is to describe the use of physio-therapy interventions in a patient diagnosed with cervicogenic headache(CGH) and temporomandibular dysfunction (TMD). This case study involveda 26 year old male. The subject’s cervical and temporomandibular joint(TMJ) active range of movement; passive accessory movements; headacheintensity, periodicity and response to analgesics; TMJ clicking and discomfort;Numerical Pain Rating Scale (NPRS) scores, were assessed on initial assessment and on discharge 14 weeks later. The physiotherapy interventionincluded cervical and TMJ mobilisation (Maitland approach); trigger pointtherapy and massage; strengthening of the deep cervical neck flexors and scapulothoracic muscles; and posture correction. The subject improved on all outcome measures and was discharged after nine physiotherapy sessions, withfull cervical and TMJ range of movement, improved muscle strength and decreased headache intensity and frequency.This case describes a positive outcome for a patient diagnosed with cervical headaches and temporomandibular dysfunction in which physiotherapy interventions aimed at correcting joint dysfunction, myofascial pain and decreased muscle strength were used effectively.

Morphea of the Breast: Case Reports and Review of Literature

Morphea of the breast is an uncommon skin condition associated with autoimmune disorders and has also been described following radiotherapy. The inflammatory stage of morphea can commonly be mistaken for a breast abscess or inflammation. We report two cases of localized scleroderma affecting the breast with no history of autoimmune disease or radiation treatment. In both the cases, the lesions improved with the use of topical steroids.

Effects of altering the ratio of dietary n-6 to n-3 fatty acids on insulin sensitivity, lipoprotein size, and postprandial lipemia in men and postmenopausal women aged 45-70 y: the OPTILIP Study

BACKGROUND

Insulin resistance is associated with elevated plasma triacylglycerol, low HDL concentrations, elevated postprandial lipemia, and a predominance of small, dense LDLs (sdLDLs). It has been hypothesized that the dietary ratio of n-6 to n-3 (n-6:n-3) polyunsaturated fatty acids (PUFAs) may have favorable effects on these risk factors by increasing insulin sensitivity.

OBJECTIVE

The objective was to measure changes in insulin sensitivity, lipoprotein size, and postprandial lipemia after a 6-mo alteration in n-6:n-3.

DESIGN

In a randomized, parallel design in 258 subjects aged 45-70 y, we compared 4 diets providing 6% of energy as PUFAs with an n-6:n-3 between 5:1 and 3:1 with a control diet that had an n-6:n-3 of 10:1. The diets were enriched in alpha-linolenic acid, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), or both. Insulin sensitivity was assessed with the homeostatic model assessment of insulin resistance and the revised quantitative insulin sensitivity test.

RESULTS

Dietary intervention did not influence insulin sensitivity or postprandial lipase activities. Fasting and postprandial triacylglycerol concentrations were lower, and the proportion of sdLDLs decreased (by 12.7%; 95% CI: -22.9%, 2.4%), with an n-6:n-3 of approximately 3:1, which was achieved by the addition of long-chain n-3 PUFAs (EPA and DHA).

CONCLUSIONS

Decreasing the n-6:n-3 does not influence insulin sensitivity or lipase activities in older subjects. The reduction in plasma triacylglycerol after an increased intake of n-3 long-chain PUFAs results in favorable changes in LDL size.

Effect of varying the ratio of n-6 to n-3 fatty acids by increasing the dietary intake of alpha-linolenic acid, eicosapentaenoic and docosahexaenoic acid, or both on fibrinogen and clotting factors VII and XII in persons aged 45-70 y: the OPTILIP study

BACKGROUND

Elevated fibrinogen, activated factor XII (FXIIa), and factor VII coagulant activity (FVIIc) are associated with higher risk of fatal ischemic heart disease. This study tested the hypothesis that lowering the dietary ratio of n-6 to n-3 polyunsaturated fatty acids (n-6:n-3) would modify these risk factors in older men and women.

OBJECTIVE

The objective of the study was to measure fasting hemostatic risk factors and postprandial changes in activated FVII (FVIIa) concentrations after a 6-mo alteration in dietary n-6:n-3.

DESIGN

In a randomized, parallel design in 258 subjects aged 45-70 y, we compared 4 diets providing 6% of energy as polyunsaturated fatty acids at an n-6:n-3 between 5:1 and 3:1 with a control diet that had an n-6:n-3 of 10:1. The diets were enriched in alpha-linolenic acid, eicosapentaenoic (EPA) and docosahexaenoic (DHA) acid, or both.

RESULTS

Fasting and 3-h plasma triacylglycerol concentrations were 11.1% and 7.2% lower with the diet that had an n-6:n-3 of approximately 3:1 and that was enriched with EPA and DHA than with the other diets. Fasting fibrinogen, FXIIa, FVIIc, FVIIa, and FVII antigen and postprandial FVIIa were not influenced by the diets. Avoiding foods high in fat the day before measurement decreased FVIIc and FVIIa by 8% and 19.2%, respectively. A test meal containing 50 g fat resulted in a mean 47% (95% CI: 42%, 52%) increase in FVIIa 6 h later, but the response did not differ by n-6:n-3.

CONCLUSION

Decreasing the n-6:n-3 to approximately 3:1 by increasing the intake of EPA and DHA lowers fasting and postprandial plasma triacylglycerol concentrations in older persons but does not influence hemostatic risk factors.

Testing for HER2 in breast cancer

HER2 is a paradigm of a molecular target whose appropriate assessment is pivotal in the targeting of novel therapies for breast cancer, notably including Herceptin/Trastuzumab. Determining the correct levels requires immunohistochemical and molecular biological skills that are reproducible and measurable, coupled with a knowledge of the appropriate morphological and pathobiological context. Attaining these goals is not easy and laboratories testing for HER2 should maintain a high level of throughput of tests and engage in a recognized external quality assurance scheme. Fluorescence in-situ hybridization testing remains a particular challenge and there is a range of testing strategies. This testing forms the model for the identification of other novel molecular targets. In the future rapid throughput techniques such as real-time quantitative polymerase chain reaction (rqPCR), tissue microarrays or both should bring significant economies of cost and scale.

Trial of heparin in viper bites

AIMS OF THE STUDY

Viper bites produce hematotoxicity and coagulopathy which may be either true disseminated intravascular coagulation (DIC) or DIC-like syndrome. Role of heparin is studied in the present study of viper bite cases as use of heparin provides a rational therapy for defibrination caused by viper envenomation.

METHODOLOGY

One hundred and twenty two patients with viper bite and incoagulable blood were randomised into test group and control group. Test group received heparin in addition to antisnake venom (ASV). Efficacy was assessed by monitoring bleeding time (BT), clotting time (CT), prothrombin time (PT), platelets, fibrinogen, blood urea (BU), serum creatinine, development of complications and overall outcome.

RESULTS

Heparin group showed favourable outcome in all parameters studied. But many of them were not statistically significant.

CONCLUSION

Heparin seems to be having a beneficial role which needs to be confirmed by larger trials and longer duration of heparin administration.

Parameters and techniques to determine intestinal health of poultry as constituted by immunity, integrity, and functionality

The intestinal microflora lives in intimate contact with its surrounding intestinal wall and the bacteria can exert beneficial or deleterious effects on the host, depending on whether they are classified as probiotics or as pathogens. The interaction is determined on one hand by characteristics of the microorganisms, and on the other hand by characteristics of the intestinal wall. Together they determine the health status of the intestine. This review describes parameters and techniques (with advantages and disadvantages) available for poultry to identify the characteristics of the intestinal health, as constituted by three components: immunity, integrity, and functionality. To investigate intestinal immunity, in situ detection of various cell populations of the immune system with specific monoclonal antibodies using immunocytochemical staining is a reliable, semi-quantitative method. In vitro assays to measure functional aspects of T lymphocytes, B lymphocytes, plasma cells, natural killer cells, macrophages, and phagocytes are applicable to intestinal wall tissue. For investigation of intestinal integrity, in situ detection of villous height and crypt depth and their ratio, and villus arrangement is still an easy, routine histological method. In addition, expression levels of specific molecules, such as E-cadherin, different growth factors, and trefoil factor, seem promising parameters. To investigate functionality of the intestine, the permeability can be measured as the rate of transport of tracer molecules across the epithelial surface. Furthermore, determination of the level of mucus secretion and its composition are a valuable tool. These parameters for immunity, integrity and functionality, or a combination thereof, are indispensable to investigate the influence of intestinal microorganisms on intestinal health.

The distribution of Biomphalaria spp. in different habitats in relation to physical, biological, water contact and cognitive factors in a rural area in Minas Gerais, Brazil

A total of 256 sites in 11 habitats were surveyed for Biomphalaria in Melquiades rural area (State of Minas Gerais) in August and November 1999 and in March 2000. Of the 1,780 Biomphalaria collected, 1,721 (96.7%) were B. glabrata and 59 (3.3%) B. straminea. Snails were found in all habitats except in wells, with the largest mean numbers in tanks, seepage ponds and canals, and the smallest numbers in springs, rice fields and fishponds. People's knowledge of the occurrence of Biomphalaria at the collection sites and the presence of Biomphalaria ova were strongly correlated with the occurrence of snails, and distance between houses and collection sites, as well as water velocity were inversely correlated with Biomphalaria occurrence (p < 0.001). The strongest predictor o f Biomphalaria occurrence was the presence of tilapia fish in fishponds. Fourteen Biomphalaria (0.8% of all snails) found at 6 sites were infected with Schistosoma mansoni. Suggestions are made for the utilization of local people's knowledge in snail surveys and further studies are recommended on the possible use of tilapia for biological control of Biomphalaria in fishponds, as well as modeling of S. mansoni transmission and reinfection.

Unlocking the archive--gene expression in paraffin-embedded tissue

The histopathology archive represents a vast, well-characterized source of specimens covering virtually every disease and is available for molecular biological investigation. The archive has in recent years become widely used for molecular genetic analysis and DNA can be routinely extracted from formalin-fixed, paraffin-embedded tissue. More recently, archival specimens have become a source of material for extensive analysis of mRNA expression utilizing DNA microarrays, real-time quantitative reverse transcriptase polymerase chain reaction (PCR), and in situ hybridization and amplification techniques. These techniques will enable a greater understanding of the changes that occur in gene function during every stage of the development of disease and will lead to better diagnosis, better evaluation of prognosis, and better treatment through targeted therapeutic regimes.

A mathematical treatment of AIDS and condom use

In this paper we examine the impact of condom use on the sexual transmission of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) amongst a homogeneously mixing male homosexual population. We first derive a multi-group SIR-type model of HIV/AIDS transmission where the homosexual population is split into subgroups according to frequency of condom use. Both susceptible and infected individuals can transfer between the different groups. We then discuss in detail an important special case of this model which includes two risk groups and perform an equilibrium and stability analysis for this special case. Our analysis shows that this model can exhibit unusual behaviour. As normal, if the basic reproduction number, R0, is greater than unity then there is a unique disease-free equilibrium which is locally unstable and a unique endemic equilibrium. However, when R0 is less than unity two endemic equilibrium solutions can also co-exist simultaneously with the disease-free solution which is locally stable. Numerical simulations using realistic parameter values confirm this and we find that in certain circumstances the disease-free solution and one of the endemic solutions are both locally asymptotically stable, while the other endemic solution is unstable. This unusual behaviour has important implications for control of the disease as reducing R0 to less than unity no longer guarantees eradication of the disease. For a restricted special case of this two-group model we show that there is only the disease-free equilibrium for R0 < or = 1 which is globally stable. For R0 > 1 the disease-free equilibrium is unstable and there is a unique endemic equilibrium which is locally stable. We then attempt to fit the model to HIV and AIDS incidence data from San Francisco, USA. The paper concludes with a brief discussion.

Schistosomiasis

The trematode parasites in the family Schistosomatidae (phylum Platyhelminthes) infect a wide range of vertebrates. Three species of the genus Schistosoma are of major medical importance. This unit deals exclusively with the parasite Schistosoma mansoni, which is the species most frequently maintained in the laboratory. Among the far-ranging investigations in the immunology of schistosomiasis are studies in vaccine development, immunopathology of granulomatous inflammation and fibrosis, eosinophil function, and in vivo regulation of T(H)1 and T(H)2 responses. This unit describes maintenance and collection procedures for various stages of the schistosome that have immunologic interest, including infection of mice with cercariae, collection of cercariae, preparation of in vitro-derived schistosomules and in vivo-derived schistosomules, and collection of adult worms and eggs. Included also are techniques for preparing soluble egg antigen (SEA), one of the more commonly used schistosome antigenic preparations. A discussion is given of the basic steps that are important in maintaining the snail intermediate host, and infecting the snails with schistosome miracidia. The unit deals exclusively with the parasite Schistosoma mansoni, which is the species most frequently maintained in the laboratory. Since part of the life cycle of all schistosomes involves a snail host, a description of proper maintenance for the snails is provided. Often, problems in experiments can be traced back to improper snail and parasite maintenance, or lack of attention to detail during mammalian exposure to the infective stage (cercaria) of the parasite.