Too much of a good thing? Iatrogenic Cushing syndrome secondary to excessive topical steroid use in lichen sclerosus

We report a patient using excessive quantities of topical steroid treatment for lichen sclerosus without supervision who developed Cushing syndrome. These treatments are very safe when used appropriately and this highlights the importance of good follow-up and patient education.

Post-acute phase and sequelae management of epidermal necrolysis: an international, multidisciplinary DELPHI-based consensus

BACKGROUND

Long-term sequelae are frequent and often disabling after epidermal necrolysis (Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)). However, consensus on the modalities of management of these sequelae is lacking.

OBJECTIVES

We conducted an international multicentric DELPHI exercise to establish a multidisciplinary expert consensus to standardize recommendations regarding management of SJS/TEN sequelae.

METHODS

Participants were sent a survey via the online tool "Survey Monkey" consisting of 54 statements organized into 8 topics: general recommendations, professionals involved, skin, oral mucosa and teeth, eyes, genital area, mental health, and allergy workup. Participants evaluated the level of appropriateness of each statement on a scale of 1 (extremely inappropriate) to 9 (extremely appropriate). Results were analyzed according to the RAND/UCLA Appropriateness Method.

RESULTS

Fifty-two healthcare professionals participated. After the first round, a consensus was obtained for 100% of 54 initially proposed statements (disagreement index < 1). Among them, 50 statements were agreed upon as 'appropriate'; four statements were considered 'uncertain', and ultimately finally discarded.

CONCLUSIONS

Our DELPHI-based expert consensus should help guide physicians in conducting a prolonged multidisciplinary follow-up of sequelae in SJS-TEN.

Anogenital Crohn's Disease and Granulomatosis: A Systematic Review of Epidemiology, Clinical Manifestations, and Treatment

BACKGROUND AND AIMS

Metastatic Crohn's disease is an extraintestinal cutaneous manifestation characterised by non-specific inflammatory lesions anatomically separate from the gut; genital involvement is rare. We conducted a systematic review of anogenital Crohn's disease and granulomatosis, to provide a synthesis of epidemiology, clinical features, and treatment outcomes.

METHODS

A systematic search of the literature was conducted via MEDLINE, EMBASE, and the Cochrane database from inception to December 1, 2020. Two investigators extracted and analysed study data. Response and remission were defined as partial improvement or complete resolution of symptoms and examination findings, respectively.

RESULTS

Of 9381 screened studies, 185 articles, [410 cases: 273 female, 137 male] were included. The predominant clinical features were oedema, ulcers, fissures, and hypertrophic lesions. Adults and children present similarly. Luminal Crohn's disease was diagnosed in nearly 80% of cases including 45-80% patients without gastrointestinal symptoms (time to inflammatory bowel disease [IBD] from anogenital Crohn's disease diagnosis [range] -43 to 11 years). Antibiotics, corticosteroids, thiopurines, and anti-tumour necrosis factor [TNF] therapy were the most frequently prescribed agents. At final follow-up, non-response, response, and remission rates were 37/304 [12%], 267/304 [88%], and 114/304 [38%], respectively. Oedema was associated with a poor response to topical therapy. Greater response rates to anti-TNF therapy were seen in patients prescribed concomitant immunomodulation [24/25, 96% vs 67/90, 74%, p = 0.02].

CONCLUSIONS

We provide an illustrative summary of the clinical presentation and treatment effectiveness of this rare, under-recognised condition, and a proposed algorithm for approach and management. Prospective studies with longer follow-up are required to define optimal treatment strategies.

Laser therapy for genital lichen sclerosus: A systematic review of the current evidence base

Background

Lichen sclerosus (LS) is a chronic, inflammatory dermatosis. Initial treatment with superpotent topical corticosteroids is the accepted and evidence-based first-line therapy. For those who do not respond after exclusion of other potentiating factors, the best second-line therapy is unclear. Laser therapy is an emerging treatment for genital LS and despite uncertain efficacy its use is gaining popularity in the private sector.

Objectives

We aimed to review the effectiveness of laser therapy for genital LS in men, women and children.

Methods

We conducted a systematic review of all primary studies reporting the use of laser in genital LS. Ovid MEDLINE, PubMed, Ovid Embase, Cochrane CENTRAL, Web of Science, CINAHL and PsycINFO were searched from inception to February 2021. The quality of the studies was assessed using the revised Cochrane risk-of-bias tool for randomized trials, ROBINS-I tool for non-randomized trials and Joanna Briggs Institute checklist for case studies.

Results

A total of 24 studies, involving 616 adults, met inclusion criteria. These were six randomized controlled trials (RCTs), one non-randomized trial, nine single arm trials and eight case series. Where assessed, most studies suggest that laser therapy in patients with LS may improve symptoms, clinical signs, quality of life and sexual function. However, results were highly heterogeneous and methodological quality was very low, therefore meta-analysis was not possible.

Conclusions

There is poor evidence to support the use of laser therapy for genital LS at present. Effectiveness of laser needs to be robustly investigated in well-conducted RCTs.

Subungual melanoma with blue naevus-like morphological features: a clinicopathological retrospective analysis of nine cases

Melanocytic lesions in the nail apparatus are often challenging. Both subungual melanomas (SUM) and blue naevus of the nail are very rare. Occasionally, melanomas may mimic blue naevus histologically. Benign and malignant blue melanocytic lesions are commonly associated with G protein mutations, a distinct abnormality not associated with conventional subungual melanomas. We describe the clinical, histological and immunohistochemical features of nine cases of SUM with blue naevus-like morphological features. Mutations in exon 4 and 5 of GNAQ and GNA11 were investigated in two cases, which showed no mutations. RNA-seq of one case revealed unknown mutations along with mutations in ATM, METK and ARID1A. Our study delineates a variant of SUM that mimics blue naevus. Awareness of this pitfall is important when evaluating heavily pigmented lesions around the nail in order to avoid misdiagnosis. Appropriate sampling of subungual lesions and clinicopathological correlation are paramount to reach the correct diagnosis.

"I Have Failed Them and Failed My Duties": Experiences of Hospital Social Workers Discharging Patients into Homelessness

Homelessness is a long-standing issue at the forefront of healthcare globally, and discharge of homeless patients from hospital settings can exacerbate gaps and burdens in healthcare systems. In hospitals, social workers often take on the majority of responsibility for facilitating patient discharge transitions out of hospital care. Research in this area to date has explored experiences and outcomes of homeless clients, and the experiences of social workers in these roles are not well known. The current study's objective was to elucidate observations and experiences of hospital social workers who discharge patients into homelessness. A total of 112 social workers responded to an online questionnaire, and responses to open-ended questions were analyzed for thematic content. Four overarching themes emerged: (1) complexity of clients, (2) systemic barriers, (3) resource gaps, and (4) negative impact on social workers. It is clear that significant change is required to address the multitude of challenges that intersect to reinforce health inequities. Results can be used by social workers, health authorities, community providers, researchers, and policymakers in discussions about best practices for homeless clients.

A Network Analysis of Selected Psychosocial Factors in Vulvodynia and Its Subtypes

OBJECTIVE

Psychosocial factors are related to pain and sex-related outcomes in provoked vulvodynia and possibly in mixed and spontaneous vulvodynia. However, a broader behavioral framework, such as the psychological flexibility model, has received limited attention in this context. Recently, additional psychosocial variables have also emerged that appear relevant to vulvodynia, including perceived injustice, body-exposure anxiety during intercourse, and unmitigated sexual communion. The present study applied network analysis to explore relations between psychological flexibility, newly emerging psychosocial variables relevant to vulvodynia, and their associations with vulvodynia outcomes. The study also explored potential differences across vulvodynia subtypes.

DESIGN

An online cross-sectional study of 349 participants with vulvodynia (112 provoked, 237 spontaneous/mixed) was carried out.

METHODS

Participants completed self-report questionnaires, including questions on pain and sexual outcomes, depression, facets of psychological flexibility, body-exposure anxiety during intercourse, unmitigated sexual communion, and perceived injustice. Networks were computed for the total sample and for provoked and mixed/spontaneous vulvodynia subsamples.

RESULTS

Perceived injustice, pain acceptance, and depression were "central" factors among the included variables, in all models. Psychological flexibility processes were relevant for all networks. Depression was more central in the network for mixed/spontaneous vulvodynia; body-exposure anxiety during intercourse was most central for the provoked subtype.

CONCLUSIONS

Among the included variables, perceived injustice, pain acceptance, depression, and psychological flexibility appear to be important in vulvodynia. As different factors are significant across subtypes, tailored treatment approaches are suggested.

A framework for involving coproduction partners in research about young people with type 1 diabetes

Background

Involvement of end‐users in research can enhance its quality, relevance, credibility and legitimacy; however, the processes through which these changes occur are unclear. Our aim was to explore a coproduction research team's experiences of their involvement in research about young people with type 1 diabetes mellitus (T1DM).

Methods

Semi‐structured interviews conducted with two young people with T1DM, two parents, one diabetes educator, one endocrinologist‐scientist and one research‐engineer explored experiences of coproduction research and its impact on both the research and the participants. Drawing on grounded theory, we undertook inductive analysis and storyline mapping to develop a theorized framework of mechanisms supporting the process of coproduction in T1DM research with young people.

Findings

The framework involving coproduction partners in research about young people with type 1 diabetes centres on the unique expertize that different team members bring to the research and describes conditions that enable expert contributions through the enactment of a variety of expert roles. The framework also describes outcomes—the impact of the expert contributions on both the research and the team members involved.

Conclusion

The findings of this small exploratory study provide a sound foundation to develop further understanding about structures and processes that are integral for the success of coproduction research teams. The framework may provide a guide for researchers planning to incorporate coproduction, on elements that are important for this model of research to succeed. It may also inform coproduction impact assessment research and be used for hypothesis testing and expansion in future studies.

647 Management of Malignant Upper Urinary Tract Obstruction

Background

Malignant Upper Urinary Tract Obstruction (MUUTO) is a common emergency presentation. These are often complex patients and require multiple specialty input to make time-critical decisions. There are currently no national guidelines for the management of MUUTO, a review was conducted to assess the management and outcomes of MUUTO.

Aim

To agreed and review a pathway for patients with MUUTO in order to streamline patient care and to review the management.

Method

The pathway was devised by several consultants at Oxford University Hospital. Through retrospective data collection, the outcomes over six months were reviewed.

Results

Over the six-month period 49 interventions were performed for MUUTO; 44 Percutaneous Nephrostomy (PCN) and five cystoscopies with retrograde ureteric stents (RUS). Patients were admitted to urology in 45% of cases and oncology in 39%. The obstruction was located above the pelvis in 16 (33%) of the cases and within the pelvis in 25 (51%). The most common cancers causing obstruction were bladder cancer (41%), prostate (16%), and colorectal (14%). MDT advice was sought in 63% of cases. The mean time from diagnosis to the intervention was four days. Of the five retrograde inserted ureteric stents, four were unsuccessful and the patients proceeded to PCN. At the conclusion of data collection, 26 (53%) patients had died.

Discussion

The most striking findings were the high failure rate of RUS and the overall poor prognosis of MUUTO. As such this review suggests that more patients should proceed directly to PCN for decompression.

The role of psychological flexibility, perceived injustice and body image in Vulvodynia: A longitudinal study

BACKGROUND

Women with Vulvodynia experience pain, related impacts on sex and daily functioning, and depression. While psychosocial factors are associated with outcomes in Vulvodynia, longitudinal data are limited, especially in mixed/spontaneous Vulvodynia. Broad psychological models such as psychological flexibility (PF) and content-specific factors, such as body-exposure anxiety (BEA) and avoidance during sexual activities and perceived injustice, have not been adequately investigated in Vulvodynia. The aim of this study was to explore whether these factors assessed at baseline predict pain severity, pain interference, sexual functioning and satisfaction and depression 3 months later.

METHODS

A longitudinal study of 349 women with Vulvodynia was conducted. Participants completed online self-report measures of pain-related and sexual outcomes, depression, BEA, perceived injustice and facets of PF (present moment awareness, pain acceptance, committed action) at baseline and after 3 months, overlapping with the Coronavirus disease 2019 (COVID-19) pandemic.

RESULTS

Seventy percent of women responded at both assessments (n = 244). There were significant decreases in pain severity, pain interference, present moment awareness, committed action and a significant increase in depression at 3 months. All the baseline psychosocial factors significantly correlated with at least one outcome at 3 months. When adjusting for baseline outcome and demographics, committed action significantly positively predicted depression at 3 months and pain acceptance significantly positively predicted pain interference at 3 months.

CONCLUSIONS

Among women with Vulvodynia, pain acceptance and committed action are prospectively associated with pain interference and depression. The reliability and generalizability of these results needs to be established given the overlap with the COVID-19 pandemic. Future studies should investigate whether targeting these factors enhances outcomes in Vulvodynia.

SIGNIFICANCE

This longitudinal study explored the role of PF, perceived injustice and body image during sexual activities in predicting pain severity, pain interference, sexual functioning, sexual satisfaction and depression in women with Vulvodynia. The study findings reveal that two facets of PF (committed action and pain acceptance) predicted pain interference and depression over time. It may be important to incorporate these processes in treatments developed for Vulvodynia.

Suitability of testicular tissue fluid from castrated piglets to verify sow -vaccination status and herd monitoring

INTRODUCTION

In a proof of concept, PCV2-specific IgG-antibodies from testicular tissue fluid of seven-day-old castrated piglets were measured to verify the vaccination status of their mothers. Twelve randomly selected sows were vaccinated twice during the last third of gestation with a PCV2 vaccine, while ten controls received only adjuvant. PCV2- specific IgG-antibody titers of serum and colostrum from the sows were correlated with PCV2-specific IgG-antibody titers of serum and testicular tissue fluid of their castrated male offspring. Vaccinated sows showed significantly higher average PCV2-specific IgG-antibody titers in serum (29250 ELISA units, EU) and colostrum (65410 EU) compared to 980 EU and 2630 EU of the control group, respectively. Moreover, significantly higher average concentrations of antibodies were also measured in the serum (9362 EU vs. 247 EU) and the testicular tissue fluid (4022 EU vs. 354 EU) of piglets from vaccinated compared to piglets from adjuvant administered sows. Importantly, a strong linear correlation between PCV2-specific IgG-antibodies in the serum of the piglets and in their testicular tissue fluid was found (rs = 0.9148). PCV2-specific IgG-antibody titers of testicular tissue fluid from five randomly selected piglets allowed the determination of the vaccination status of the herd with a reliability of 98% for vaccinated and 73% for unvaccinated sows. Furthermore, using castration waste products is a very animal friendly method to replace painful and time-consuming blood samplings for herd monitoring or to verify vaccination status.

Vulval acne: a case series describing clinical features and management

Intermittent inflammation of the vulval pilosebaceous units is common and usually self-limiting, but some patients experience recurrent and more troublesome symptoms. There is a scarcity of information on this problem. We describe the clinical and histological features in these patients and the response to treatment. A retrospective, observational study of 16 patients with this phenomenon of recurrent, protracted folliculocentric inflammation of the vulval pilosebaceous unit was performed. Details on the clinical features, histology and response to treatment were collected. Mean age at presentation was 32 years (range 21-45). All patients reported recurrent painful papules and pustules on the labia majora and labia minora. Nine patients reported a cyclical pattern to the development of lesions, with premenstrual exacerbation being most common. Histological examination of these lesions showed a folliculocentric microabscess formation surrounded by an acute and chronic inflammatory cell infiltrate, with a focal foreign-body granulomatous reaction. All our patients responded well to tetracycline, antiandrogenic or retinoid therapy. We propose the term 'vulval acne' for this condition and propose a stepwise approach to its management. We hope to highlight this as a common but underreported entity.

Not a fungi to be with: Shiitake mushroom flagellate dermatitis

Shiitake dermatitis is a rare adverse cutaneous reaction to the ingestion of raw or undercooked shiitake mushrooms (Lentinula edodes). We report the case of a patient who developed a striking linear flagellate dermatitis without urticaria three days after returning from a trip from Tokyo where he had eaten shiitake mushrooms. The rash resolved after two weeks with topical corticosteroids and antihistamines given for symptomatic relief. Shiitake dermatitis is thought to be either a toxic or hypersensitivity reaction to lentinan, a heat-inactivated polysaccharide found in the cell walls of shiitake mushrooms. Although this mushroom is widely consumed in Eastern Asia, with the increasing globalisation of cuisine and travel, cases are likely to become more common in the Western world.

2419Reparative macrophage transplantation for myocardial repair: a refinement of bone marrow mononuclear cell-based therapy

Background

Recent research has revealed that reparative (alternatively activated or M2-like) macrophages play an important role in post-myocardial infarction (MI) cardiac repair, proposing that augmentation of these cells will enhance recovery from MI. Transplantation of bone marrow mononuclear cells (BM-MNCs) is an emerging therapy for MI while its therapeutic efficacy in previous clinical trials is not satisfactory. Given that BM-MNCs are a natural source of macrophages, we hypothesized that induced differentiation/polarisation of BM-MNCs to reparative macrophages before transplantation may enhance the effect of BM-MNC transplantation.

Purpose

This study aimed to develop a robust in vitro protocol to produce reparative macrophages from BM-MNCs and to establish the pre-clinical proof of concept data for reparative macrophage transplantation for the treatment of MI.

Methods and results

Mouse BM-MNCs were treated with M-CSF plus IL-4, IL-10, TGF-β1 or combinations of these in vitro. The concomitant M-CSF+IL-4 protocol (both 20ng/ml) produced the highest rate (89.7±0.7%) and number (1.7-fold larger than the original cell number) of CD11b+F4/80+CD206+ macrophages. Expression and secretion of tissue repair-related factors of the produced cells, including IGF-1, TGF-β1, VEGF and IL1-ra, were more extensive compared to BM-MNCs. Then, 5x105 BM-MNC-derived reparative macrophages, 5x105 BM-MNCs, or saline only (control) were intramyocardially injected in a mouse MI model based on coronary artery ligation. At 4 weeks after treatment, echocardiography demonstrated that reparative macrophage transplantation markedly improved cardiac function (left ventricular ejection fraction; 57.2±1.6%, n=11) compared to both BM-MNC transplantation (48.4±1.3%, n=9) and control group (44.4±2.0%, n=9). Histological studies showed that infarct size was the smallest after reparative macrophage transplantation in association with the greatest tissue repair in the peri-infarct myocardium, including augmented microvascular formation, reduced cardiomyocyte hypertrophy and reduced pathological interstitial fibrosis. These were corresponded to amplified myocardial upregulation of tissue repair-related genes. Of note, survival of donor reparative macrophages in the heart post-transplantation was >10-fold greater compared to BM-MNCs. It was also found that reparative macrophage transplantation increased host-derived cardiac reparative macrophages. This might be a part of the mechanism by which reparative macrophage transplantation augmented myocardial repair, and our in vitro antibody neutralisation study indicated that TGF-β1 played a role in this donor macrophage-to-host macrophage pathway.

Conclusion

M-CSF+IL-4 treatment was effective in producing reparative macrophages from BM-MNCs in vitro. Addition of this pre-treatment improved the therapeutic effect of BM-MNC transplantation. Further pre-clinical and clinical development of this advanced cell therapy is warrantied.

Acknowledgement/Funding

British Heart Foundation (RG/15/3/31236); Heart Research UK (RG2618/12/13 and TRP06/15); St Barts Medical School London

APOE4 Genotype Exerts Greater Benefit in Lowering Plasma Cholesterol and Apolipoprotein B than Wild Type (E3/E3), after Replacement of Dietary Saturated Fats with Low Glycaemic Index Carbohydrates

We examined the impact of APOE genotype on plasma lipids and glucose in a secondary analysis of data from a five-arm, randomised controlled, parallel dietary intervention trial ('RISCK' study), to investigate the impact of replacing saturated fatty acids (SFA) with either monounsaturated fat (MUFA) or carbohydrate of high or low glycaemic index (GI) on CVD risk factors and insulin sensitivity. We tested the impact of APOE genotype (carriage of E2 and E4 alleles versus E3/E3), determined retrospectively, on plasma lipids, lipoproteins and glucose homeostasis at baseline (n = 469), and on the change in these variables after 24 weeks of dietary intervention (n = 389). At baseline, carriers of E2 (n = 70), E4 (n = 125) and E3/E3 (n = 274) expressed marked differences in total plasma cholesterol (TC, p = 0.001), low density lipoprotein cholesterol (LDL-C, p < 0.0001), apolipoprotein B (apo B, p < 0.0001) and total to high density lipoprotein cholesterol ratio (TC:HDL-C, p = 0.002), with plasma concentrations decreasing in the order E4 > E3/E3 > E2. Following intervention, there was evidence of a significant diet x genotype interaction with significantly greater decreases in TC (p = 0.02) and apo B (p = 0.006) among carriers of E4 when SFA was replaced with low GI carbohydrate on a lower fat diet (TC -0.28 mmol/L p = 0.03; apo B -0.1 g/L p = 0.02), and a relative increase in TC (in comparison to E3/E3) when SFA was replaced with MUFA and high GI carbohydrates (TC 0.3 mmol/L, p = 0.03). Among carriers of E2 (compared with E3/E3) there was an increase in triacylglycerol (TAG) when SFA was replaced with MUFA and low GI carbohydrates 0.46 mmol/L p = 0.001). There were no significant interactions between APOE genotype and diet for changes in indices of glucose homeostasis. In conclusion, variations in APOE genotype led to differential effects on the lipid response to the replacement of SFA with MUFA and low GI carbohydrates.

Fibrin Glue-aided, Instant Epicardial Placement Enhances the Efficacy of Mesenchymal Stromal Cell-Based Therapy for Heart Failure

Transplantation of mesenchymal stromal cells (MSCs) is a promising new therapy for heart failure. However, the current cell delivery routes result in poor donor cell engraftment. We therefore explored the role of fibrin glue (FG)-aided, instant epicardial placement to enhance the efficacy of MSC-based therapy in a rat ischemic cardiomyopathy model. We identified a feasible and reproducible method to instantly produce a FG-MSC complex directly on the heart surface. This complex exhibited prompt, firm adhesion to the heart, markedly improving initial retention of donor MSCs compared to intramyocardial injection. In addition, maintenance of retained MSCs was enhanced using this method, together contributing the increased donor cell presence. Such increased donor cell quantity using the FG-aided technique led to further improved cardiac function in association with augmented histological myocardial repair, which correlated with upregulation of tissue repair-related genes. We identified that the epicardial layer was eliminated shortly after FG-aided epicardial placement of MSCs, facilitating permeation of the donor MSC's secretome into the myocardium enabling myocardial repair. These data indicate that FG-aided, on-site, instant epicardial placement enhances MSC engraftment, promoting the efficacy of MSC-based therapy for heart failure. Further development of this accessible, advanced MSC-therapy is justified.

Factors influencing the rate of incidents in a United Kingdom high secure psychiatric hospital: Weekend, ward round and diagnostic effect?

Introduction

Broadmoor is a high secure psychiatric hospital divided into personality disorder (PD) and mental illness (MI) pathways. Whenever an incident occurs, it should be recorded. To better understand which factors influence the rate of incidents, such as diagnosis or intervention by medical and psychological staff, we examined the difference in the number of incidents recorded on weekdays versus weekends, ward round (WR) versus non-WR days and the PD versus MI pathways.

Method

All incidents recorded over a one-year period (3.11.2014–2.11.2015) were examined. Extraneous incidents were excluded, leaving subgroups of “aggressive” (physical and verbal) and “physical” (excluding verbal) incidents which were analysed. Data were adjusted for the difference in number of beds in each pathway.

Results

Of the 2369 incident reports included, more were recorded per day on weekdays than weekends, with little difference on WR versus non-WR days. The rates of both types of incidents were similar on both PD and MI admission wards, although the rate of “physical” incidents was 2.6 times higher and “aggressive” incidents 3.3 times higher in PD compared to MI rehabilitation wards.

Conclusion

The findings suggest the presence of medical and psychological staff during the week, and possibly the requirements they place on patients, may increase the rate of incidents within the hospital. Despite comparable rates on admission, MI rehabilitation wards have far fewer incidents than PD rehab wards, which may reflect the more intractable nature of PD versus MI. More work is required to confirm these findings.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Vulval Crohn's disease – a multi-specialty approach

We report a case of Crohn's disease where the patient initially presented with vulval ulceration to the gynaecology unit. Initial investigations were planned jointly by both the gynaecology and genitourinary medicine staff. An examination under general anaesthetic by both teams was performed and biopsies taken. These showed a chronic inflammatory process with epithelioid granulomas. The teams then referred the case to the dermatology team who made the diagnosis of vulval Crohn's disease and initiated treatment with prednisolone and azathioprine. The case illustrates the need for a multi-speciality approach when dealing with such cases.

Cattle movement as a risk factor for epidemics

Cattle movement is one of the most important risk factors for the occurrence of an epidemic. It is a legal requirement in Switzerland that every cattle movement be reported, and this information is held in the Swiss cattle movement database (Tierverkehrsdatenbank, TVD). Using this data we examined all movements, focusing on the geographical distribution of these movements in relation to the spread of epizootic diseases. We considered the period 01 January 2011 through 30 January 2012, in which a total of 786'462 cattle were moved. Looking at premises individually, a maximum of 901 possible transfers of an infectious agent were found on a specific day after the arrival of another cattle. Furthermore, we found that there were more cattle movements in summer than in winter, due to movements of cattle to and from alpine pastures. There were also prominent regional differences. On the first day after the arrival of a cattle there was a minimum of zero and a maximum of 99'168 possible transfers of an infectious agent. Nevertheless, in most cases there were no cattle moved on the first day following the arrival of a cattle (91.4%). In terms of our epizootics of interest, the following numbers of cattle were moved within the relevant incubation periods: 19'779'551 possible transfers for the Lumpy skin disease, with an incubation period of 28 days; 9'891'665 or 15'025'741 possible transfers for foot and mouth disease, depending on the incubation period of 14 or 21 days; 15'025'741 possible transfers for cattle plague and vesicular stomatitis, both with an incubation period of 21 days. The presented data show a large cattle traffic in Switzerland, and therefore suggest that it is very seldom that an infectious agent is able to start an epidemic.

Usual vulval intraepithelial neoplasia in HIV-positive women - a case series

Usual or undifferentiated type vulval intraepithelial neoplasia (VIN) is more common in young women and is usually associated with high-risk human papillomavirus infection. It is associated with the development of basaloid or warty squamous cell carcinoma. Studies have shown that HIV-positive women have an increased risk of VIN and invasive vulval carcinoma, but there is a paucity of data about this cohort of women. The objective of this study was to describe the clinical features and treatment responses of HIV-positive women diagnosed with VIN in a specialist vulval dermatology clinic. HIV-positive women diagnosed with VIN from 2007 to 2013 were retrospectively identified. Data were collected on demographics, clinical features, treatments and outcomes. Seven cases were retrospectively identified. The median CD4 cell count at presentation was 500 cells/mm³ (range 59-761). Five had multifocal VIN. Five were treated with imiquimod alone, one had surgical excision and one patient was treated with imiquimod and surgery. Five of the seven had complete resolution of disease. HIV-positive patients with VIN had good responses to treatment with imiquimod. They were likely to be stable on combination antiretroviral therapy at presentation, have multifocal disease and concurrent vaginal, anal or cervical intraepithelial neoplasia.

Vulval Crohn's disease: a clinical study of 22 patients

Vulval Crohn's disease [VCD] is a challenging condition that can occur without gastrointestinal Crohn's disease [GCD]. We reviewed the clinical features and effects of therapy in a cohort of 22 patients with VCD to determine whether the presence of GCD affected the clinical presentation and treatment response. Of these, 64% had GCD and 65% of these presented with GCD prior to VCD. Fissuring, ulceration, and scarring were more common in those with VCD alone. Potent and ultra-potent topical steroids showed benefit in most patients. There was no clear evidence of sustained remission with metronidazole. Azathioprine was the most commonly used oral immunosuppressive agent, with an efficacy of 57%. Patients with both VCD and GCD had a better clinical response compared with those with VCD alone [70% and 25%, respectively]. Infliximab and adalimumab were effective in 56% and 71% of patients, respectively. Excision of redundant tissue was helpful in four patients. The absence of GCD may delay the diagnosis in women who present with vulval symptoms alone. The more active clinical features in those with VCD alone may represent a more aggressive condition, or the severity of the cutaneous disease may have been reduced by immunosuppression taken for GCD. Several patients obtained sustained remission in their GCD with anti-tumor necrosis factor alpha [anti-TNFα] agents while the VCD remained active.

An unusual perineal plaque

We present the case of a 61-year-old male with a long-standing perineal and scrotal lesion. Investigations eventually revealed cutaneous tuberculosis, with complete resolution after appropriate treatment. It highlights the variable presentation of cutaneous tuberculosis and the importance of considering the diagnosis in chronic lesions.

Influence of feeding and UVB exposition on the absorption mechanisms of calcium in the gastrointestinal tract of veiled chameleons (Chamaeleo calyptratus)

The purpose of this study was to investigate the influence of feeding and UVB exposition on the occurrence and distribution patterns of vitamin D receptors (VDR) and calbindin D28k (Cb-D28k) in the gastrointestinal tract of veiled chameleons. Thus, 56 veiled chameleon hatchlings were divided into six treatment groups: UV (with UVB exposure); No (no supplements, no UVB exposure); CaAUV (with calcium (Ca), vitamin A supplementation, UVB exposure); CaA (with Ca, vitamin A supplementation); CaADUV (with Ca, vitamin A, vitamin D supplementation, UVB exposure); and CaAD (with Ca, vitamin A, vitamin D supplementation). Animals were reared under the suspected conditions for 6 months on locust-based diets. Tissue samples of stomach, duodenum, ileum and colon were taken, and semi-quantitative immunohistochemical methods (IHC) were performed to detect Cb-D28k and VDR. VDR immunoreactions were higher in the luminal epithelium of the duodenum than in that of the ileum. VDR immunoreactions in the luminal epithelium were higher at the base of the villi of the duodenum as compared to the tip. Cb-D28k immunoreactions were mainly observed in the luminal epithelium of the duodenum. The two groups treated with all dietary supplements (CaADUV, CaAD) exhibited a higher Cb-D28k immunoreaction as those with no supplements and UVB exposure only. No immunoreaction for both proteins could be detected in the stomach. This study suggests that the duodenum plays an important role in the active transcellular absorption of Ca in veiled chameleons as shown by the immunohistochemical detection of VDR and Cb-D28k. Expression of Cb-D28k, in particular, appears to be regulated by dietary supplementation of vitamin D and vitamin A. VDRs, however, tended to be upregulated when animals were not supplemented with Ca, vitamin D and vitamin A. This may be due to the decreased Ca concentrations which caused vitamin D activation in the skin without any supplementation, but UVB exposure.

Vulval disease in HIV-positive women attending a tertiary vulval dermatology clinic over a five-year period

There is a paucity of data on vulval disease in HIV-infected women. We describe the spectrum of vulval disease in HIV-infected women attending a tertiary vulval dermatology referral centre over a five-year period. Seven vulval conditions were identified in 14 women. Most were attending for HIV care (n = 12, 86%), and on combined antiretroviral therapy (CART) with a CD4 cell count above 200 cells/µL (n = 9, 64%) at diagnosis. Imiquimod therapy was effective in treating undifferentiated vulval intraepithelial neoplasia (uVIN) - the most common diagnosis. There were no cases of invasive vulval carcinoma. Hypertrophic herpes simplex virus occurred in one woman stable on CART with good immune reconstitution. Clinicians should be vigilant about the spectrum of vulval disease in HIV-infected women and consider genital examination as part of routine care.

Multi-test analysis and model-based estimation of the prevalence of Taenia saginata cysticercus infection in naturally infected dairy cows in the absence of a 'gold standard' reference test

The diagnostic values of seven serological tests (ELISAs) and of the obligatory European Union-approved routine visual meat inspection for the detection of Taenia saginata cysticercosis were investigated. A total of 793 slaughtered dairy cows were selected in three European Union approved abattoirs in Switzerland, an endemic area (apparent prevalence by enhanced meat inspection up to 4.5%) with typically low parasite burdens. ELISAs based on a somatic larval antigen, isoelectric focused somatic larval antigen, larval excretory/secretory antigens, peptide HP6-2, peptide Ts45S-10, pooled peptide solution and a monoclonal antibody antigen capture assay were initially screened. As there is no perfect diagnostic 'gold standard' reference test, the obligatory meat inspection and four selected serological tests were further analysed using Bayesian inference to estimate the "true" prevalence and the diagnostic test sensitivities and specificities. The ELISA for specific antibody detection based on excretory/secretory antigens showed highest sensitivity and specificity with 81.6% (95% credible interval: 70-92) and 96.3% (95% credible interval: 94-99), respectively. The Bayesian model estimated the specificity of the ELISA, based on the synthetic peptide Ts45S-10 as 55.2% (95% credible interval: 46-65) and sensitivity as 84.7% (95% credible interval: 82-88). The sensitivity of the ELISA based on mAbs, detecting circulating antigen, was 14.3% (95% credible interval: 9-23) with a specificity of 93.7% (95% credible interval: 92-96). The diagnostic sensitivity of the obligatory standard European Union meat inspection procedure for the detection of T. saginata cysticercus infection at the abattoir was estimated to be 15.6% (95% credible interval: 10-23). Based on these data, the modelled prevalence of cysticercosis in dairy cows presented at abattoirs in Switzerland was estimated to be 16.5% (95% credible interval: 13-21). These cattle also had a high prevalence of infection with Dicrocoelium dendriticum (60.8%) and Fasciola hepatica (13.5%).

The association between trunk muscle endurance and lumbo-pelvic stability in adolescent low back pain: A cross sectional study

Decreased trunk muscle endurance has been identified as a risk factor for adolescent LBP, and poor lumbo-pelvic stability has been found to be associated with LBP in the adult population. The aim of the study was to investigate the association between adolescent LBP, trunk muscle endurance and poor lumbo-pelvic stability. Design: A cross sectional study. Participants: 80 adolescents in grade 8 to grade 11, aged 12 to 17 years, at three high schools in Gauteng, who agreed to participate in the study. Method: Data was collected by means of a validated questionnaire and physical tests. The active straight leg raise test was used to record the lumbo-pelvic stabilising muscles. The Sorensen, Shirado and side-bridge tests were used to record trunk extensor, flexor and side flexor muscle endurance, respectively. Results: The results revealed a lifetime prevalence of LBP of 82.50%, one year prevalence of 78.80% and point prevalence of 23.80%. Adolescents with LBP demonstrated decreased trunk extensor muscle endurance but increased trunk flexor muscle endurance (p=0.044), compared to non-LBP adolescents. Poor lumbo-pelvic stability was not associated with adolescent LBP, but was associated with decreased extensor trunk muscle endurance (p=0.031). Conclusion: There was an association between trunk flexor muscle endurance and adolescent LBP, and between decreased trunk extensor muscle endurance and poor lumbo-pelvic stability. No association was found between LBP and poor lumbo-pelvic stability.

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.