Efficacy and safety of fumaric acid esters in young patients aged 10-17 years with moderate-to-severe plaque psoriasis: a randomized, double-blinded, placebo-controlled trial

BACKGROUND

Apart from biologics, no systemic drugs are approved in Europe for children with moderate-to-severe psoriasis. Retrospective observational studies have shown promising results for fumaric acid esters (FAE) in this setting.

OBJECTIVES

To show superiority of FAE over placebo in terms of treatment response after 20 weeks in children and adolescents aged 10-17 years.

METHODS

In a multicentre, randomized, double-blind, placebo-controlled phase IIIb study, patients aged 10-17 years with moderate-to-severe plaque psoriasis requiring systemic therapy were randomized 2 : 1 to receive FAE (n = 91) or placebo (n = 43) over 20 weeks, followed by an open-label FAE treatment phase. The coprimary endpoints were ≥ 75% improvement in Psoriasis Area and Severity Index (PASI 75) and Physician's Global Assessment (PGA) score of 0 or 1 (clear or almost clear) at week 20. The study was registered with EudraCT number 2012-000035-82.

RESULTS

At week 20, 55% [95% confidence interval (CI) 0·44-0·65] of FAE-treated patients achieved a PASI 75 response vs. 19% (95% CI 0·08-0·33) in the placebo group (absolute difference 36%, 95% CI 0·20-0·53; P < 0·001). In total, 42% (95% CI 0·32-0·53) in the FAE group vs. 7% (95% CI 0·01-0·19) in the placebo group achieved a PGA score of 0 or 1 at week 20 (absolute difference 35%, 95% CI 0·21-0·49; P < 0·001). During the double-blind period, drug-related adverse events occurred more frequently in patients receiving FAE compared with placebo (76% vs. 47%). Gastrointestinal disorders were the most common adverse events.

CONCLUSIONS

FAE administered over a period of 20 weeks demonstrated a better response than placebo; the difference was statistically significant and clinically meaningful. Application up to 40 weeks was generally well tolerated. However, further studies are required.

Repurposing of a Thromboxane Receptor Inhibitor Based on a Novel Role in Metastasis Identified by Phenome-Wide Association Study

Although new drug discoveries are revolutionizing cancer treatments, repurposing existing drugs would accelerate the timeline and lower the cost for bringing treatments to cancer patients. Our goal was to repurpose CPI211, a potent and selective antagonist of the thromboxane A₂-prostanoid receptor (TPr), a G-protein-coupled receptor that regulates coagulation, blood pressure, and cardiovascular homeostasis. To identify potential new clinical indications for CPI211, we performed a phenome-wide association study (PheWAS) of the gene encoding TPr, TBXA2R, using robust deidentified health records and matched genomic data from more than 29,000 patients. Specifically, PheWAS was used to identify clinical manifestations correlating with a TBXA2R single-nucleotide polymorphism (rs200445019), which generates a T399A substitution within TPr that enhances TPr signaling. Previous studies have correlated 200445019 with chronic venous hypertension, which was recapitulated by this PheWAS analysis. Unexpectedly, PheWAS uncovered an rs200445019 correlation with cancer metastasis across several cancer types. When tested in several mouse models of metastasis, TPr inhibition using CPI211 potently blocked spontaneous metastasis from primary tumors, without affecting tumor cell proliferation, motility, or tumor growth. Further, metastasis following intravenous tumor cell delivery was blocked in mice treated with CPI211. Interestingly, TPr signaling in vascular endothelial cells induced VE-cadherin internalization, diminished endothelial barrier function, and enhanced transendothelial migration by tumor cells, phenotypes that were decreased by CPI211. These studies provide evidence that TPr signaling promotes cancer metastasis, supporting the study of TPr inhibitors as antimetastatic agents and highlighting the use of PheWAS as an approach to accelerate drug repurposing.

[Pigmented macules as possible early signs of genetic syndromes]

Solitary congenital or early apparent pigmented macules are usually without relevance; however, when multiple, extensive or in a patterned arrangement, they are not uncommonly the first sign of an underlying genetic syndrome. The present article gives an overview on the clinical significance of multiple café-au-lait macules, multiple lentigines and pigmentary mosaicism and discusses the differential diagnosis of associated syndromes. Early diagnosis with the essential contribution of the dermatologist is not only important for genetic counseling but can also contribute to avoidance of sometimes life-threatening complications.

Pachyonychia congenita und Steatocystoma multiplex durch Mutation im Keratin-17-Gen

Die Pachyonychia congenita (PC) wird durch heterozygote Mutationen in den Keratin-Genen KRT6A, KRT6B, KRT6C, KRT16 oder KRT17 verursacht. Die Einteilung in PC Typ 1 und PC Typ 2 nach klinischen Kriterien wurde zugunsten einer molekulargenetischen Klassifikation auf Basis der 5 betroffenen Gene (PC-K6a, PC-K6b, PC-K6c, PC-K16, PC-K17) verlassen. Die Erkrankung wird autosomal-dominant vererbt, Spontanmutationen kommen in etwa 30 % der Fälle vor. Über 97 % der PC-Patienten weisen die 3 Hauptsymptome Verdickung der Fußnägel, Plantarkeratosen und Fußsohlenschmerzen auf.

Lokalisierte Steatozystome, Vellushaarzysten oder das diffuse Steatocystoma multiplex zeichnen die PC durch Keratin-17-Mutationen aus. Konnatale oder perinatale Zähne und follikuläre Hyperkeratosen an Ellenbogen, Knien und Rumpf sind ebenfalls häufig mit einer Mutation in KRT17 vergesellschaftet. Wir berichten über eine 40-jährige Patientin mit Steatocystoma multiplex, Verdickung und distaler Dystrophie aller Nägel, schmerzhaften Plantarkeratosen und palmoplantarer Hyperhidrose. Molekulargenetisch konnte mittels Next-Generation-Sequencing eine Mutation im Exon 1 des KRT17-Gens als ursächlich nachgewiesen werden.

Pityriasis rubra pilaris – eine seltene entzündliche Dermatose mit vielen Facetten

Die Pityriasis rubra pilaris (PRP) ist eine seltene entzündliche, papulosquamöse Dermatose, die in 6 verschiedenen Manifestationsformen (Subtypen) sowohl bei Kindern als auch bei Erwachsenen mit großer Variabilität auftreten kann. Bei allen Subtypen sind in den Anfangsstadien follikulär gebundene, keratotische Papeln zu beobachten, die nach variabler Latenz zu unterschiedlich großen, gut begrenzten Plaques mit krankheitstypischem, orange-rotem Farbton konfluieren. Dabei finden sich bei den ausgedehnteren Verlaufsformen charakteristischerweise innerhalb der Plaques Inseln gesunder Haut (nappes claires). Nicht selten entsteht eine palmare und plantare, wechselnd stark ausgeprägte Hyperkeratose. Die PRP bietet ein breites klinisches Spektrum, das von einem lokalisierten Befall der Extremitäten bis hin zu erythrodermatischen Formen reicht, die mitunter bereits im Säuglingsalter beginnen können.

Die vorliegende Arbeit gibt eine Übersicht über den aktuellen Kenntnisstand dieser bislang wenig verstandenen Dermatose.

Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie des Universitätsklinikums Würzburg: Geschichte und Gegenwart

Dieser Beitrag beleuchtet die fast 150 Jahre lange Geschichte der Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie des Universitätsklinikums Würzburg und ihrer Vorgängerinstitutionen von der Gründung bis zur Gegenwart. Dargestellt werden die wichtigsten Entwicklungsschritte von den ersten dermatologischen Vorlesungsinhalten im späten 18. Jahrhundert über die erste eigene Abteilung für Hautkrankheiten in Würzburg im Jahre 1872, die mit dem 1921 erfolgten Bezug des Luitpoldkrankenhauses verbundene Erweiterung des Fachgebiets, die Wirren in der Zeit des Nationalsozialismus und die Modernisierungen in der Nachkriegszeit bis hin zum aktuellen Stand als Klinik der universitären Maximalversorgung mit krankheitsorientierter molekularbiologischer und immunologischer Forschung und Lehre.

GPCR regulation of secretion

Modulation of neurotransmitter exocytosis by activated Gi/o coupled G-protein coupled receptors (GPCRs) is a universal regulatory mechanism used both to avoid overstimulation and to influence circuitry. One of the known modulation mechanisms is the interaction between Gβγ and the soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNAREs). There are 5 Gβ and 12 Gγ subunits, but specific Gβγs activated by a given GPCR and the specificity to effectors, such as SNARE, in vivo are not known. Although less studied, Gβγ binding to the exocytic fusion machinery (i.e. SNARE) provides a more direct regulatory mechanism for neurotransmitter release. Here, we review some recent insights in the architecture of the synaptic terminal, modulation of synaptic transmission, and implications of G protein modulation of synaptic transmission in diseases. Numerous presynaptic proteins are involved in the architecture of synaptic terminals, particularly the active zone, and their importance in the regulation of exocytosis is still not completely understood. Further understanding of the Gβγ-SNARE interaction and the architecture and mechanisms of exocytosis may lead to the discovery of novel therapeutic targets to help patients with various disorders such as hypertension, attention-deficit/hyperactivity disorder, post-traumatic stress disorder, and acute/chronic pain.

Gβγ SNARE Interactions and Their Behavioral Effects

Presynaptic terminals possess interlocking molecular mechanisms that control exocytosis. An example of such complexity is the modulation of release by presynaptic G Protein Coupled Receptors (GPCRs). GPCR ubiquity at synapses-GPCRs are present at every studied presynaptic terminal-underlies their critical importance in synaptic function. GPCRs mediate presynaptic modulation by mechanisms including via classical Gα effectors, but membrane-delimited actions of Gβγ can also alter probability of release by altering presynaptic ionic conductances. This directly or indirectly modifies action potential-evoked presynaptic Ca²⁺ entry. In addition, Gβγ can interact directly with SNARE complexes responsible for synaptic vesicle fusion to reduce peak cleft neurotransmitter concentrations during evoked release. The interaction of Gβγ with SNARE is displaced via competitive interaction with C2AB-domain containing calcium sensors such as synaptotagmin I in a Ca²⁺-sensitive manner, restoring exocytosis. Synaptic modulation of this form allows selective inhibition of postsynaptic receptor-mediated responses, and this, in combination with Ca²⁺ sensitivity of Gβγ effects on SNARE complexes allows for specific behavioral outcomes. One such outcome mediated by 5-HT receptors in the spinal cord seen in all vertebrates shows remarkable synergy between presynaptic effects of Gβγ and postsynaptic 5-HT-mediated changes in activation of Ca²⁺-dependent K⁺ channels. While acting through entirely separate cellular compartments and signal transduction pathways, these effects converge on the same effect on locomotion and other critical functions of the central nervous system.

[Staphylococcal Scalded Skin Syndrome in a Very Low Birth Weight Premature Infant]

INTRODUCTION

Staphylococcal scalded skin syndrome (SSSS) was often endemic in the past but is nowadays rare. The hematogeneous spread of exfoliative toxins A (ETA) or B (ETB) produced by specific Staphylococcus aureus strains causes a scald-like eruption with disseminated bullous lesions.

CASE REPORT

A perioral impetigo lesion occurred on day 14 of life in a preterm male infant (1,065 g, 30 weeks of gestational age). Empiric antibiotic therapy with cefotaxime and vancomycin was given for 6 days and led to complete resolution. A Staphylococcus aureus strain was isolated. After a symptom-free interval a relapse was noted on day 26 of life. Despite restarting the antibiotic therapy immediately the initial lesion expanded, and disseminated flaccid blisters on an erythematous base appeared within a few hours. On histological examination the cleavage was in the level of the granular layer. There was no mucosal involvement, and the Nikolsky I sign was positive. The antibiotic therapy was changed to a combination of cefotaxime, flucloxacillin and clindamycin which rapidly stopped progression of the exfoliation. Supportive therapy included adequate analgesia, parenteral rehydration, and application of local antiseptics. The preterm infant completely recovered. In the primary lesion an ETA-producing Staphylococcus aureus strain was isolated. Nasal microtrauma by a nasogastric tube was assumed to have caused the fulminant disease. At the same time, no other Staphylococcus aureus infections were seen in our Department of Neonatology.

DISCUSSION

According to the literature, the incidence of SSSS is higher in premature infants and newborns than in older children. Possible causes include lower antibody levels against exfoliative toxins and renal immaturity. Rapid diagnosis and immediate appropriate antibiotic therapy are essential to prevent secondary infection, dehydration with electrolyte disturbance, death, and endemic spread.

Abstract 55: Chronic Loss of Serotonin Transporter Function Alters Platelet Adhesion and Spreading

Clinical observations indicate that patients taking selective serotonin reuptake inhibitors(SSRIs) have an increased risk of bleeding. However it remains unclear how SSRIs, which inhibit the serotonin transporter(SERT), modulate homeostasis and platelet activation. There are two primary mechanisms by which serotonin(5HT) affects platelet function: activation of the 5HT2A receptor and uptake by SERT. It has also been demonstrated that SERT regulates aIIbB3(GPIIbIIIa) function, the common signaling pathway in platelet activation and crucial for platelet aggregation. We sought to elucidate how the serotonergic system modulates aIIbB3 function by examining platelet spreading and attachment to immobilized fibrinogen. To model altered serotonergic tone, we used mice with a genetic deletion of SERT(SERT KO). As observed with SSRI use, the blood 5HT concentration in SERT KO mice is miniscule. We found that SERT KO mice display increased tail bleed time and thrombin time. Interestingly, SERT KO platelets showed reduced spreading but increased attachment on immobilized fibrinogen. 5HT(100nM) was able to rescue the reduced spreading on immobilized fibrinogen. To determine the mechanism, we examined platelet spreading with kentanserin(5HT2A antagonist) or citalopram(SSRI). We found that acute administration of citalopram did not alter spreading at physiologically relevant levels. Blockade of 5HT2A activation however, caused WT platelets to behave similarly to SERT KO with reduced spreading. Src is a tyrosine kinase that plays a major role in platelet spreading. Using in-cell western, P-Src(416) was decreased in SERT KO mice following spreading on immobilized. After addition of 5HT, P-Src(416) in SERT KO platelets was normalized to WT P-Src levels. Furthermore, treatment with ketanserin caused WT P-Src(416) to decreased to SERT KO P-Src(416) levels. These finding suggest that the peripheral serotonergic system is “recalibrated” in the absence of 5HT and leads to altered function of aIIbB3 via 5HT2A. From this data, we have elucidated a novel regulatory mechanism of 5HT for platelet fibrinogen binding that could regulate the recruitment of platelets by fibrinogen binding to a growing thrombus.

Using peptide arrays created by the SPOT method for defining protein-protein interactions

Evaluating sites of protein-protein interactions can be an arduous task involving extensive mutagenesis work and attempts to express and purify individual proteins in sufficient quantities. Peptide mapping is a useful alternative to traditional methods as it allows rapid detection of regions and/or individual residues important for binding, and it can be readily applied to numerous proteins at once. Here we describe the use of the ResPep SL SPOT method to evaluate protein-protein binding interactions such as that between G-protein βγ subunits and SNARE proteins, identifying both regions of interest and subsequently individual residues which can then be manipulated in further biochemical assays to confirm their validity.

Protease-activated receptor (PAR) 1 and PAR4 differentially regulate factor V expression from human platelets

With the recent interest of protease-activated receptors (PAR) 1 and PAR4 as possible targets for the treatment of thrombotic disorders, we compared the efficacy of protease-activated receptor (PAR)1 and PAR4 in the generation of procoagulant phenotypes on platelet membranes. PAR4-activating peptide (AP)-stimulated platelets promoted thrombin generation in plasma up to 5 minutes earlier than PAR1-AP-stimulated platelets. PAR4-AP-mediated factor V (FV) association with the platelet surface was 1.6-fold greater than for PAR1-AP. Moreover, PAR4 stimulation resulted in a 3-fold greater release of microparticles, compared with PAR1 stimulation. More robust FV secretion and microparticle generation with PAR4-AP was attributable to stronger and more sustained phosphorylation of myosin light chain at serine 19 and threonine 18. Inhibition of Rho-kinase reduced PAR4-AP-mediated FV secretion and microparticle generation to PAR1-AP-mediated levels. Thrombin generation assays measuring prothrombinase complex activity demonstrated 1.5-fold higher peak thrombin levels on PAR4-AP-stimulated platelets, compared with PAR1-AP-stimulated platelets. Rho-kinase inhibition reduced PAR4-AP-mediated peak thrombin generation by 25% but had no significant effect on PAR1-AP-mediated thrombin generation. In conclusion, stimulation of PAR4 on platelets leads to faster and more robust thrombin generation, compared with PAR1 stimulation. The greater procoagulant potential is related to more efficient FV release from intracellular stores and microparticle production driven by stronger and more sustained myosin light chain phosphorylation. These data have implications about the role of PAR4 during hemostasis and are clinically relevant in light of recent efforts to develop PAR antagonists to treat thrombotic disorders.

Efficacy and safety of methantheline bromide (Vagantin(®) ) in axillary and palmar hyperhidrosis: results from a multicenter, randomized, placebo-controlled trial

BACKGROUND

Focal hyperhidrosis can severely affect quality of life. So far, knowledge on the effect of systemic therapy of focal hyperhidrosis is limited.

OBJECTIVE

To assess the efficacy and safety of methantheline bromide (MB) in the treatment of axillary and palmar-axillary hyperhidrosis.

METHODS

A multicenter controlled randomized double-blind clinical trial was conducted in patients with axillary or palmar-axillary hyperhidrosis defined by a sweat production >50 mg/5 min. Patients received 3 × 50 mg MB daily or placebo over a period of 28 ± 1 days. Main outcome criterion was the reduction of sweat as measured by gravimetry on day 28 ± 1. Quality of life was assessed by Dermatology Life Quality Index (DLQI) and Hyperhidrosis Disease Severity Score (HDSS).

RESULTS

A total of 339 patients were randomly assigned to receive MB or placebo. On day 28 ± 1, the mean axillary sweat production was 99 mg for MB and 130 mg for placebo compared with 168 mg and 161 mg respectively at baseline (P = 0.004). Patient's HDSS score decreased in the MB group from 3.2 to 2.4 compared with 3.2 to 2.7 for placebo (P = 0.002). Similar results could be obtained for the DLQI with 9.7 for MB and 12.2 for placebo, which decreased from 16.4 or 17 respectively (P = 0.003). Tolerability was good for both groups. The most frequent adverse event was dry mouth.

CONCLUSION

Fifty milligrams methantheline bromide three times a day is an effective and safe treatment of axillary hyperhidrosis.

Fracture healing in protease-activated receptor-2 deficient mice

Protease-activated receptor-2 (PAR-2) provides an important link between extracellular proteases and the cellular initiation of inflammatory responses. The effect of PAR-2 on fracture healing is unknown. This study investigates the in vivo effect of PAR-2 deletion on fracture healing by assessing differences between wild-type (PAR-2(+/+)) and knock-out (PAR-2(-/-)) mice. Unilateral mid-shaft femur fractures were created in 34 PAR-2(+/+) and 28 PAR-2(-/-) mice after intramedullary fixation. Histologic assessments were made at 1, 2, and 4 weeks post-fracture (wpf), and radiographic (plain radiographs, micro-computed tomography (µCT)) and biomechanical (torsion testing) assessments were made at 7 and 10 wpf. Both the fractured and un-fractured contralateral femur specimens were evaluated. Polar moment of inertia (pMOI), tissue mineral density (TMD), bone volume fraction (BV/TV) were determined from µCT images, and callus diameter was determined from plain radiographs. Statistically significant differences in callus morphology as assessed by µCT were found between PAR-2(-/-) and PAR-2(+/+) mice at both 7 and 10 wpf. However, no significant histologic, plain radiographic, or biomechanical differences were found between the genotypes. The loss of PAR-2 was found to alter callus morphology as assessed by µCT but was not found to otherwise effect fracture healing in young mice.

Segmental multilayered argon plasma coagulation: effective therapy option for perianal and scrotal Hailey-Hailey disease

AIM

Hailey-Hailey disease (HHD) is a genodermatosis characterized by recurrent chronic weeping plaques at intertriginous sites. In severe cases, topical and systemic treatments are often insufficient. Extensive excisions are traumatic for patients and have a high morbidity. Superficial ablative procedures such as dermabrasion have become established, but are difficult to perform in the perianal region and scrotum. Therefore, alternative therapies are required.

METHOD

Four patients with extensive anogenital HHD were treated by argon plasma coagulation (APC). This leads to a controlled coagulation of nearly constant depth. After dividing the affected areas into segments, a multilayered APC was performed in every second segment to the upper corium. The remaining segments were treated in the same way after healing of the initially treated parts.

RESULTS

A disease-free period of up to 37 months was observed in all four patients. There was no case of reduced cutaneous sensitivity or extensive scarring.

CONCLUSIONS

Argon plasma coagulation is effective and safe for perianal and scrotal HHD. The benefits include the accessibility to difficult anatomic sites and good control of ablation. The risk of anal stenosis is minimized by the segmental two-step procedure. The rapid re-epithelialization occurs from structures not affected by the disease and allows rapid mobilization of patients.

Ichthyosis vulgaris: novel FLG mutations in the German population and high presence of CD1a+ cells in the epidermis of the atopic subgroup

BACKGROUND

Ichthyosis vulgaris (IV) is a genetic disorder with a prevalence of 1:250-1000 caused by filaggrin (FLG) mutations, which also predispose to atopic diseases.

OBJECTIVES

To study the genotype/phenotype relationship in IV and to analyse whether the suggested skin barrier defect is associated with differences of epidermal dendritic cells.

PATIENTS/METHODS

We evaluated a cohort of 26 German patients with IV, established an IV severity score and analysed epidermal ultrastructure, histology, filaggrin and CD1a antigens. Mutations were screened by restriction enzyme analysis. Particular sequencing techniques allowed the complete FLG analysis to reveal novel mutations.

RESULTS

The combined null allele frequency of R501X and 2282del4 was 67.3%. Patients also showed the mutations S3247X and R2447X as well as five novel FLG mutations: 424del17 and 621del4 (profilaggrin S100 domain), 2974delGA (repeat 2), R3766X (repeat 10(1)) and E4265X (repeat 10(2)). Their combined allele frequency in controls was <0.7%. No mutation was found in one IV patient, all in all approximately 27% were heterozygous, and the majority (approximately 69%) showed two null alleles. The IV severity score and ultrastructure showed a significant correlation with genotypes. Interestingly, CD1a cell counts showed a significant difference between nonatopic and atopic IV patients both with eczema and without eczema.

CONCLUSIONS

We confirm that the mutations R501X and 2282del4 represent the most frequent genetic cause in German IV patients. The novel mutations are probably population and family specific. The observed differences of CD1a cells support the hypothesis that there is a barrier defect that predisposes to atopic manifestations, possibly independent of atopic eczema.

A novel missense mutation in GJB2 disturbs gap junction protein transport and causes focal palmoplantar keratoderma with deafness

Gap junctions are intercellular channels that mediate rapid intercellular communication. They consist of connexins, small transmembrane proteins that belong to a large family found throughout the animal kingdom. In the skin, several connexins are expressed and are involved in the regulation of epidermal growth and differentiation. One of the skin expressed gap junction genes is GJB2, which codes for connexin 26 and is associated with a wide variety of keratinisation disorders. Here, we report on a family with a novel GJB2 mutation (p.His73Arg) causing a syndrome of focal palmoplantar keratoderma with severe progressive sensorineural hearing impairment, a phenotype reminiscent of Vohwinkel syndrome. Using fluorescent connexin fusion proteins, we show that the mutation induces a transport defect similar to that found for the Vohwinkel syndrome mutation p.Asp66His. Co-transfection into cells expressing wild type connexin26 shows that the mutant has a dominant negative effect on connexin trafficking. We suggest that there may be a weak genotype-phenotype correlation for mutations in GJB2.

Erfolgreiche Dexamethason-Pulstherapie bei großflächig erosivem perianalen Lichen ruber

A 70-year-old man presented with a 6-month history of extensive, progressive perianal erosions. In addition, he had white reticulate striae and small erosions on the penis. The clinical diagnosis of erosive lichen planus was confirmed histologically. After several topical approaches failed and his ss-blocker was stooped, 3 pulses of dexamethasone (100 mg dexamethasone i.v. on 3 consecutive days every 4 weeks) led to complete and long-lasting remission.

[Congenital melanocytic nevi--a multifaceted problem]

Congenital melanocytic nevi are specific pigmented lesions that differ from acquired melanocytic nevi in terms of the age at which they develop and, usually, also in their clinical and histological features. Their potential for malignant transformation and their association with leptomeningeal seeding of nevomelanocytic cells have long been known, at least in the case of large melanocytic nevi. In addition, significant psychosocial stigmatization may affect patients with larger congenital nevi, in particular when they appear at exposed sites. Together, these aspects, in combination with the individual reaction of the patient and his/her parents, must be considered before a therapeutic recommendation is made. In the present review, our current knowledge of this condition is summarized with the aim of helping to determine the most appropriate management for the individual affected.

Stadiengerechte Therapie der COPD

The treatment of chronic obstructive pulmonary disease (COPD) has improved substantially over recent years, and is increasingly based on evidence from prospective studies. Cessation of smoking is the most important and effective single measure which can be taken. In the early stages, intensive measures for nicotine withdrawal should be taken to prevent the catastrophic effects of disease progression. Pharmacological treatment of COPD in the earlier stages (0-II) should be symptom oriented. Asymptomatic patients at these stages do not require permanent pharmacotherapy. From Stage II, COPD patients benefit from pulmonary rehabilitation programs. Patients with stages III and IV should usually be put on long-term corticosteroid inhalation, preferably in combination with long-acting bronchodilators. Systemic corticosteroids, even at low doses, are not indicated. They are useful only for the short-term treatment of acute exacerbations. These treatment modalities improve the quality of life and morbidity of COPD patients. They also decrease exacerbations and hospitalization rates, which should help to reduce mortality due to this important disease.

Die Behandlung des parapneumonischen Ergusses und des Pleuraempyems

Pleural effusions of infectious origin usually present as a complication of pneumonia, or, more rarely, of thoracic surgical procedures. Treatment is based upon the clinical picture, the appearance of the pleural fluid, on certain laboratory parameters, and upon the success of therapeutic interventions. The initial antibiotic regimen should cover the causative organisms that may empirically be expected in the individual setting of the patient. Similar to the situation in pneumonias, the spectrum of organisms in community-acquired effusions or empyemas differs substantially from that in hospital-acquired pleural infections. The management of pleural empyemas should follow an interdisciplinary strategy which involves the pulmonologist and the thoracic surgeon. The single most important intervention is the early and effective drainage of the pleural cavity. Loculated effusions that do not promptly improve after drainage can additionally be treated by a trial of intrapleural fibrinolysis for a period of approximately three days. However, the precise role of fibrinolytics in the setting of complicated pleural effusions and empyemas remains to be better defined. Early definitive surgical treatment, preferentially by video-assisted thoracoscopic surgery (VATS), should be the goal in all patients who do not promptly respond to drainage and/or intrapleural fibrinolytic therapy and who qualify for a surgical intervention.