Stereotactic ultrahypofractionated MR-guided radiotherapy for localized prostate cancer - Acute toxicity and patient-reported outcomes in the prospective, multicenter SMILE phase II trial

Background

Due to superior image quality and daily adaptive planning, MR-guided stereotactic body radiation therapy (MRgSBRT) has the potential to further widen the therapeutic window in radiotherapy of localized prostate cancer. This study reports on acute toxicity rates and patient-reported outcomes after MR-guided adaptive ultrahypofractionated radiotherapy for localized prostate cancer within the prospective, multicenter phase II SMILE trial.

Materials and methods

A total of 69 patients with localized prostate cancer underwent MRgSBRT with daily online plan adaptation. Inclusion criteria comprised a tumor stage ≤ T3a, serum PSA value ≤ 20 ng/ml, ISUP Grade group ≤ 4. A dose of 37.5 Gy was prescribed to the PTV in five fractions on alternating days with an optional simultaneous boost of 40 Gy to the dominant intraprostatic lesion defined by multiparametric MRI. Acute genitourinary (GU-) and gastrointestinal (GI-) toxicity, as defined by CTCAE v. 5.0 and RTOG as well as patient-reported outcomes according to EORTC QLQ-C30 and -PR25 scores were analyzed at completion of radiotherapy, 6 and 12 weeks after radiotherapy and compared to baseline symptoms.

Results

There were no toxicity-related treatment discontinuations. At the 12-week follow-up visit, no grade 3 + toxicities were reported according to CTCAE. Up until the 12-week visit, in total 16 patients (23 %) experienced a grade 2 GU or GI toxicity. Toxicity rates peaked at the end of radiation therapy and subsided within the 12-week follow-up period. At the 12-week follow-up visit, no residual grade 2 GU toxicities were reported and 1 patient (1 %) had residual grade 2 enteritic symptoms. With exception to a significant improvement in the emotional functioning score following MRgSBRT, no clinically meaningful changes in the global health status nor in relevant subscores were reported.

Conclusion

Daily online-adaptive MRgSBRT for localized prostate cancer resulted in an excellent overall toxicity profile without any major negative impact on quality of life.

Improvement of functional outcome for patients with newly diagnosed grade 2 or 3 gliomas with co-deletion of 1p/19q - IMPROVE CODEL: the NOA-18 trial

Background

Given the young age of patients with CNS WHO grade 2 and 3 oligodendrogliomas and the relevant risk of neurocognitive, functional, and quality-of-life impairment with the current aggressive standard of care treatment, chemoradiation with PCV, of the tumour located in the brain optimizing care is the major challenge.

Methods

NOA-18 aims at improving qualified overall survival (qOS) for adult patients with CNS WHO grade 2 and 3 oligodendrogliomas by randomizing between standard chemoradiation with up to six six-weekly cycles with PCV and six six-weekly cycles with lomustine and temozolomide (CETEG) (n = 182 patients per group accrued over 4 years) thereby delaying radiotherapy and adding the chemoradiotherapy concept at progression after initial radiation-free chemotherapy, allowing for effective salvage treatment and delaying potentially deleterious side effects. QOS represents a new concept and is defined as OS without functional and/or cognitive and/or quality of life deterioration regardless of whether tumour progression or toxicity is the main cause. The primary objective is to show superiority of an initial CETEG treatment followed by partial brain radiotherapy (RT) plus PCV (RT-PCV) at progression over partial brain radiotherapy (RT) followed by procarbazine, lomustine, and vincristine (PCV) chemotherapy (RT-PCV) and best investigators choice (BIC) at progression for sustained qOS. An event concerning a sustained qOS is then defined as a functional and/or cognitive and/or quality of life deterioration after completion of primary therapy on two consecutive study visits with an interval of 3 months, tolerating a deviation of at most 1 month. Assessments are done with a 3-monthly MRI, assessment of the NANO scale, HRQoL, and KPS, and annual cognitive testing. Secondary objectives are evaluation and comparison of the two groups regarding secondary endpoints (short-term qOS, PFS, OS, complete and partial response rate). The trial is planned to be conducted at a minimum of 18 NOA study sites in Germany.

Discussion

qOS represents a new concept. The present NOA trial aims at showing the superiority of CETEG plus RT-PCV over RT-PCV plus BIC as determined at the level of OS without sustained functional deterioration for all patients with oligodendroglioma diagnosed according to the most recent WHO classification.

Trial registration

Clinicaltrials.govNCT05331521. EudraCT 2018–005027-16.

Stereotactic MRI-guided radiation therapy for localized prostate cancer (SMILE): a prospective, multicentric phase-II-trial

Background

Normofractionated radiation regimes for definitive prostate cancer treatment usually extend over 7–8 weeks. Recently, moderate hypofractionation with doses per fraction between 2.2 and 4 Gy has been shown to be safe and feasible with oncologic non-inferiority compared to normofractionation. Radiobiologic considerations lead to the assumption that prostate cancer might benefit in particular from hypofractionation in terms of tumor control and toxicity. First data related to ultrahypofractionation demonstrate that the overall treatment time can be reduced to 5–7 fractions with single doses > 6 Gy safely, even with simultaneous focal boosting of macroscopic tumor(s). With MR-guided linear accelerators (MR-linacs) entering clinical routine, invasive fiducial implantations become unnecessary. The aim of the multicentric SMILE study is to evaluate the use of MRI-guided stereotactic radiotherapy for localized prostate cancer in 5 fractions regarding safety and feasibility.

Methods

The study is designed as a prospective, one-armed, two-stage, multi-center phase-II-trial with 68 patients planned. Low- and intermediate-risk localized prostate cancer patients will be eligible for the study as well as early high-risk patients (cT3a and/or Gleason Score ≤ 8 and/or PSA ≤ 20 ng/ml) according to d’Amico. All patients will receive definitive MRI-guided stereotactic radiation therapy with a total dose of 37.5 Gy in 5 fractions (single dose 7.5 Gy) on alternating days. A focal simultaneous integrated boost to MRI-defined tumor(s) up to 40 Gy can optionally be applied. The primary composite endpoint includes the assessment of urogenital or gastrointestinal toxicity ≥ grade 2 or treatment-related discontinuation of therapy. The use of MRI-guided radiotherapy enables online plan adaptation and intrafractional gating to ensure optimal target volume coverage and protection of organs at risk.

Discussion

With moderate hypofractionation being the standard in definitive radiation therapy for localized prostate cancer at many institutions, ultrahypofractionation could be the next step towards reducing treatment time without compromising oncologic outcomes and toxicities. MRI-guided radiotherapy could qualify as an advantageous tool as no invasive procedures have to precede in therapeutic workflows. Furthermore, MRI guidance combined with gating and plan adaptation might be essential in order to increase treatment effectivity and reduce toxicity at the same time.

Erasmus Wilson's role in soap advertisements: Cleansing a soiled reputation

Sir Erasmus Wilson was a pioneer in dermatology and one of the most famous doctors in Victorian England. He enjoyed a sterling professional reputation, with one exception. During the 1860s, his name appeared in a wide variety of cosmetic advertisements endorsing commercial products such as Pears soap, which is still marketed today, as well as hair washes and pomades. Questions were raised in The Lancet about the propriety of Wilson's involvement with such commercial products. Wilson denied in a letter to The Lancet any connection with these advertisements; nonetheless, some confusion has lingered over the years about whether Wilson received any financial compensation from the Pears Soap Company in return for his product endorsements, and whether he enjoyed a business relationship with cosmetic companies that added to his wealth. This contribution presents a comprehensive review of Erasmus Wilson's relationship with cosmetic companies and his struggle to distance himself from them.

The Second of Two One-Year, Multicenter, Open-Label, Repeat-Dose, Phase II Safety Studies of PrabotulinumtoxinA for the Treatment of Moderate to Severe Glabellar Lines in Adult Patients

BACKGROUND

PrabotulinumtoxinA is a 900-kDa botulinum toxin type A produced by Clostridium botulinum.

OBJECTIVES

The authors sought to investigate the safety of prabotulinumtoxinA for treatment of glabellar lines.

METHODS

This was a multicenter, open-label, repeat-dose, 1-year phase II safety study. Adults with moderate to severe glabellar lines at maximum frown, as independently assessed by both investigator and patient on the validated 4-point photonumeric Glabellar Line Scale (0 = no lines, 1 = mild, 2 = moderate, 3 = severe), were enrolled. On day 0, patients received an initial treatment (IT) of 20 U prabotulinumtoxinA (4 U/0.1 mL final vacuum-dried formulation injected into 5 glabellar sites). On and after day 90, patients received a repeat treatment (RT) if their Glabellar Line Scale score was ≥2 at maximum frown by investigator assessment. Safety outcomes were evaluated throughout the study.

RESULTS

The 570 study patients received a median total dose of 60 U, that is, 3 treatments. Sixty-one patients (10.7%) experienced adverse events (AEs) assessed as possibly study drug related; 6.5% experienced study drug-related AEs after the IT. With each RT, progressively lower percentages of patients experienced study drug-related AEs. Eight patients (1.4%) experienced study drug-related AEs of special interest: 5 experienced eyelid ptosis (0.9%), 3 eyebrow ptosis (0.5%), 1 blepharospasm (0.2%), and 1 blurred vision (0.2%). Seven patients (1.2%) experienced serious AEs, but none were study drug related. A total of 4060 serum samples were tested for antibotulinum toxin antibodies; no seroconversion was observed.

CONCLUSIONS

The safety of RTs of 20 U of prabotulinumtoxinA for moderate to severe glabellar lines was confirmed in this second phase II study based on a broad range of outcomes.

LEVEL OF EVIDENCE: 2

A Randomized, Comparator-Controlled Study of HARC for Cheek Augmentation and Correction of Midface Contour Deficiencies

BACKGROUND

HARC is a soft and flexible hyaluronic acid filler containing lidocaine, manufactured using XpresHAn® technology, restoring natural-looking volume and soft contours.

OBJECTIVES

To evaluate safety and effectiveness of HARC for cheek augmentation and correction of midface contour deficiencies compared to a control product HAJV (hereafter referred to as Control). Primary objective was to demonstrate non-inferiority of HARC compared to the Control, by blinded evaluation of change from baseline in midface fullness 12 weeks after last injection, using a 4 grade midface volume scale (MMVS).

MATERIALS AND METHODS

Subjects over the age of 21 with loss of fullness in the midface area (MMVS score 2, 3, or 4) were randomized 2:1 to treatment with HARC(n=142) or Control (n=68). Optional touch-up was allowed after 4 weeks. Study assessments included MMVS, aesthetic improvement, subject satisfaction, and safety. Subjects were followed for 48 weeks.

RESULTS

Overall, most subjects were female (89%) and mean age was 53 years (range 24-80). Total mean volume injected was 4.3 mL for HARC and 4.9 mL for Control. Primary objective was met; mean change from baseline in MMVS score at week 12: -1.4 (HARC), -1.3 (Control), 95% CI: -0.22, 0.06. HARC effectiveness was supported by a high degree of aesthetic improvement and subject satisfaction throughout 48 weeks. Related adverse events were generally mild and transient.

CONCLUSIONS

 HARC was well tolerated and non-inferior to Control for correction of midface fullness at 12 weeks after last injection. Aesthetic improvement and subject satisfaction were high and lasted through week 48.  J Drugs Dermatol. 2021;20(9):949-956. doi:10.36849/JDD.6191.

Clinical Relevance of Elastin in the Structure and Function of Skin

Elastin is the main component of elastic fibers, which provide stretch, recoil, and elasticity to the skin. Normal levels of elastic fiber production, organization, and integration with other cutaneous extracellular matrix proteins, proteoglycans, and glycosaminoglycans are integral to maintaining healthy skin structure, function, and youthful appearance. Although elastin has very low turnover, its production decreases after individuals reach maturity and it is susceptible to damage from many factors. With advancing age and exposure to environmental insults, elastic fibers degrade. This degradation contributes to the loss of the skin's structural integrity; combined with subcutaneous fat loss, this results in looser, sagging skin, causing undesirable changes in appearance. The most dramatic changes occur in chronically sun-exposed skin, which displays sharply altered amounts and arrangements of cutaneous elastic fibers, decreased fine elastic fibers in the superficial dermis connecting to the epidermis, and replacement of the normal collagen-rich superficial dermis with abnormal clumps of solar elastosis material. Disruption of elastic fiber networks also leads to undesirable characteristics in wound healing, and the worsening structure and appearance of scars and stretch marks. Identifying ways to replenish elastin and elastic fibers should improve the skin's appearance, texture, resiliency, and wound-healing capabilities. However, few therapies are capable of repairing elastic fibers or substantially reorganizing the elastin/microfibril network. This review describes the clinical relevance of elastin in the context of the structure and function of healthy and aging skin, wound healing, and scars and introduces new approaches being developed to target elastin production and elastic fiber formation.

DaxibotulinumtoxinA for Injection for the Treatment of Glabellar Lines: Efficacy Results From SAKURA 3, a Large, Open-Label, Phase 3 Safety Study

BACKGROUND

DaxibotulinumtoxinA for Injection (DAXI) is botulinum toxin Type A formulated with a novel peptide excipient. Two pivotal, single-treatment, placebo-controlled trials demonstrated efficacy and safety for moderate or severe glabellar lines.

OBJECTIVE

To further evaluate DAXI in a large, open-label, repeat-treatment study.

METHODS

Subjects (n = 2,691) were enrolled from the preceding pivotal trials or de novo and received 40U DAXI. Those who received repeat treatments could be retreated when they returned to baseline on the Investigator Global Assessment-Frown Wrinkle Severity (IGA-FWS) and Patient FWS (PFWS) scales at/after 12 weeks and up to 36 weeks after treatment.

RESULTS

High (>96%) response rates (none or mild severity) on the IGA-FWS scale were seen after each of the 3 treatments, with peak response between Weeks 2 to 4. At Week 24, ≥32% had a response of none or mild severity. Peak response rates of ≥92% were observed at Weeks 2 to 4 on the PFWS scale. The median duration for return to moderate or severe severity was 24 weeks. The safety profile was favorable and consistent with previous trials.

CONCLUSION

DaxibotulinumtoxinA for Injection efficacy was highly consistent across treatment cycles. These results confirm the previously observed efficacy rates and duration of response.

Topical Oxymetazoline Cream 1.0% for Persistent Facial Erythema Associated With Rosacea: Pooled Analysis of the Two Phase 3, 29-Day, Randomized, Controlled REVEAL Trials

Background: Rosacea is a chronic dermatologic condition with limited treatment options. Methods: Data were pooled from two identically designed phase 3 trials. Patients with moderate to severe persistent erythema of rosacea were randomized to receive oxymetazoline cream 1.0% or vehicle once daily for 29 days and were followed for 28 days posttreatment. The primary efficacy outcome was the proportion of patients with ≥2-grade improvement from baseline on both Clinician Erythema Assessment (CEA) and Subject Self-Assessment (SSA) at 3, 6, 9, and 12 hours postdose, day 29. Results: The pooled population included 885 patients (78.8% female); 85.8% and 91.2% had moderate erythema based on CEA and SSA, respectively. The primary outcome was achieved by significantly more patients in the oxymetazoline than vehicle group (P<0.001). Individual CEA and SSA scores and reduction in facial erythema (digital image analysis) favored oxymetazoline over vehicle (P<0.001). The incidence of treatment-emergent adverse events was low (oxymetazoline, 16.4%; vehicle, 11.8%). No clinically relevant erythema worsening (based on CEA and SSA) was observed during the 28-day posttreatment follow-up period (oxymetazoline, 1.7%; vehicle, 0.6%). Conclusion: Oxymetazoline effectively reduced moderate to severe persistent facial erythema of rosacea and was well tolerated. J Drugs Dermatol. 2018;17(11):1201-1208.

How to Use Oral and Topical Cosmeceuticals to Prevent and Treat Skin Aging

Skin aging is caused by DNA damage in nuclei and mitochondria, inflammation, glycation, decreased function of keratinocytes and fibroblasts and breakdown of heparan sulfate, hyaluronic acid, collagen, and elastin. Identifying patients at an increased risk of skin aging using a standardized methodology to diagnose the Baumann Skin Type will allow doctors to prescribe an efficacious antiaging skin care regimen. Cosmeceuticals can activate LGR6+ stem cells, improve cell response to signals such as growth factors, stimulate collagen genes, neutralize free radicals, and decrease breakdown of collagen and elastin. Giving written instructions will increase patient compliance and improve outcomes.

Betablockers do not increase efficacy of band ligation in primary prophylaxis but they improve survival in secondary prophylaxis of variceal bleeding

BACKGROUND

Endoscopic band ligation (EBL) is used for primary (PP) and secondary prophylaxis (SP) of variceal bleeding. Current guidelines recommend combined use of non-selective beta-blockers (NSBBs) and EBL for SP, while in PP either NSBB or EBL should be used.

AIM

To assess (re-)bleeding rates and mortality in cirrhotic patients receiving EBL for PP or SP for variceal bleeding.

METHODS

(Re-)bleeding rates and mortality were retrospectively assessed with and without concomitant NSBB therapy after first EBL in PP and SP.

RESULTS

Seven hundred and sixty-six patients with oesophageal varices underwent EBL from 01/2005 to 06/2015. Among the 284 patients undergoing EBL for PP, n = 101 (35.6%) received EBL only, while n = 180 (63.4%) received EBL + NSBBs. In 482 patients on SP, n = 163 (33.8%) received EBL only, while n = 299 (62%) received EBL + NSBBs. In PP, concomitant NSBB therapy neither decreased bleeding rates (log-rank: P = 0.353) nor mortality (log-rank: P = 0.497) as compared to EBL alone. In SP, similar re-bleeding rates were documented in EBL + NSBB vs EBL alone (log-rank: P = 0.247). However, EBL + NSBB resulted in a significantly lower mortality rate (log-rank: P<0.001). A decreased risk of death with EBL + NSBB in SP (hazard ratio, HR: 0.50; P<0.001) but not of rebleeding, transplantation or further decompensation was confirmed by competing risk analysis. Overall NSBB intake reduced 6-months mortality (HR: 0.53, P = 0.008) in SP, which was most pronounced in patients without severe/refractory ascites (HR: 0.37; P = 0.001) but not observed in patients with severe/refractory ascites (HR: 0.80; P = 0.567).

CONCLUSIONS

EBL alone seems sufficient for PP of variceal bleeding. In SP, the addition of NSBB to EBL was associated with an improved survival within the first 6 months after EBL.

WITHDRAWN: Efficacy and safety of topical oxymetazoline cream 1.0% for treatment of persistent facial erythema associated with rosacea: findings from the 2 phase 3, 29-day, randomized, controlled REVEAL trials

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Efficacy and safety of oxymetazoline cream 1.0% for treatment of persistent facial erythema associated with rosacea: Findings from the 52-week open label REVEAL trial

BACKGROUND

Limited treatments are available for persistent erythema of rosacea.

OBJECTIVE

To examine the long-term safety and efficacy of oxymetazoline cream 1.0% in patients with rosacea with moderate-to-severe persistent erythema.

METHODS

Patients applied oxymetazoline once daily for 52 weeks. Safety assessments included treatment-emergent adverse events (TEAEs), skin blanching, inflammatory lesion counts, telangiectasia, disease severity, and rebound effect. Efficacy was assessed by the Clinician Erythema Assessment and Subject Self-Assessment composite score at 3 and 6 hours after the dose on day 1 and at weeks 4, 26, and 52.

RESULTS

Among 440 patients, 8.2% reported treatment-related TEAEs; the most common were application-site dermatitis, paresthesia, pain, and pruritus. The rate of discontinuation due to adverse events (mostly application-site TEAEs) was 3.2%. No clinically meaningful changes were observed in skin blanching, inflammatory lesions, or telangiectasia. At week 52, 36.7%, and 43.4% of patients achieved a 2-grade or greater composite improvement from baseline in both Clinician Erythema Assessment and Subject Self-Assessment 3 and 6 hours after a dose, respectively. Less than 1% of patients experienced a rebound effect following treatment cessation.

LIMITATIONS

A vehicle-control group was not included.

CONCLUSION

This long-term study demonstrated sustained safety, tolerability, and efficacy of oxymetazoline for moderate-to-severe persistent erythema of rosacea.

Cosmeceuticals in skin of color

Patients with skin of color have similar skin care needs as lighter-skin patients. However, they are less likely to use sun protection on a daily basis, which leads to an increased risk of dyschromia, skin cancer, and other disorders. This article discusses the importance of a correct and consistent skin care regimen and the various cutaneous issues that should be considered when prescribing a skin care regimen for patients with darker skin types. Adopting a standardized methodology to identify affordable, efficacious products and to streamline the process of skin-type diagnosis, skin care regimen prescribing, patient communication, and staff education will result in improved patient outcomes and increased patient satisfaction.

Evaluation of Micro-Focused Ultrasound for Lifting and Tightening Neck Laxity

BACKGROUND

A novel device using micro-focused ultrasound with high-resolution ultrasound visualization (MFU-V) produces non-invasive lifting and tightening of lax skin on the face and neck when treatment is delivered at a single focal depth (Ulthera® System; Ulthera, Inc., Mesa, AZ).<br/>

OBJECTIVE

The following study was performed to test the hypothesis that customized application of MFU-V at two focal depths will produce clinical results that are superior to treatment at a single focal depth.<br/>

METHODS AND MATERIALS

Adult subjects (N=71) with skin laxity in the lower face and neck were enrolled; 64 met all entrance criteria and received treatment. On the basis of physical and anatomical characteristics, patients were assigned in nonrandomized fashion to one of three treatment groups to undergo treatment on the submental, submandibular, lower neck, and platysmal areas with MFU-V at single or dual depths.<br/>

RESULTS

Among evaluable subjects (N=64), investigator-assessment and subject-self-assessment demonstrated improved aesthetic changes at 60, 90, and 180 days after treatment. Overall, subjects that received MFU-V at two focal depths to the entire treatment area achieved slightly greater aesthetic improvement than subjects receiving MFU-V at single focal depths. There were no unexpected adverse events.<br/>

CONCLUSION

Applying treatment with MFU-V at two focal depths may provide improved aesthetic results in some subjects. <br /><br /> <em>J Drugs Dermatol. </em>2016;15(5):607-614.

Structure-function integrity of the adult hippocampus depends on the transcription factor Bcl11b/Ctip2

The dentate gyrus is one of the only two brain regions where adult neurogenesis occurs. Throughout life, cells of the neuronal stem cell niche undergo proliferation, differentiation and integration into the hippocampal neural circuitry. Ongoing adult neurogenesis is a prerequisite for the maintenance of adult hippocampal functionality. Bcl11b, a zinc finger transcription factor, is expressed by postmitotic granule cells in the developing as well as adult dentate gyrus. We previously showed a critical role of Bcl11b for hippocampal development. Whether Bcl11b is also required for adult hippocampal functions has not been investigated. Using a tetracycline‐dependent inducible mouse model under the control of the forebrain‐specific CaMKIIα promoter, we show here that the adult expression of Bcl11b is essential for survival, differentiation and functional integration of adult‐born granule cell neurons. In addition, Bcl11b is required for survival of pre‐existing mature neurons. Consequently, loss of Bcl11b expression selectively in the adult hippocampus results in impaired spatial working memory. Together, our data uncover for the first time a specific role of Bcl11b in adult hippocampal neurogenesis and function.

Safety and Efficacy of Bimatoprost for Eyelash Growth in Postchemotherapy Subjects

OBJECTIVE

To evaluate long-term efficacy and safety of bimatoprost for treatment of chemotherapy-induced eyelash hypotrichosis.

DESIGN

One-year, multicenter, double-masked, parallel-group study.

SETTING

Twenty-one centers in the United States and one center in the United Kingdom.

PARTICIPANTS

This study randomized (3:1) 130 subjects to bimatoprost 0.03% or vehicle applied topically to upper eyelid margins for six months. All subjects used bimatoprost for a second six months.

MEASUREMENTS

Responders for the primary composite end point achieved ≥1-grade improvement in Global Eyelash Assessment score and ≥3-point improvement in Confidence, Attractiveness, and Professionalism domain score of the Eyelash Satisfaction Questionnaire at Month 4. Secondary assessments included eyelash length, thickness, and darkness, using digital image analysis.

RESULTS

The responder rate was significantly higher with bimatoprost versus vehicle at Month 4 (37.5% vs. 18.2%; p=0.041) and Month 6 (46.9% vs. 18.2%; p=0.004). Significant improvements favoring bimatoprost occurred in eyelash length (p=0.008), thickness (p<0.001), or darkness (p=0.029) at Month 4, with similar results at Month 6 (p<0.001, length; p<0.001, thickness; p=0.002, darkness). Responder rates reached 61.5 percent at Month 12 for subjects continuing bimatoprost and 67.6 percent for those switched from vehicle to bimatoprost. Conjunctival hyperemia (16.7%) and punctate keratitis (9.4%) were the most common adverse events.

CONCLUSION

Bimatoprost provides rapid eyelash recovery, whether started shortly after chemotherapy (4 to 12 weeks) or delayed for six months, with minimal adverse events.

CLINICAL TRIAL REGISTRY

NCT00907426.

[Therapeutic education of total laryngectomy patients: Influence of social factors]

Current health policies promote patient education, parti­cu­lar­ly in oncology. Therapeutic education program must be tailo­red to the characteristics, needs and expectations of the population. In the ENT Department of Head and Neck Surgery, Larrey Hospital in Toulouse, a therapeutic education program for patient with total laryngectomy has been experienced since 2011. But its propagation remains difficult. The aim of this study is to determine if social factors are nfluencing the parti­cipation of the laryngectomized population in the program. The brochure explaining this program and a registration form coupled with a survey questionnaire were distributed to the regio­nal population of patient with total laryngectomy. After two months of investigation we collected 42 responses. It is clear from their analysis that social factors underlie partici­pa­tion, particularly educational level, available financial resources level and the socio-professional group.

Split-face vitamin C consumer preference study

BACKGROUND

Vitamin C is commonly used to treat aged skin. It has shown regenerative effects on skin wrinkles, texture, strength, and evenness of tone through its roles as an antioxidant, tyrosinase inhibitor, and inducer of collagen synthesis. Available vitamin C formulations on the anti-aging skin care market vary by their pH, packaging, and vehicle, which may decrease absorption, and therefore, the efficacy of the product.

OBJECTIVE

The purpose of this study was to assess the subjective efficacy, wearability, tolerance and overall preference of two professional vitamin C topical serums and sunscreens in Caucasian females using a split face method.

METHODS

A virtual split-face study of 39 Caucasian women compared two popular vitamin C and SPF product combinations - C-ESTA® Face Serum and Marini Physical Protectant SPF 45 (Jan Marini Skin, San Jose, CA; Products A) and CE Ferulic® and Physical Fusion UV Defense SPF 50 (Products B; SkinCeuticals Inc, Garland, TX). The products were assigned to each subject's left or right side of the face, and subjects rated and compared products through 5 online surveys at baseline, 24 hours, days 3, 7, and 14.

RESULTS

Over 86% of the 35 subjects who completed the study preferred the smell and 83% preferred the feel and application of vitamin C Serum A over Serum B. Seventy-one percent of subjects preferred the feel and application of Sunscreen A over Sunscreen B. Results also showed a significant skin texture improvement and skin tone with Products A vs Product B. Products A trended higher for multiple additional categories.

CONCLUSIONS

Products A exhibited superior anti-aging benefits than Products B. Subjects preferred the smell, feel, and application of Products A and experienced significantly less irritation than Products B. Overall, Products A were preferred over Products B with subjects willing to pay more for Products A over Products B.

High-intensity focused ultrasound for the reduction of subcutaneous adipose tissue using multiple treatment techniques

BACKGROUND

High-intensity focused ultrasound (HIFU) is a noninvasive alternative to traditional invasive body sculpting procedures.

OBJECTIVE

To assess the effectiveness and tolerability of HIFU treatment using high and low fluence settings with 2 treatment techniques, grid repeat (GR) and site repeat (SR).

MATERIALS AND METHODS

Two multicenter studies were conducted. Subjects underwent 1 HIFU treatment with 1 of 5 treatment protocols (total fluence, 150-180 J/cm). Primary end point was change from baseline in waist circumference (CBWC) at 12 weeks. Secondary end points included CBWC at 4 and 8 weeks and investigator- and subject-assessed clinical improvement. Adverse events were monitored throughout the study.

RESULTS

In the intent-to-treat (ITT) population, all subjects had a statistically significant mean circumferential reduction of -2.3 ± 2.9 cm (p < .0001) from baseline at 12 weeks, with no significant differences among the 5 treatment groups (ITT: p = .153). Analysis of secondary end points in the ITT population demonstrated a significant circumferential reduction starting as early as 4 weeks in all subjects (-1.1 ± 1.9 cm, p < .0001). Most subjects in all treatment groups showed improvements at 12 weeks as rated by the investigators and subjects.

CONCLUSION

High-intensity focused ultrasound treatment using either a low or high fluence setting in a GR or SR method is effective for circumferential waist reduction, resulting in statistically significant CBWC in all treatment groups.

Telemonitoring of patients with Parkinson's disease using inertia sensors

BACKGROUND

Medical treatment in patients suffering from Parkinson's disease is very difficult as dose-finding is mainly based on selective and subjective impressions by the physician.

OBJECTIVES

To allow for the objective evaluation of patients' symptoms required for optimal dosefinding, a telemonitoring system tracks the motion of patients in their surroundings. The system focuses on providing interoperability and usability in order to ensure high acceptance.

METHODS

Patients wear inertia sensors and perform standardized motor tasks. Data are recorded, processed and then presented to the physician in a 3D animated form. In addition, the same data is rated based on the UPDRS score. Interoperability is realized by developing the system in compliance with the recommendations of the Continua Health Alliance. Detailed requirements analysis and continuous collaboration with respective user groups help to achieve high usability.

RESULTS

A sensor platform was developed that is capable of measuring acceleration and angular rate of motions as well as the absolute orientation of the device itself through an included compass sensor. The system architecture was designed and required infrastructure, and essential parts of the communication between the system components were implemented following Continua guidelines. Moreover, preliminary data analysis based on three-dimensional acceleration and angular rate data could be established.

CONCLUSION

A prototype system for the telemonitoring of Parkinson's disease patients was successfully developed. The developed sensor platform fully satisfies the needs of monitoring patients of Parkinson's disease and is comparable to other sensor platforms, although these sensor platforms have yet to be tested rigorously against each other. Suitable approaches to provide interoperability and usability were identified and realized and remain to be tested in the field.

A double-blind, randomized, multicenter, controlled trial of suspended polymethylmethacrylate microspheres for the correction of atrophic facial acne scars

BACKGROUND

Acne scarring remains a stubborn clinical problem. Few treatments have been shown to be definitely effective for this problem. Polymethylmethacrylate (PMMA) microspheres in collagen (ArteFill, Suneva Medical Inc, Santa Barbara, CA) have shown long-term benefit for nasolabial fold treatment. A pilot study has shown benefit for PMMA-collagen in atrophic acne scarring.

OBJECTIVE

We sought to demonstrate the safety and effectiveness of PMMA-collagen for acne scarring in a controlled, blinded trial.

METHODS

Subjects with at least 4 moderate to severe rolling, atrophic scars randomly received PMMA-collagen or saline injections. Subjects underwent up to 2 injection sessions and were followed up for 6 months. Efficacy was assessed using a validated rating scale for each scar.

RESULTS

In all, 147 subjects underwent injections. Success was achieved by 64% of those treated with PMMA-collagen compared with 33% of control subjects (P = .0005). The treatment showed excellent safety with generally mild, reversible adverse events. No significant differences in efficacy or safety were noted between genders, for darker skin types, or in older age groups.

LIMITATIONS

Subjects were followed up for only 6 months.

CONCLUSION

PMMA-collagen demonstrates substantial effectiveness in the treatment of atrophic acne scars of the face while maintaining an excellent safety profile. Further follow-up should be undertaken to demonstrate longer-term benefit and safety.

Molecular requirements for inhibition of the chemokine receptor CCR8--probe-dependent allosteric interactions

BACKGROUND AND PURPOSE

Here we present a novel series of CCR8 antagonists based on a naphthalene-sulfonamide structure. This structure differs from the predominant pharmacophore for most small-molecule CC-chemokine receptor antagonists, which in fact activate CCR8, suggesting that CCR8 inhibition requires alternative structural probes.

EXPERIMENTAL APPROACH

The compounds were tested as inverse agonists and as antagonists against CCL1-induced activity in Gα(i) signalling and chemotaxis. Furthermore, they were assessed by heterologous competition binding against two radiolabelled receptor ligands: the endogenous agonist CCL1 and the virus-encoded antagonist MC148.

KEY RESULTS

All compounds were highly potent inverse agonists with EC(50) values from 1.7 to 23 nM. Their potencies as antagonists were more widely spread (EC(50) values from 5.9 to 1572 nM). Some compounds were balanced antagonists/inverse agonists whereas others were predominantly inverse agonists with >100-fold lower potency as antagonists. A correspondingly broad range of affinities, which followed the antagonist potencies, was disclosed by competition with [(125)I]-CCL1 (K(i) 3.4-842 nM), whereas the affinities measured against [(125)I]-MC148 were less widely spread (K(i) 0.37-27 nM), and matched the inverse agonist potencies.

CONCLUSION AND IMPLICATIONS

Despite highly potent and direct effects as inverse agonists, competition-binding experiments against radiolabelled agonist and tests for antagonism revealed a probe-dependent allosteric effect of these compounds. Thus, minor chemical changes affected the ability to modify chemokine binding and action, and divided the compounds into two groups: predominantly inverse agonists and balanced antagonists/inverse agonists. These studies have important implications for the design of new inverse agonists with or without antagonist properties.

Current aesthetic use of abobotulinumtoxinA in clinical practice: an evidence-based consensus review

The amount and complexity of scientific and clinical evidence for aesthetic use of botulinum neurotoxin type A (BoNT-A) has expanded rapidly in recent years, especially for abobotulinumtoxinA, necessitating reassessment of current knowledge about aesthetic use of abobotulinumtoxinA and other BoNT-A preparations. A committee of 13 plastic surgeons, facial plastic surgeons, and dermatologists engaged in a live discussion of information from a systematic literature review and an Internet-based survey of their beliefs and practices. The committee achieved consensus on most issues. It was concluded that doses of different BoNT-A preparations cannot be interconverted with a fixed ratio. The size of the "field of effect" is difficult to measure, and comparisons between preparations have yielded equivocal results. Nonresponse due to neutralizing antibodies appears exceedingly rare with currently available BoNT-A preparations and of little concern clinically. BoNT-A dose, injection depth, and injection technique should be adjusted according to the anatomic area being treated and each patient's individual characteristics and goals. Aesthetic use of BoNT-A has a good safety profile. Most adverse events are minor and related to the trauma of injection, although special care is needed in certain anatomic areas. Detailed recommendations for treatment of different anatomic areas are presented. BoNT-A products are often used in conjunction with other treatment modalities (eg, fillers and resurfacing), but little agreement was reached on best practices. The findings reported in this consensus document may serve as a practical guide for aesthetic practitioners as they apply the latest knowledge about BoNT-A in providing their patients with optimal care.

Ethics in cosmetic dermatology

The dispensing of nonprescription skin products by dermatologists and the performance of ineffective cosmetic procedures are the most controversial subjects associated with the practice of cosmetic dermatology. These topics have been hotly debated within the profession for several decades, with each side presenting cogent arguments. The debate is also characterized by strong passion and emotions on both sides that are not easily reconciled. Dermatologists and their patients are best served by an objective, organized approach to clearly delineating the various aspects of these issues and providing guidelines for practitioners that can be shared with patients.

Long-term effects of a binary mixture of perfluorooctane sulfonate (PFOS) and bisphenol A (BPA) in zebrafish (Danio rerio)

Previous in vitro studies have reported the potential of perfluorooctane sulfonate (PFOS) to increase the toxicity of other compounds. Given the complex nature of mixtures of environmental pollutants in aquatic systems together with the persistent and bioaccumulative properties of PFOS, this study aimed at evaluating the long-term effects and toxicity-increasing behavior of PFOS in vivo using the zebrafish (Danio rerio). Fish were maintained in flow-through conditions and exposed to single and binary mixtures of PFOS and the endocrine disruptor bisphenol A (BPA) at nominal concentrations of 0.6, 100 and 300 μg/L and 10, 200 and 400 μg/L, respectively. F1 and F2 generations were evaluated from 0 to 180 days post-fertilization (dpf) and F3 generation was evaluated from 0 to 14 dpf. Survival was documented in all generations, whereas growth, fecundity, fertilization rate, histological alterations (in liver, thyroid and gonads) and vitellogenin (Vtg) induction in males were evaluated for F1 and F2 generations. Data for growth were collected at 30, 90 and 180 dpf and data for histological evaluations and Vtg induction were analyzed at 90 and 180 dpf. No significant effects on survival were seen in the F1 generation in any treatment following 180 d exposure; however, in the F2 generation, 300 μg/L PFOS both alone and in combination with BPA (10, 200 and 400 μg/L) induced 100% mortality within 14 dpf. PFOS (0.6 and 300 μg/L) did not increase the Vtg-inducing potential of BPA (10, 200 and 400 μg/L) in a binary mixture. In contrast, binary mixtures with 300 μg/L PFOS suppressed the Vtg levels in F1 males at 90 dpf when compared to single BPA exposures. Whereas the lowest tested PFOS concentration (0.6 μg/L) showed an estrogenic potential in terms of significant Vtg induction, Vtg levels were generally found to decrease with increasing PFOS-exposure in both F1 and F2 generations. In F1 generation, BPA-exposure was found to increase Vtg levels in a concentration-dependent manner. Histological analyses of F1 and F2 fish revealed hepatocellular vacuolization, predominantly in males, following PFOS-exposure both alone and in combination with BPA. Hepatotoxicity by PFOS might explain the suppressed Vtg response seen in PFOS-exposed F1 and F2 males. PFOS-exposed fish also showed granulomas, mainly in the liver. Given previous reports of the immunosuppressive potential of PFOS, the granulomas could be a consequence of a PFOS-induced reduction of the immune response potential. In conclusion, the hypothesis that the presence of PFOS increases the endocrine potential of BPA could not be confirmed in zebrafish. Adverse effects on liver structure and survival were only seen at concentrations well above ecologically relevant concentrations; however, the decline in survival rates following PFOS-exposure seen over generations again documents the importance of long-term studies for the investigation of persistent environmental pollutants.

A new proprietary onion extract gel improves the appearance of new scars: a randomized, controlled, blinded-investigator study

OBJECTIVE

This randomized, controlled, single-blind study evaluated the appearance of new dermal scars after eight weeks of once-daily application of a nonprescription proprietary onion extract gel formulation compared to control (no application scars) in a dermatological surgical setting.

METHODS

At Visit 1, 44 healthy male and female subjects aged 18 to 70 years gave informed consent, were screened, and enrolled in the study. Two bilateral, 8mm seborrheic keratoses, one on the right and one on the left chest, were surgically removed from each subject. The wounds were photographed at all visits. Two weeks later (Visit 2), each subject was randomly assigned to apply onion extract gel to either the right or left side wound site once daily for eight weeks and no treatment on the opposite wound. The investigator was blinded to which wound was treated. At two, four, and eight weeks after gel application, right and left scars were graded by the investigator and subjects for improvement from baseline in overall appearance, texture, redness, and softness using 4-point ordinal scales (0=no improvement, 1=mild improvement; 2= moderate improvement; 3=significant improvement). Safety was evaluated by adverse events.

RESULTS

Six subjects (13.6%) experienced mild stinging that resolved spontaneously. At two weeks, the subjects rated gel-applied scars to be significantly softer than control scars (p=0.014). After four and eight weeks of application, the investigator and subjects rated all appearance variables of the gel-applied scars to be significantly more improved from baseline than control scars (p=0.017 to p<0.01).

CONCLUSION

The new proprietary onion extract gel is safe and significantly improves scar appearance after four weeks of once-daily application.

Investigator global evaluations of efficacy of injectable poly-L-lactic acid versus human collagen in the correction of nasolabial fold wrinkles

BACKGROUND

Injectable poly-L-lactic acid (PLLA) is indicated in the United States for use in immune-competent patients for correction of shallow-to-deep nasolabial fold contour deficiencies and other facial wrinkles in which a deep dermal grid pattern injection technique is appropriate. It is also indicated for restoration and/or correction of signs of lipoatrophy in patients with human immunodeficiency virus.

OBJECTIVE

The authors examine the efficacy of injectable PLLA for correction of nasolabial fold wrinkles, based on Investigator Global Evaluations (IGE).

METHODS

A randomized, multicenter, subject-blinded, parallel-group study compared injectable PLLA versus human collagen for correction of nasolabial fold wrinkles for 13 months after up to four treatments (intent-to-treat population, 233). Injectable PLLA-treated subjects were followed up for an additional 12 months (total, 25 months) after the final treatment session. Efficacy was also assessed through secondary IGE for improvement, which is the subject of this report.

RESULTS

IGE reports of improvement were significantly greater in subjects who received injectable PLLA versus those who received human collagen (p < .001). Overall improvement with injectable PLLA was 100% three weeks after the final treatment, remaining above 85% through month 25. Overall IGE of improvement with human collagen declined from 94.0% at week three to 6.0% at month 13. Both treatment groups had similar safety profiles.

CONCLUSIONS

IGE of improvement were significantly greater with injectable PLLA treatment than with human collagen treatment at all time points following the last treatment. Injectable PLLA treatment continued to show a beneficial effect for up to 25 months.

Sodium L-ascorbyl-2-phosphate 5% lotion for the treatment of acne vulgaris: a randomized, double-blind, controlled trial

BACKGROUND

Antioxidants are becoming increasingly important in the treatment of skin disease. In addition to their known anti-inflammatory effects, antioxidants may act to prevent the oxidation of sebum which has been proposed to be comedogenic in acne patients. Sodium L-ascorbyl-2-phosphate (APS) is a stable vitamin C derivative and highly effective antioxidant that has demonstrated efficacy in acne in open label studies.

OBJECTIVE

To evaluate the efficacy and safety of APS 5% lotion for the treatment of acne in a blinded controlled study.

METHODS

A total of 50 subjects were randomized in a double-blind controlled trial to receive APS 5% lotion or vehicle for 12 weeks. Evaluation included an Investigator's Global Assessment Score, a Subjects' Global Assessment Score, lesion counts, cutaneous tolerability, and adverse events.

RESULTS

APS 5% lotion demonstrated statistically significant improvement when compared to vehicle in all of the parameters measured. The adverse event frequency and cutaneous tolerability profile for APS 5% lotion were similar to vehicle.

LIMITATIONS

Adjunctive topical or oral agents and their impact on acne were not studied in this trial.

CONCLUSIONS

This study demonstrates that 5% sodium L-ascorbyl-2-phosphate is efficacious as monotherapy for the treatment of acne. APS 5% lotion offers a novel addition to our current acne armamentarium.

Growth Kinetics of the Endosymbiont Buchnera aphidicola in the Aphid Schizaphis graminum

The aphid Schizaphis graminum is dependent on its prokaryotic endosymbiont, Buchnera aphidicola. As a means of determining B. aphidicola numbers during the growth cycle of the aphid we have used the quantitative PCR to measure the number of copies of rrs (the gene coding for 16S rRNA, which is present as one copy in the B. aphidicola genome). In addition we have measured the aphid wet weight and the DNA and protein content. The results indicate an approximately parallel (23- to 31-fold) increase of these properties during the period of aphid growth. A 1-day-old aphid (24 mug [wet weight]) has 0.2 x 10 copies of rrs, while a 9-day-old aphid (497 mug [wet weight]) has 5.6 x 10 copies. The coupling of endosymbiont and aphid growth is consistent with the requirement of the endosymbiont for growth and reproduction of the aphid.

Randomized, placebo-controlled study of a new botulinum toxin type a for treatment of glabellar lines: efficacy and safety

BACKGROUND

A new botulinum toxin type A (BoNT-A) has been assessed in the United States for treatment of glabellar lines. In April 2009, the US FDA approved the Biologics License Application for a new US formulation of BoNT-A (Dysport [abobotulinum toxin A]; Medicis Aesthetics Inc., Scottsdale, AZ).

OBJECTIVE

To compare efficacy and safety of a single treatment of BoNT-A with placebo in subjects with moderate to severe glabellar lines.

METHODS AND MATERIALS

One hundred fifty-eight subjects with moderate to severe glabellar lines were randomized 2:1 to receive 50 U of BoNT-A (n=105) or placebo (n=53). Responders were defined as having no or mild glabellar lines at 30 days posttreatment according to investigator and subject assessments (co-primary endpoint) using the validated Glabellar Line Scale Score at maximum frown. Subject diaries were used to document onset of effect. When conducting the research, the authors conformed to the ethical guidelines of the 1975 Declaration of Helsinki.

RESULTS

According to investigator assessment, the proportion of responders to BoNT-A at Day 30 was 89.5%, versus 7.5% for placebo (p<.001); according to subject assessment, the proportion of responders was 75.7%, versus 9.8% for placebo (p<.001).

CONCLUSION

A single treatment with BoNT-A (50 U) was significantly superior to placebo in the correction of moderate to severe glabellar lines, with comparable tolerability.

Dermal fillers

The new bioengineered human collagen products and the various hyaluronic acid (HA) fillers are all safe and effective agents for soft tissue augmentation. There is no one best filler for all purposes and optimal results are achieved by using these products in various combinations. In my opinion, HA-containing products provide volume while collagen products are better suited to provide structural support. Less downtime is associated with the collagen products, due to the platelet-aggregating effects of collagen and the eosinophil-stabilizing effects of lidocaine. Using collagen in combination with HA, during the same office visit, may help reduce some of the bruising and swelling seen with HA alone.

An analysis of efficacy data from four phase III studies of botulinum neurotoxin type A-ABO for the treatment of glabellar lines

BACKGROUND

A new formulation of a botulinum neurotoxin type A (BoNTA-ABO; Dysport [abobotulinumtoxinA], Medicis Aesthetics, Scottsdale, AZ) has recently been approved in the United States for the treatment of moderate to severe glabellar lines.

OBJECTIVE

We describe the results of four phase III studies of BoNTA-ABO for the treatment of glabellar lines.

METHODS

Of the four studies reported here, three were double-blind, multicenter, randomized, placebo-controlled studies and one was an open-label extension study. A second phase III, open-label extension study is ongoing. Studies enrolled ethnically diverse, healthy adults with glabellar lines of at least moderate severity at maximum frown. Patients were followed for up to 180 days after treatment. The fixed-dose, single treatment study randomized 158 patients to receive placebo or a single 50-unit BoNTA-ABO dose. The fixed-dose, repeat treatment study enrolled 311 patients to assess treatment following repeat BoNTA-ABO treatment of 50 units. A variable-dose study randomized 816 patients to receive placebo or a single variable dose (50 to 80 units, based on gender and muscle mass assessment). The fourth phase III study was open-label to evaluate repeat dosing (50 units). Clinical evaluations were performed on days 14 and 30, and monthly thereafter. Primary efficacy endpoints were based on the investigators' and patients' assessment of glabellar line severity at day 30 using wrinkle severity rating scales. Responders were defined as patients who had a composite 2+ grade improvement in wrinkle severity, meaning that a patient had a baseline Glabellar Line Severity Scale (GLSS) score of 2 (moderate glabellar lines) and a day 30 GLSS score of 0 (no glabellar lines/none), or a baseline GLSS score of 3 (severe glabellar lines) and a day 30 GLSS score of 0 (no glabellar lines/none) or 1 (mild glabellar lines), for both the blinded investigator's and patient's assessments.

RESULTS

Patients (1116 total; 720 BoNTA-ABO, 396 placebo) treated with BoNTA-ABO received 50 to 80 units. The median duration of response was 85 days for fixed dosing and 109 days for variable dosing. Similar efficacy occurred at doses adjusted for gender and muscle mass, although male patients required higher doses than female patients in the variable-dose study. Responses appeared as early as 24 hours, with a median time to onset of three days. The open-label extension study evaluated 1200 patients for 13 months. Maintenance of efficacy was seen after multiple treatment cycles, indicating that patients did not develop a tolerance. A second open-label study is ongoing and is not included in this report.

CONCLUSIONS

BoNTA-ABO significantly improved moderate to severe glabellar lines compared with placebo, with onset of effect seen as soon as 24 hours after treatment and a median duration of effect of 85 and 109 days for fixed and variable dosing, respectively.

Preliminary clinical study using a multiplex real-time PCR test for the detection of bacterial and fungal DNA directly in blood

Early diagnosis of sepsis, rapid identification of the causative pathogen(s) and prompt initiation of appropriate antibiotic treatment have a combined impact on mortality due to sepsis. In this observational study, a new DNA-based system (LightCycler SeptiFast (LC-SF) test; Roche Diagnostics) allowing detection of 16 pathogens at the species level and four groups of pathogens at the genus level has been evaluated and compared with conventional blood cultures (BCs). One hundred BC and LC-SF results were obtained for 72 patients admitted to the intensive-care unit over a 6-month period for suspected sepsis. Microbiological data were compared with other biological parameters and with clinical data. The positivity rate of BCs for bacteraemia/fungaemia was 10%, whereas the LC-SF test allowed detection of DNA in 15% of cases. The LC-SF performance, based on its clinical relevance, was as follows: sensitivity, 78%; specificity, 99%; positive predictive value, 93%; and negative predictive value, 95%. Management was changed for four of eight (50%) of the patients because organisms were detected by the LC-SF test but not by BC. LC-SF results were obtained in 7-15 h, in contrast to the 24-72 h required for BC. According to the LC-SF results, initial therapy was inadequate in eight patients, and antibiotic treatment was changed. Our results suggest that the LC-SF test may be a valuable complementary tool in the management of patients with clinically suspected sepsis.

Ethics of selling skin care

One of the most controversial topics surrounding the practice of dermatology is in-office dispensing of nonprescription skin care products by dermatologists. The controversy is not new, with legitimate arguments debated for and against it. The ongoing debate will continue, emotionally charged and with sharply demarcated battle lines, but without the promise of ever reaching a consensus. Regardless of one's position, the objective is to develop strategies to improve the practice of dermatology and the welfare of patients.

"Natural" ingredients in cosmetic dermatology

Recently, both clinical and bench research has begun to provide scientific validation for the use of certain botanical ingredients. Related findings regarding proposed biological mechanisms of action have translated into clinical practice. Botanical compounds for which dermatologic and cosmetic applications have emerged include: olive oil, chamomile, colloidal oatmeal, oat kernal extract, feverfew, acai berry, coffee berry, curcumin, green tea, pomegranate, licorice, paper mulberry, arbutin, and soy. Many of these botanical sources offer biologically active components that require further in vitro and in vivo investigation in order for us to properly educate ourselves, and our patients, regarding over-the-counter products based on these ingredients.

Antioxidants used in skin care formulations

The formation of free radicals is a widely accepted pivotal mechanism leading to skin aging. Free radicals are highly reactive molecules with unpaired electrons that can directly damage various cellular structural membranes, lipids, proteins, and DNA. The damaging effects of these reactive oxygen species are induced internally during normal metabolism and externally through various oxidative stresses. The production of free radicals increases with age, while the endogenous defense mechanisms that counter them decrease. This imbalance leads to the progressive damage of cellular structures, and thus, results in accelerated aging. Antioxidants are substances that can provide protection from endogenous and exogenous oxidative stresses by scavenging free radicals. Topical antioxidants are available in multivariate combinations through over-the-counter skin care products that are aimed at preventing the clinical signs of photoaging.