Retinoids in the treatment of photoageing: A histological study of topical retinoid efficacy in black skin

BACKGROUND

Photoageing describes complex cutaneous changes that occur due to chronic exposure to solar ultraviolet radiation (UVR). The 'gold standard' for the treatment of photoaged white skin is all-trans retinoic acid (ATRA); however, cosmetic retinol (ROL) has also proven efficacious. Recent work has identified that black skin is susceptible to photoageing, characterized by disintegration of fibrillin-rich microfibrils (FRMs) at the dermal-epidermal junction (DEJ). However, the impact of topical retinoids for repair of black skin has not been well investigated.

OBJECTIVES

To determine the potential of retinoids to repair photoaged black skin.

METHODS

An exploratory intervention study was performed using an in vivo, short-term patch test protocol. Healthy but photoaged black volunteers (>45 years) were recruited to the study, and participant extensor forearms were occluded with either 0.025% ATRA (n = 6; 4-day application due to irritancy) or ROL (12-day treatment protocol for a cosmetic) at concentrations of 0.3% (n = 6) or 1% (n = 6). Punch biopsies from occluded but untreated control sites and retinoid-treated sites were processed for histological analyses of epidermal characteristics, melanin distribution and dermal remodelling.

RESULTS

Treatment with ATRA and ROL induced significant acanthosis (all p < 0.001) accompanied by a significant increase in keratinocyte proliferation (Ki67; all p < 0.01), dispersal of epidermal melanin and restoration of the FRMs at the DEJ (all p < 0.01), compared to untreated control.

CONCLUSIONS

This study confirms that topical ATRA has utility for the repair of photoaged black skin and that ROL induces comparable effects on epidermal and dermal remodelling, albeit over a longer timeframe. The effects of topical retinoids on black photoaged skin are similar to those reported for white photoaged skin and suggest conserved biology in relation to repair of UVR-induced damage. Further investigation of topical retinoid efficacy in daily use is warranted for black skin.

Perioperative myocardial injury is associated with increased postoperative non-cardiac complications in patients undergoing vascular surgery: a post hoc analysis of a randomised clinical pilot trial

BACKGROUND

Elevated cardiac biomarkers, such as high-sensitivity cardiac Troponin T and N-terminal pro-B-type natriuretic peptide improve the prediction of major adverse cardiac events. However, very few trials have investigated the association between perioperative cardiac injury and non-cardiac complications. The primary aim of this study was to determine the association between peri-operative myocardial injury and non-cardiac complications in patients undergoing vascular surgery. Additionally, the association between elevated pre-operative high-sensitivity cardiac Troponin T or N-terminal pro-B-type natriuretic peptide and non-cardiac complications was explored.

METHODS

This study is a post hoc analysis of a multicentre randomised controlled trial. Patients were recruited from three centres in Sweden between 2016 and 2019. Cardiac troponin level was measured pre-operatively and at 4, 24, and 48 h after the start of surgery in patients undergoing vascular surgery. N-terminal pro-B-type natriuretic peptide was measured pre-operatively. The primary outcome was a composite of major postoperative non-cardiac complications assessed at 30 days.

RESULTS

A total of 184 patients undergoing peripheral or aortic vascular surgery were included in this study. The primary endpoint occurred in 67 (36%) patients. Perioperative myocardial injury was significantly associated with non-cardiac complications, with an adjusted odds ratio (OR) of 2.71 (95% confidence interval 1.33-5.55, P = 0.01). Sensitivity and specificity were 0.40 and 0.81, respectively. No association was found between pre-operative hs-cTnT or NT-proBNP and non-cardiac complications.

CONCLUSION

In this pilot study, we found that new peri-operative myocardial injury is associated with an increased risk of non-cardiac complications within 30 days after index surgery in patients undergoing vascular surgery. Pre-operative high-sensitivity cardiac Troponin T or N-terminal pro-B-type natriuretic peptide did not appear to predict non-cardiac complications. Larger studies are needed to confirm our findings.

TRIAL REGISTRATION

EudraCT database: 2016-001584-36.

Functional neuronal circuits promote disease progression in cancer

The molecular and functional contributions of intratumoral nerves to disease remain largely unknown. We localized synaptic markers within tumors suggesting that these nerves form functional connections. Consistent with this, electrophysiological analysis shows that malignancies harbor significantly higher electrical activity than benign disease or normal tissues. We also demonstrate pharmacologic silencing of tumoral electrical activity. Tumors implanted in transgenic animals lacking nociceptor neurons show reduced electrical activity. These data suggest that intratumoral nerves remain functional at the tumor bed. Immunohistochemical staining demonstrates the presence of the neuropeptide, Substance P (SP), within the tumor space. We show that tumor cells express the SP receptor, NK1R, and that ligand/receptor engagement promotes cellular proliferation and migration. Our findings identify a mechanism whereby intratumoral nerves promote cancer progression.

Validation of medical service insurance claims as a surrogate for ascertaining vitiligo cases

The epidemiology of vitiligo, especially its disease burden on the healthcare system, can be assessed indirectly by analyzing health insurance claims data. Validating this approach is integral to ensuring accurate case identification and cohort characterization. The primary aim of this study was to develop and validate an indirect measure of vitiligo ascertainment using health insurance claims data. These data were used secondarily to identify demographic characteristics, body site involvement, vitiligo subtypes, disease associations, and treatments. This study assessed the validity of identifying vitiligo from billing claims within a Canadian provincial universal health insurance program, versus vitiligo cases accrued from direct medical chart reviews. Claims-based algorithms combining ICD-9-CM diagnostic code 709 with treatment-specific data were derived and tested to identify vitiligo patients. This was compared against cases arising from the manual review of medical records of 606 patient with a diagnostic code for "dyschromia" (ICD-9-CM diagnostic code 709) from January 1 to December 31, 2016. Based on the chart reviews, 204 (33.7%) patients were confirmed to have vitiligo. 42 separate claims-based algorithms combining ICD-9-CM diagnostic code 709 with treatment data specific to vitiligo were modeled and individually tested to evaluate their accuracy for vitiligo ascertainment. One algorithm achieved a sensitivity, specificity, PPV and NPV of 86.8% (95% CI 82.1-91.4), 92.5% (95% CI 90.0-95.1), 85.5% (95% CI 80.7-90.3), and 93.2% (95% CI 90.8-95.7), respectively. There was a 2.2 female-to-male ratio. The most common medical treatments were tacrolimus (74.5%) and topical corticosteroids (54.3%). Hypertension (24.2%) and hypothyroidism (19.6%) were the predominant co-morbidities associated with vitiligo. Health insurance claims data can be used to indirectly ascertain vitiligo for epidemiologic purposes with relatively high diagnostic performance between 85.5 and 93.2%.

Doubling down on the future of gynecologic oncology: The SGO future of the profession summit report

The original vision of the field of gynecologic oncology was to establish a multidisciplinary approach to the management of patients with gynecologic cancers. Fifty years later, scientific advances have markedly changed the overall practice of gynecologic oncology, but the profession continues to struggle to define its value-financial and otherwise. These issues were examined in full at the Society of Gynecologic Oncology (SGO) Future of the Profession Summit and the purpose of this document is to summarize the discussion, share the group's perceived strengths, weaknesses, opportunities, and threats (SWOT) for gynecologic oncologists, further educate members and others within the patient care team about the unique role of gynecologic oncologists, and plan future steps in the short- and long- term to preserve the subspecialty's critical mission of providing comprehensive, longitudinal care for people with gynecologic cancers.

Detection of atmospheric nuclear explosions: the infrasound component of the International Monitoring System

The infrasound component of the International Monitoring System (IMS') for Comprehensive Nuclear-Test-Ban Treaty verification will consist of 60 array stations distributed as uniformly as possible over the surface of the globe. This network will be far larger and more sensitive than any other previously operated infrasound network. In this paper, we discuss the design and performance characteristics of this monitoring network and the current status of the site survey and installation programs. A brief review of significant developments in infrasound monitoring technology in the last few years is also presented along with a summary of the various areas where data from this unique global network is likely to be of value to the scientific community.

Effectiveness of profile by Sanford behavioral weight loss program for weight loss following endometrial cancer treatment

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Patients lost greater body weight (15.3%) over 12 months with a behavioral weight management program vs. standard care (2.3%).

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Health coach utilization was high with patients averaging 28.3 health coaching appointments over 12 months.

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This behavioral weight management program should be evaluated for reducing risk of endometrial cancer recurrence.

Objective

To examine differences in weight change and Body Mass Index (BMI) at 12 months among women in remission from endometrial cancer who enrolled in a behavioral weight loss (BWL) program and a matched patient control group.

Methods

Women (n = 22) were enrolled into the BWL program and were compared against a control group (n = 28) that accounted for age, BMI, cancer type, cancer stage, and treatment dates. The BWL program included weekly health coaching meetings that targeted nutrition, activity, and behavior change topics.

Results

Women enrolled in the BWL program completed 28.3 ± 14.1 appointments over 12 months resulting in an average weight change of −14.2 ± 7.8 kg (−13.3 ± 7.4%) at 6 months and −16.4 ± 12.5 kg (−15.3 ± 11.4%) at 12 months (all p < 0.001). Women in the control group had a weight change of −1.7 ± 8.4 kg (−2.3 ± 7.6%) at 12 months which was significantly different than the BWL condition (p < 0.001). BMI was significantly reduced in the BWL group at 6 months (−4.8 ± 4.5, p < 0.001) and 12 months (−5.2 ± 5.9, p < 0.001) and significantly different than in the control group at 12 months (−0.9 ± 3.2, p = 0.007).

Conclusions

The BWL program yielded clinically significant weight loss for endometrial cancer survivors. Future work should include longer follow up periods and include additional behavioral and psychosocial outcomes.

Intra-Tumoral Nerve-Tracing in a Novel Syngeneic Model of High-Grade Serous Ovarian Carcinoma

Dense tumor innervation is associated with enhanced cancer progression and poor prognosis. We observed innervation in breast, prostate, pancreatic, lung, liver, ovarian, and colon cancers. Defining innervation in high-grade serous ovarian carcinoma (HGSOC) was a focus since sensory innervation was observed whereas the normal tissue contains predominantly sympathetic input. The origin, specific nerve type, and the mechanisms promoting innervation and driving nerve-cancer cell communications in ovarian cancer remain largely unknown. The technique of neuro-tracing enhances the study of tumor innervation by offering a means for identification and mapping of nerve sources that may directly and indirectly affect the tumor microenvironment. Here, we establish a murine model of HGSOC and utilize image-guided microinjections of retrograde neuro-tracer to label tumor-infiltrating peripheral neurons, mapping their source and circuitry. We show that regional sensory neurons innervate HGSOC tumors. Interestingly, the axons within the tumor trace back to local dorsal root ganglia as well as jugular-nodose ganglia. Further manipulations of these tumor projecting neurons may define the neuronal contributions in tumor growth, invasion, metastasis, and responses to therapeutics.

Rat-Bite Fever: Developing and testing a modified time-kill protocol based on Edberg and Edberg 1983 experiemnt in order to test S. moniliformis growth in 0.05% SPS and proposed growth curve

Introduction/Objective

Streptobacillus moniliformis is the primary causative agent of rat-bite fever (RBF) and Haverhill fever (HF). Rat-bite fever and Haverhill fever are difficult to diagnose in a clinical setting and are likely severely under-represented and under-reported worldwide. Clinical presentation often includes fever, chills, myalgia, headache, and vomiting. Patients may also develop a maculopapular rash covering their extremities approximately 2-4 days after onset of fever followed by polyarthritis in roughly 50% of patients with a mortality rate of 10-13% if left untreated. This is further complicated by the fact that submission and processing guidelines of clinical samples for the recovery of the organism are based on ‘outdated’ techniques and clinical laboratory methods that are over 50 years removed from current procedures, instrumentation and guidance.

Methods/Case Report

DNA from collected frozen time-point samples, were collected (n=84) and extracted using an in-house custom protocol utilizing 180 µl of bacterial lysis buffer with 20 µl of PCR grade proteinase K, for a total of 200 µl. The blood culture time-point samples were then thawed on ice, and 200 µl of blood culture sample was then added to the lysis mix, vortexed and incubated at 65°C for 10 minutes (an additional 95°C inactivation step was omitted to avoid whole blood clotting). After incubation, each sample was vortexed briefly again and extracted using the Roche automated MagNA Pure Compact instrument with an initial input volume of 400 µl and stored in a final elution buffer volume of 100 µl. All quantatitive time kill data was colleced via a CDC in-house designed PCR assay developed for S. moniliformis.

Results (if a Case Study enter NA)

Experimenting with varying amounts of blood inoculum, 10 ml of blood was determined to provide the best results for detection and growth/viability as well as propose a theoretical growth curve for the organism.

Conclusion

We found that in 100% of the isolates tested (and all the variations of testing within), SPS (up to a concentration of 0.05 % w/v) in commercially available blood culture bottles appeared to be inactivated, allowing for the growth detection and culturing of S. moniliformis using an automated continuous blood culture system when 10 ml of blood was inoculated.

Abstract 3001: Multicellular structures of serous ovarian cancer nature isolated from pleural effusions are sufficient to recreate peritoneal carcinomatosis in immunosuppressed mice

High-grade serous ovarian cancer (HGSOC) is a lethal disease often diagnosed in grade III International Federation of Gynecology and Obstetrics (FIGO) upon colonization of the peritoneal cavity, or in grade IV FIGO when it colonizes the pleural cavity. When in the pleural cavity, the disease often manifests with accumulation of pleural effusions containing multicellular structures (MCS). In this work, we studied whether MCS isolated from a pleural effusion of a patient that did not respond to chemotherapy are sufficient to cause peritoneal carcinomatosis in immunosuppressed mice when implanted orthotopically. Nude mice were injected intraperitoneally with MCS isolated from the pleural effusions of a heavily treated patient. We determined the time taken for the disease to develop, the tissues targeted, presence or absence of ascites, the macroscopic and microscopic disease appearance, and the expression of standard biomarkers of HGSOC. We contrasted the histopathology of the tumors recreated in mice against that of the original tumor taken during diagnostic surgery. MCS from pleural effusions were sufficient to recreate disease in the mice, which reached their humane-endpoint seven months following MCS injection (n=3). The animals developed abundant cellular peritoneal ascites. In addition, macro and microscopic discrete disease was observed in the fat surrounding the ovaries, the omental-pancreatic area, the peritoneal wall, a lymph node, the diaphragm, and the lung. The histopathology of the disease showed infiltrating papillary architecture, areas with cells arranged in a solid pattern, and tumor nests with slit-like lumens that stained positive for mutant p53, p16, and WT1. Our results provide proof of principle that MCS isolated from pleural effusions of a HGSOC patient are sufficient to recreate peritoneal carcinomatosis in nude mice, depicting most morphological features found at postoperative diagnosis.

Citation Format: Alicia A. Goyeneche, Ashwyna Sunassee, Sabrina J. Ritch, Michael Koch, Maria Bell, Zu-hua Gao, Carlos M. Telleria. Multicellular structures of serous ovarian cancer nature isolated from pleural effusions are sufficient to recreate peritoneal carcinomatosis in immunosuppressed mice [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 3001.

Weight management following endometrial cancer treatment: A pilot trial to evaluate the efficacy of the profile by Sanford program

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Background: Excess weight and weight gain are risk factors for endometrial cancer and cancer recurrence following treatment for women with endometrial cancer. Conversely, weight loss among women with obesity has been shown to reduce endometrial cancer risk. Intensive behavioral weight management programs may be an effective method to improve health and reduce weight following treatment. Methods: Twenty-two women following endometrial cancer treatment (age = 59.4 ± 11.5; weight = 241.3 ± 46.3; BMI = 40.5 ± 7.8; time since last treatment 19 ± 17.4 months) were enrolled in a behavioral weight management program and followed for 12 months and 28 matched controls (age = 58.4 ± 11.5; weight = 246.9 ± 60.3; BMI = 41.6 ± 8.6) were assessed over 12 months. The program consists of weekly health coaching meetings to discuss nutrition, activity, and behavior change topics. The nutrition plan targets ≥4 cups of vegetables per day, a ‘lean and green’ grocery meal, complimented with meal replacement foods to provide a nutritionally complete meal plan. Cost of participant membership, coaching, and meal replacements were covered for 6 months and available to purchase for months 7-12. Results: The treatment group completed 28.3 ± 14.1 appointments throughout 12 months resulting in an average weight change of -31.2 ± 17.3 pounds (-13.3 ± 7.4%) at 6 months and -36.1 ± 27.6 pounds (-15.3 ± 11.4%) at 12 months (all p<0.001). Controls had a weight change of -3.9 ± 18.4 pounds (-2.3 ± 7.6%) at 12 months which was significantly different than the treatment group (p<0.001). BMI was significantly reduced in the treatment group at 6 months (-4.8 ± 4.5, p<0.001) and 12 months (-5.2 ± 5.9, p<0.001) and significantly different than in the control group at 12 months (-0.9 ± 3.2, p=0.007). Conclusions: This behavioral weight management program with health coaching and structured nutrition provided clinically significant weight loss that was sustained to 12 months. Future research should examine long-term enrollment in the Profile by Sanford program with reduction in endometrial cancer recurrence.[Table: see text]

A validated photonumeric scale for infraorbital dark circles and its application in evaluating the efficacy of a cosmetic treatment product in a split-face randomized clinical trial

OBJECTIVE

As a result of their complex aetiology and periodicity, dark circles are difficult to characterize and measure, with current assessment techniques relying on specialist equipment, image analysis or proprietary grading scales. There is therefore a need to develop and validate a photonumeric scale for assessing infraorbital dark circles, which can provide an objective and consumer relevant tool for evaluating this condition and the efficacy of treatment products and procedures.

METHODS

A panel of expert clinical evaluators reviewed approximately three thousand facial photographs collected over a 5-year period and selected images representing a dynamic range of dark circles. A 10-point photonumeric scale was created, with corresponding descriptors and images for each grade of the scale. To rigorously validate the scale, linearity, sensitivity and precision were assessed by colorimetry and in-clinic evaluation. Reproducibility was assessed photographically with both experienced and inexperienced clinical evaluators, whereas intragrader repeatability was assessed live in-clinic. The scale was then employed in a split-face randomized clinical trial on 58 subjects to evaluate the efficacy of a cosmetic treatment product over 8 weeks.

RESULTS

Colour analysis of the images showed the scale was linear, with statistically significant correlations observed when colour data (CIElab; Individual Typology Angle) were plotted against the corresponding grades (r > 0.9, P < 0.001). Colour difference (Delta E) was calculated between the infraorbital zone and the surrounding skin, and when data were plotted against the grades, a statistically significant correlation was observed (r = 0.99, P < 0.01). The magnitude of the Delta E suggested that changes in grade are visibly perceptible to the human eye, and therefore, the scale is sensitive and clinically relevant. Intergrader reproducibility showed strong correlation (0.96) and >90% agreement between experienced evaluators, whereas intragrader repeatability assessment showed >90% perfect agreement between grades. Use of this scale in a clinical trial demonstrated the efficacy of a cosmetic product, with a mean statistically significant (P < 0.001) decrease in grade of 0.74 compared to baseline, and 0.59 versus the untreated control, after 8 weeks of treatment.

CONCLUSION

Our photonumeric scale for infraorbital dark circles is sensitive and robust and provides an objective and easy-to-use tool to evaluate dark circles and their treatment.

Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation

Background

Early warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death. Sometimes healthcare professionals (HCPs) do not trigger the alarm and escalate for help according to the EWS protocol and it is unclear why this is the case. The aim of this qualitative evidence synthesis was to answer the question ‘why do HCPs fail to escalate care according to EWS protocols?’ The findings will inform the update of the National Clinical Effectiveness Committee (NCEC) National Clinical Guideline No. 1 Irish National Early Warning System (INEWS).

Methods

A systematic search of the published and grey literature was conducted (until February 2018). Data extraction and quality appraisal were conducted by two reviewers independently using standardised data extraction forms and quality appraisal tools. A thematic synthesis was conducted by two reviewers of the qualitative studies included and categorised into the barriers and facilitators of escalation. GRADE CERQual was used to assess the certainty of the evidence.

Results

Eighteen studies incorporating a variety of HCPs across seven countries were included. The barriers and facilitators to the escalation of care according to EWS protocols were developed into five overarching themes: Governance, Rapid Response Team (RRT) Response, Professional Boundaries, Clinical Experience, and EWS parameters. Barriers to escalation included: Lack of Standardisation, Resources, Lack of accountability, RRT behaviours, Fear, Hierarchy, Increased Conflict, Over confidence, Lack of confidence, and Patient variability. Facilitators included: Accountability, Standardisation, Resources, RRT behaviours, Expertise, Additional support, License to escalate, Bridge across boundaries, Clinical confidence, empowerment, Clinical judgment, and a tool for detecting deterioration. These are all individual yet inter-related barriers and facilitators to escalation.

Conclusions

The findings of this qualitative evidence synthesis provide insight into the real world experience of HCPs when using EWSs. This in turn has the potential to inform policy-makers and HCPs as well as hospital management about emergency response system-related issues in practice and the changes needed to address barriers and facilitators and improve patient safety and quality of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00403-9.

ACR Appropriateness Criteria® Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD), a rare complication of pregnancy, includes both benign and malignant forms, the latter collectively referred to as gestational trophoblastic neoplasia (GTN). When metastatic, the lungs are the most common site of initial spread. Beta-human chorionic gonadotropin, elaborated to some extent by all forms of GTD, is useful in facilitating disease detection, diagnosis, monitoring treatment response, and follow-up. Imaging evaluation depends on whether GTD manifests in one of its benign forms or whether it has progressed to GTN. Transabdominal and transvaginal ultrasound with duplex Doppler evaluation of the pelvis are usually appropriate diagnostic procedures in either of these circumstances, and in posttreatment surveillance. The appropriateness of more extensive imaging remains dependent on a diagnosis of GTN and on other factors. The use of imaging to assess complications, typically hemorrhagic, should be guided by the location of clinical signs and symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The missing sink - quantification, categorisation and sourcing of beached macro-debris in the Scottish Orkney Islands

Around the coastline of the UK, macro-debris has been observed in average densities of over 700 items per metre. Systematic beach-cleans were conducted at 35 sites around the Scottish Orkney Islands, in order to quantify and categorise the level of marine debris found there. Litter was collected from 100 m transects and categorised by its material, broad source (terrestrial or marine) and potential sector source. Variation between sites, and the relative contribution of pre-determined environmental variables in influencing said variation, were analysed using the "capscale" function for a canonical analysis of principle coordinates (CAP). 513 items/m were observed, (77% plastic), with "String/cord (<1cm diameter)" being the most abundant and widely distributed litter type. 47% of macro-debris was attributed to the fishing sector and < 10% to leisure, living and tourism-associated activities. Conversely, the unique regional hydrodynamics must be examined further, before the source of any given item can be categorically assigned.

Baseline characteristics, disease severity and treatment history of patients with atopic dermatitis included in the German AD Registry TREATgermany

BACKGROUND

The Atopic Dermatitis (AD) TREATgermany registry was initiated by the German Society for Dermatology (DDG) in 2011 to evaluate the 'real-life' situation of health care for patients with AD.

OBJECTIVES

Interim data analysis on baseline characteristics as well as current and prescribed systemic treatments of the TREATgermany registry patients.

METHODS

Patients (≥18 years) with moderate-to-severe AD [objective (o)SCORAD > 20], or with current or previous anti-inflammatory systemic treatment for AD within 24 months, were included and are followed up over at least 24 months. To assess clinical signs, the eczema area severity index (EASI, 0-72), the oSCORAD (0-83) and the Investigator Global Assessment (IGA; 6-point scale) were used. The disease severity was globally scored by the patients [Patient Global Assessment (PGA); six-step Likert scale]. Disease symptoms were assessed by the patient-oriented eczema measure (POEM, 0-28) and numeric rating scales (NRS, 0-10). Health-related quality of life was measured using the dermatological life quality index (DLQI, 0-30).

RESULTS

A total of 612 patients were recruited across 32 sites between 06/2016 and 01/2019 (mean age: 42.6 ± 14.2 years; mean oSCORAD: 40.8 ± 16.3). The mean POEM score was 16.3 ± 7.5. Pruritus was rated highest among subjective symptoms (NRS: 5.4 ± 2.7). The mean DLQI value was 11.3 ± 7.5. The frequency of arterial hypertension was lower (20.8%) compared with the general population, whilst this was higher for depression (10%). More than 60% of the patients had received systemic glucocorticosteroids, and 36.8% had received cyclosporine A prior to inclusion. Dupilumab was the leading substance documented as either 'current' (12.1%) or 'prescribed' (31.4%) at baseline.

CONCLUSIONS

These 'real-life' data clearly demonstrate the substantial disease burden. Most of TREATgermany patients were already treated with or prescribed dupilumab at baseline. Moreover, current findings indicate the urgent need for further alternative agents in order to achieve a perceptible improvement of quality of life of patients with moderate-to-severe AD.

A Rare Case of Infertility: SRY Positive 46, XX Testicular Disorder of Sexual Differentiation

Aim To highlight the complexity of infertility causes by describing the rare case of a man with a testicular disorder of sexual differentiation. Diagnosis A 33 years old Caucasian male presented with a 3-year-old history of primary infertility. His investigations revealed a low testosterone and a raised LH and FSH levels. A sample sent for sperm analysis revealed azoospermia. Chromosomal analysis and karyotyping revealed a 46 XX SRY positive karyotype. Treatment The patient was initiated on testosterone replacement and on calcium/vitamin D supplements. Conclusion Fertility evaluation requires complex assessments and a broad knowledge of possible causes.

Non-use of cancer information services among people experiencing cancer in Ireland

PURPOSE

The purpose of this study was to explore the reasons for non-use of a national cancer society's cancer information services among people experiencing cancer.

METHOD

This study used a qualitative design. Semi-structured interviews were conducted with a total of 17 participants who had not previously utilised the Cancer Society's information services. Data were analysed using Thematic Analysis.

RESULTS

The key themes to emerge from the date were 'living in the here and now' and 'awareness of the Cancer Society'. For most participants, not utilising cancer information services was a means of coping with the initial diagnosis and the impact of treatment. Those who progressed to being ready to seek information identified the multi-disciplinary team as the primary source of trusted information, with particular mention of cancer nurse specialists. For participants with children, their role as a parent was central in how they managed their diagnosis. The majority of participants lacked awareness of the range of services provided by the Cancer Society.

CONCLUSIONS

Reasons for non-use of cancer information services were identified as: readiness to seek information and a lack of knowledge of the Cancer Societies' services. Cancer information services need to continue make a concerted effort to enhance visibility and awareness of its services to optimise patient engagement.

Optimal sunscreen use, during a sun holiday with a very high ultraviolet index, allows vitamin D synthesis without sunburn

Background

Sunlight contains ultraviolet (UV)A and UVB radiation. UVB is essential for vitamin D synthesis but is the main cause of sunburn and skin cancer. Sunscreen use is advocated to reduce the sun's adverse effects but may compromise vitamin D status.

Objectives

To assess the ability of two intervention sunscreens to inhibit vitamin D synthesis during a week‐long sun holiday.

Methods

The impact of sunscreens on vitamin D status was studied during a 1‐week sun holiday in Tenerife (28° N). Comparisons were made between two formulations, each with a sun protection factor (SPF) of 15. The UVA‐protection factor (PF) was low in one case and high in the other. Healthy Polish volunteers (n = 20 per group) were given the sunscreens and advised on the correct application. Comparisons were also made with discretionary sunscreen use (n = 22) and nonholiday groups (51·8° N, n = 17). Sunscreen use in the intervention groups was measured. Behaviour, UV radiation exposure, clothing cover and sunburn were monitored. Serum 25‐hydroxyvitamin D₃ [25(OH)D₃] was assessed by high‐performance liquid chromatography–tandem mass spectrometry.

Results

Use of intervention sunscreens was the same (P = 0·60), and both equally inhibited sunburn, which was present in the discretionary use group. There was an increase (P < 0·001) in mean ± SD 25(OH)D₃ (28·0 ± 16·5 nmol L⁻¹) in the discretionary use group. The high and low UVA‐PF sunscreen groups showed statistically significant increases (P < 0·001) of 19·0 ± 14·2 and 13·0 ± 11·4 nmol L⁻¹ 25(OH)D₃, respectively with P = 0·022 for difference between the intervention sunscreens. The nonholiday group showed a fall (P = 0·08) of 2·5 ± 5·6 nmol L⁻¹ 25(OH)D₃.

Conclusions

Sunscreens may be used to prevent sunburn yet allow vitamin D synthesis. A high UVA‐PF sunscreen enables significantly higher vitamin D synthesis than a low UVA‐PF sunscreen because the former, by default, transmits more UVB than the latter.

What's already known about this topic?

Action spectra (wavelength dependence) for erythema and the cutaneous formation of vitamin D overlap considerably in the ultraviolet (UV)B region.

Theoretically, sunscreens that inhibit erythema should also inhibit vitamin D synthesis.

To date, studies on the inhibitory effects of sunscreens on vitamin D synthesis have given conflicting results, possibly, in part, because people typically apply sunscreen suboptimally.

Many studies have design flaws.

What does this study add?

Sunscreens (sun protection factor, SPF 15) applied at sufficient thickness to inhibit sunburn during a week‐long holiday with a very high UV index still allow a highly significant improvement of serum 25‐hydroxyvitamin D₃ concentration.

An SPF 15 formulation with high UVA protection enables better vitamin D synthesis than a low UVA protection product. The former allows more UVB transmission.

Linked Editorial: https://doi.org/10.1111/bjd.18273.

https://doi.org/10.1111/bjd.18492 available online

https://www.bjdonline.com/article/optimal-sunscreen-use-during-a-sun-holiday-with-a-very-high-ultraviolet-index-allows-vitamin-d-synthesis-without-sunburn/

On the emerging relationship between the stratospheric Quasi-Biennial oscillation and the Madden-Julian oscillation

A strong relationship between the quasi-biennial oscillation (QBO) of equatorial stratospheric winds and the amplitude of the Madden-Julian oscillation (MJO) during the boreal winter has recently been uncovered using observational data from the mid-1970s to the present. When the QBO is in its easterly phase in the lower stratosphere, it favors stronger MJO activity during boreal winter, while the MJO tends to be weaker during the westerly phase of the QBO. Here we show using reconstructed indices of the MJO and QBO back to 1905 that the relationship between enhanced boreal winter MJO activity and the easterly phase of the QBO has only emerged since the early 1980s. The emergence of this relationship coincides with the recent cooling trend in the equatorial lower stratosphere and the warming trend in the equatorial upper troposphere, which appears to have sensitized MJO convective activity to QBO-induced changes in static stability near the tropopause. Climate change is thus suggested to have played a role in promoting coupling between the MJO and the QBO.

Sunscreen applied at ≥ 2 mg cm-2 during a sunny holiday prevents erythema, a biomarker of ultraviolet radiation-induced DNA damage and suppression of acquired immunity

BACKGROUND

Sun protection factor (SPF) is assessed with sunscreen applied at 2 mg cm^-2 . People typically apply around 0·8 mg cm^-2 and use sunscreen daily for holidays. Such use results in erythema, which is a risk factor for skin cancer.

OBJECTIVES

To determine (i) whether typical sunscreen use resulted in erythema, epidermal DNA damage and photoimmunosuppression during a sunny holiday, (ii) whether optimal sunscreen use inhibited erythema and (iii) whether erythema is a biomarker for photoimmunosuppression in a laboratory study.

METHODS

Holidaymakers (n = 22) spent a week in Tenerife (very high ultraviolet index) using their own sunscreens without instruction (typical sunscreen use). Others (n = 40) were given SPF 15 sunscreens with instructions on how to achieve the labelled SPF (sunscreen intervention). Personal ultraviolet radiation (UVR) exposure was monitored electronically as the standard erythemal dose (SED) and erythema was quantified. Epidermal cyclobutane pyrimidine dimers (CPDs) were determined by immunostaining, and immunosuppression was assessed by contact hypersensitivity (CHS) response.

RESULTS

There was no difference between personal UVR exposure in the typical sunscreen use and sunscreen intervention groups (P = 0·08). The former had daily erythema on five UVR-exposed body sites, increased CPDs (P < 0·001) and complete CHS suppression (20 of 22). In comparison, erythema was virtually absent (P < 0·001) when sunscreens were used at ≥ 2 mg cm^-2 . A laboratory study showed that 3 SED from three very different spectra suppressed CHS by around ~50%.

CONCLUSIONS

Optimal sunscreen use prevents erythema during a sunny holiday. Erythema predicts suppression of CHS (implying a shared action spectrum). Given that erythema and CPDs share action spectra, the data strongly suggest that optimal sunscreen use will also reduce CPD formation and UVR-induced immunosuppression.

An explanation for the mysterious distribution of melanin in human skin: a rare example of asymmetric (melanin) organelle distribution during mitosis of basal layer progenitor keratinocytes

BACKGROUND

Melanin is synthesized by melanocytes in the basal layer of the epidermis. When transferred to surrounding keratinocytes melanin is the key ultraviolet radiation-protective biopolymer responsible for skin pigmentation. Most melanin is observable in the proliferative basal layer of the epidermis and only sparsely distributed in the stratifying/differentiating epidermis. The latter has been explained as 'melanin degradation' in suprabasal layers.

OBJECTIVES

To re-evaluate the currently accepted basis for melanin distribution in human epidermis and to discover whether this pattern is altered after a regenerative stimulus.

METHODS

Normal epidermis of adult human skin, at rest and after tape-stripping, was analysed by a range of (immuno)histochemical and high-resolution microscopy techniques. In vitro models of melanin granule uptake by human keratinocytes were attempted.

RESULTS

We propose a different fate for melanin in the human epidermis. Our evidence indicates that the bulk of melanin is inherited only by the nondifferentiating daughter cell postmitosis in progenitor keratinocytes via asymmetric organelle inheritance. Moreover, this preferred pattern of melanin distribution can switch to a symmetric or equal daughter cell inheritance mode under conditions of stress, including regeneration.

CONCLUSIONS

In this preliminary report, we provide a plausible and histologically supported explanation for how human skin pigmentation is efficiently organized in the epidermis. Steady-state epidermis pigmentation may involve much less redox-sensitive melanogenesis than previously thought, and at least some premade melanin may be available for reuse. The epidermal melanin unit may be an excellent example with which to study organelle distribution via asymmetric or symmetric inheritance in response to microenvironment and tissue demands.

The contribution of cattle urine and dung to nitrous oxide emissions: Quantification of country specific emission factors and implications for national inventories

Urine patches and dung pats from grazing livestock create hotspots for production and emission of the greenhouse gas, nitrous oxide (N₂O), and represent a large proportion of total N₂O emissions in many national agricultural greenhouse gas inventories. As such, there is much interest in developing country specific N₂O emission factors (EFs) for excretal nitrogen (EF_3, pasture, range and paddock) deposited during gazing. The aims of this study were to generate separate N₂O emissions data for cattle derived urine and dung, to provide an evidence base for the generation of a country specific EF for the UK from this nitrogen source. The experiments were also designed to determine the effects of site and timing of application on emissions, and the efficacy of the nitrification inhibitor, dicyandiamide (DCD) on N₂O losses. This co-ordinated set of 15 plot-scale, year-long field experiments using static chambers was conducted at five grassland sites, typical of the soil and climatic zones of grazed grassland in the UK. We show that the average urine and dung N₂O EFs were 0.69% and 0.19%, respectively, resulting in a combined excretal N₂O EF (EF₃), of 0.49%, which is <25% of the IPCC default EF₃ for excretal returns from grazing cattle. Regression analysis suggests that urine N₂O EFs were controlled more by composition than was the case for dung, whilst dung N₂O EFs were more related to soil and environmental factors. The urine N₂O EF was significantly greater from the site in SW England, and significantly greater from the early grazing season urine application than later applications. Dycandiamide reduced the N₂O EF from urine patches by an average of 46%. The significantly lower excretal EF₃ than the IPCC default has implications for the UK's national inventory and for subsequent carbon footprinting of UK ruminant livestock products.

Patient reported outcome of adult perioperative anaesthesia in the United Kingdom: a cross-sectional observational study

BACKGROUND

Understanding the patient perspective on healthcare is central to the evaluation of quality. This study measured selected patient-reported outcomes after anaesthesia in order to identify targets for research and quality improvement.

METHODS

This cross-sectional observational study in UK National Health Service hospitals, recruited adults undergoing non-obstetric surgery requiring anaesthesia care over a 48 h period. Within 24 h of surgery, patients completed the Bauer questionnaire (measuring postoperative discomfort and satisfaction with anaesthesia care), and a modified Brice questionnaire to elicit symptoms suggestive of accidental awareness during general anaesthesia (AAGA). Patient, procedural and pharmacological data were recorded to enable exploration of risk factors for these poor outcomes.

RESULTS

257 hospitals in 171 NHS Trusts participated (97% of eligible organisations). Baseline characteristics were collected on 16,222 patients; 15,040 (93%) completed postoperative questionnaires. Anxiety was most frequently cited as the worst aspect of the perioperative experience. Thirty-five per cent of patients reported severe discomfort in at least one domain: thirst (18.5%; 95% CI 17.8-19.1), surgical pain (11.0%; 10.5-11.5) and drowsiness (10.1%; 9.6-10.5) were most common. Despite this, only 5% reported dissatisfaction with any aspect of anaesthesia-related care. Regional anaesthesia was associated with a reduced burden of side-effects. The incidence of reported AAGA was one in 800 general anaesthetics (0.12%)

CONCLUSIONS

Anxiety and discomfort after surgery are common; despite this, satisfaction with anaesthesia care in the UK is high. The inconsistent relationship between patient-reported outcome, patient experience and patient satisfaction supports using all three of these domains to provide a comprehensive assessment of the quality of anaesthesia care.

Vegetation dynamics associated with changes in atmospheric nitrogen deposition and climate in hardwood forests of Shenandoah and Great Smoky Mountains National Parks, USA

Ecological effects of atmospheric nitrogen (N) and sulfur (S) deposition on two hardwood forest sites in the eastern United States were simulated in the context of a changing climate using the dynamic coupled biogeochemical/ecological model chain ForSAFE-Veg. The sites are a mixed oak forest in Shenandoah National Park, Virginia (Piney River) and a mixed oak-sugar maple forest in Great Smoky Mountains National Park, Tennessee (Cosby Creek). The sites have received relatively high levels of both S and N deposition and the climate has warmed over the past half century or longer. The model was used to evaluate the composition of the understory plant communities, the alignment between plant species niche preferences and ambient conditions, and estimate changes in relative species abundances as reflected by plant cover under various scenarios of future atmospheric N and S deposition and climate change. The main driver of ecological effects was soil solution N concentration. Results of this research suggested that future climate change might compromise the capacity for the forests to sustain habitat suitability. However, vegetation results should be considered preliminary until further model validation can be performed. With expected future climate change, preliminary estimates suggest that sustained future N deposition above 7.4 and 5.0 kg N/ha/yr is expected to decrease contemporary habitat suitability for indicator plant species located at Piney River and Cosby Creek, respectively.