552 Benign Pilomatricoma with Osseous Metaplasia: A Rare Case

Pilomatricomas are a frequently misdiagnosed benign neoplasm of the skin derived from hair matrix cells. Pilomatricomas may undergo calcification and ossification although the latter is rare and poorly documented, with only eight cases reported since 2006. We present a case of pilomatricoma with osseous metaplasia arising from the scalp in an 87-year-old female patient. She was referred by her general practitioner via the two-week pathway, for a suspicious lesion.

On examination, there was a 2×1cm nodule, with protruding hardened yellow sebaceous material, on the right side of the patient's occipital scalp. The lump was hard, non-tender and had been present for 17 years. The surrounding area was bleeding and slightly ulcerated. A clinical diagnosis of a ruptured epidermal cyst was made, and the patient was prepared for excision under local anaesthetic.

The excised lesion of 23×18×10mm with 22×9mm of skin was sent for histology. This revealed a partially ulcerated dermal lesion composed of islands of keratin with ‘ghost cell’ outlines. Foreign body granulomas, transition to mature lamellar bone and foci of calcification were noted. There were no definite populations of basaloid cells and features of malignancy were not seen. These findings are consistent with benign pilomatricoma with osseous metaplasia. The patient was discharged 4 weeks later with satisfactory wound healing.

Differentiating this tumour from other commonly encountered benign masses remains a challenge, as seen in this case which was initially mis-diagnosed as a ruptured epidermal cyst.

Anakinra for palmoplantar pustulosis: results from a randomized, double-blind, multicentre, two-staged, adaptive placebo-controlled trial (APRICOT)

BACKGROUND

Palmoplantar pustulosis (PPP) is a rare, debilitating, chronic inflammatory skin disease that affects the hands and feet. Clinical, immunological and genetic findings suggest a pathogenic role for interleukin (IL)-1.

OBJECTIVES

To determine whether anakinra (an IL-1 receptor antagonist) delivers therapeutic benefit in PPP.

METHODS

This was a randomized (1 : 1), double-blind, two-staged, adaptive, UK multicentre, placebo-controlled trial [ISCRTN13127147 (registered 1 August 2016); EudraCT number: 2015-003600-23 (registered 1 April 2016)]. Participants had a diagnosis of PPP (> 6 months) requiring systemic therapy. Treatment was 8 weeks of anakinra or placebo via daily, self-administered subcutaneous injections. Primary outcome was the Palmoplantar Pustulosis Psoriasis Area and Severity Index (PPPASI) at 8 weeks.

RESULTS

A total of 374 patients were screened; 64 were enrolled (31 in the anakinra arm and 33 in the placebo arm) with a mean (SD) baseline PPPASI of 17·8 (10·5) and a PPP investigator's global assessment of severe (50%) or moderate (50%). The baseline adjusted mean difference in PPPASI favoured anakinra but did not demonstrate superiority in the intention-to-treat analysis [-1·65, 95% confidence interval (CI) -4·77 to 1·47; P = 0·30]. Similarly, secondary objective measures, including fresh pustule count (2·94, 95% CI -26·44 to 32·33; favouring anakinra), total pustule count (-30·08, 95% CI -83·20 to 23·05; favouring placebo) and patient-reported outcomes, did not show superiority of anakinra. When modelling the impact of adherence, the PPPASI complier average causal effect for an individual who received ≥ 90% of the total treatment (48% in the anakinra group) was -3·80 (95% CI -10·76 to 3·16; P = 0·285). No serious adverse events occurred.

CONCLUSIONS

No evidence for the superiority of anakinra was found. IL-1 blockade is not a useful intervention for the treatment of PPP.

STAT4 expression and activation is increased during mitosis in vitro and in vivo in skin- and mucosa-derived cell types: implications in neoplastic and inflammatory skin diseases

BACKGROUND

The signal transducer and activator of transcription-4 (STAT4/Stat4) is a transcription factor known to convey signals from interleukin-12, interleukin-23, and interferon-alpha/beta to the nucleus, resulting in activation of dendritic cells, T-helper cell differentiation and production of interferon-gamma.

OBJECTIVE

To demonstrate a novel role for STAT4 in cell mitosis.

RESULTS

Phosphoserine STAT4 (pSerSTAT4) is increased in cells undergoing mitosis and is distributed throughout the cytoplasm during this stage of the cell cycle, whilst phosphotyrosine STAT4 (pTyrSTAT4) is confined to the chromosomal compartment. This distinct pattern of pSerSTAT4 during mitosis is seen in vitro in human keratinocytes and in other cell types. This is also present in vivo in cells undergoing mitosis in normal skin, psoriasis and squamous cell carcinoma. Inhibition of STAT4 phosphorylation by lisofylline and depletion of STAT4 by RNA interference results in a delay in progression of mitosis and leads to a reduction in cells completing cytokinesis.

CONCLUSION

Our data demonstrate that STAT4 plays a role in enabling the normal and timely division of cells undergoing mitosis.

Using the Exos Handmaster to measure digital range of motion: reliability and validity

Traditional assessment of digital range of motion via a standard goniometer is a weak correlate of hand function and task performance. Yet it remains one of the primary, quantitative methods of hand assessment used to determine an individual's ability to return to work or to assess his or her permanent functional impairment. Another technique more representative of functional performance would be immensely useful for clinicians, patients, employers and third-party payers. The objective of this research was to investigate the clinical feasibility of using the Exos Handmaster, a Hall-effect instrumented exoskeleton, to measure angular joint rotation of the metacarpophalangeal and interphalangeal joints. The work reported in this paper includes a description of modifications to the fixation technique and calibration procedures of the Handmaster and the results of an investigation of the unit's reliability and validity.

Objective and subjective approaches to the force and displacement characteristics of input devices used by the disabled

This study was designed to determine how well therapists were able to estimate the mechanical characteristics of adapted switches. This was accomplished using two related experiments. In the first experiment, objective data characterizing the activation force-displacement trajectories for eight commonly used adapted switches were collected. In the second experiment, subjective data identifying the relative ranking of activation force as well as activation displacement by experienced and novice therapists were compiled. The major finding was that although therapists' subjective estimates of activation force and displacement were reasonably good there were specific areas of weakness that should be rectified with quantitative, objective data. In particular, subjective estimates of the mechanical properties appeared to be inadequate when used to evaluate switches separated by only small differences in force or displacement and for those whose properties were larger or smaller than their expected values. Possible difficulties in dissociating activation force and displacement were also noted. The technical and clinical implications of these results are discussed.

A human factors approach to adapted access device prescription and customization

Adapted access device prescription and customization is often a lengthy and cumbersome process. To date, few objective procedures are available to assist in the prescription process. Rather, clinician and client rely on a trial-and-error approach that is often severely constrained by the size of their adaptive device collection as well as the extent of clinical expertise. Furthermore, the large number of available options and lack of information delineating the mechanical and physical characteristics of these devices means that therapists must take time away from direct clinical contact to probe each adaptation in detail. There is available in the human factors domain a body of literature that is highly relevant to adapted access. Of particular interest are the studies that have addressed issues related to the suitability of standard and alternative input devices in terms of task productivity (via improvements in input speed, accuracy, and endurance), and their ability to minimize the risk of acute and chronic work-related dysfunction. This paper aims to consider the relevance of human factors research for physically disabled individuals. Three human factors issues--digit travel, digit loading, and device positioning--have been selected as representative of factors important in the configuration of adapted access devices.

Cognitive-behavioral stress management intervention buffers distress responses and immunologic changes following notification of HIV-1 seropositivity

Forty-seven asymptomatic, healthy gay men were randomly assigned to a cognitive-behavioral stress management (CBSM) condition or an assessment-only control group 5 weeks before being notified of their HIV-1 antibody status. Seventy-two hours before and 1 week after serostatus notification, blood samples and psychometric data were collected. Control subjects showed significant increases in depression, but only slight decrements in mitogen responsivity and lymphocyte cell counts pre- to postnotification of seropositivity. Seropositive CBSM Ss did not show significant pre-post changes in depression, but did reveal significant increases in helper-inducer (CD4) and natural killer (CD56) cell counts as well as a slight increment in proliferative responses to phytohemagglutinin (PHA). Individual difference analyses suggest that the psychological buffering and immunomodulating effects of the CBSM manipulation may be attributable, in part, to relaxation skills learned and practiced or to a general willingness to comply with the intervention guidelines.

Cognitive-behavioral stress management intervention buffers distress responses and immunologic changes following notification of HIV-1 seropositivity

Forty-seven asymptomatic, healthy gay men were randomly assigned to a cognitive-behavioral stress management (CBSM) condition or an assessment-only control group 5 weeks before being notified of their HIV-1 antibody status. Seventy-two hours before and 1 week after serostatus notification, blood samples and psychometric data were collected. Control subjects showed significant increases in depression, but only slight decrements in mitogen responsivity and lymphocyte cell counts pre- to postnotification of seropositivity. Seropositive CBSM Ss did not show significant pre-post changes in depression, but did reveal significant increases in helper-inducer (CD4) and natural killer (CD56) cell counts as well as a slight increment in proliferative responses to phytohemagglutinin (PHA). Individual difference analyses suggest that the psychological buffering and immunomodulating effects of the CBSM manipulation may be attributable, in part, to relaxation skills learned and practiced or to a general willingness to comply with the intervention guidelines.

Psychological and neuroendocrine measures related to functional immune changes in anticipation of HIV-1 serostatus notification

Our previous work indicated that gay males ultimately found to be seronegative showed impaired lymphocyte proliferative responses to phytohemagglutinin (PHA) and pokeweed mitogen (PWM) upon entering a study in which they would be notified of their human immunodeficiency virus-Type 1 (HIV-1) antibody status. To examine the degree to which alterations in various neuroendocrine and psychological markers might be related to this phenomenon we measured plasma cortisol, beta-endorphin, denial coping strategies, intrusive thoughts related to AIDS risk, and several affective distress markers in 46 HIV-1 seronegative subjects at each of the timepoints previously studied. Results indicated that cortisol levels were elevated at study entry and decreased across the subsequent five-week period--mirroring the changes in mitogen responsivity across these timepoints. Analyses of individual differences showed that higher baseline cortisol and lower denial coping scores predicted lower PHA values at baseline. Persisting intrusive thoughts about risk of HIV-1 infectivity (after seronegativity notification) were consistently associated with higher plasma cortisol levels. Finally, beta-endorphin levels did not change significantly across the 10-week observation period, were not associated with psychological variables, and were inconsistently associated with immune functioning.

[On the question of cortisol administration in adrenocortical insufficiency (author's transl)]

The question whether clinically normal adrenal cortical function can be satisfactorily checked by laboratory studies during substitution treatment with adrenocortical hormones was investigated in 39 patients with adrenal insufficiency. The routine measurement of serum cortisol levels (2 to maximally 7 hours after the morning dose of hydrocortisone or cortisone acetate) revealed marked individual variations which were relatively independent of the morning dosage. Similar extreme variations were found for free urinary corticoids in 24-hour urine. Both values could not be correlated with the clinically individualised and satisfactory long-term substitution dosage and cannot be used, therefore, in the customary manner to assess a normal hormonal state. It appears unlikely that such information can altogether be obtained from plasma levels.

Female endocrine control mechanisms during the neonatal period. 3. The effect of clomiphene citrate

The purpose of this paper is to report on the in vivo effect of different doses of cis- and trans-clomiphene on the RNA and protein synthesis in the ovary, liver, adrenal gland and uterus of newborn guinea pigs. After the sc injection of either isomer the biochemical parameters were determined at different time intervals. Both isomers induced an increase of the RNA- and protein-synthesizing activity in the uterus, but failed to do so in the ovary, liver and adrenal gland. According to data reported here and also by other investigators it may be assumed that the lack of ovarian response to the treatment with cis- or trans-clomiphene is primarily due to the functional immaturity of the female hypothalamus and/or pituitary during the neonatal period. Both isomers failed to modify the pattern of gonadotrophin release, as shown by the constancy of the ovarian RNA and protein synthesis after the administration of either of the isomers.

In the uterus, both cis- and trans-clomiphene strikingly imitated the biochemical stimulation produced by natural oestrogens. In contrast to oestradiol-17β, both clomiphene isomers showed a later onset and longer duration of the oestrogenic activity. The first increase of the amino acid incorporation into uterine proteins was noted after 5 hours in the cis-clomiphene treated group and after 8 hours in the trans-clomiphene treated animals as compared to 1 hour when oestradiol-17β was used. This difference seems to be due to a delayed transfer of the cytoplasmic oestradiol receptor to the nucleus after the injection of cis- or trans-clomiphene. As compared to oestradiol-treated animals, the clomiphene injection provoked a prolonged elevation of the uterine protein-synthesizing activity, most likely reflecting an effect of the enterohepatic recirculation of both isomers.

Studies on the anti-oestrogenic and oestrogen-like action of clomiphene citrate animal experiments

The anti-oestrogenic and oestrogen-like potencies of clomiphene citrate are presumably mainly responsible for the mode of action of this synthetic compound in different organs of the female endocrine system. The investigations described in this paper should give more informations about these properties of clomiphene. Therefore the in vivo effect of cis- or trans-clomiphene on some metabolic pathways of the uterine tissue was tested. Studying the influence of cis- or trans-clomiphene on the ³H-oestradiol uptake into uterine tissue in vivo, the cis-isomer indicated the higher anti-oestrogenic effectiveness. In contrast to this observation both isomers were able to imitate biochemical effects of natural oestrogens in the uterus, i.e. the stimulation of the protein- and RNA-synthesizing activity of this organ. These biochemical alterations however, appeared some hours later as compared with 17β-oestradiol. On the base of these results and of experimental data obtained from the literature a model for the mode of action of clomiphene in the female reproductive system is proposed.