Cutaneous Manifestations of EGFR-Inhibitors in African Americans and Treatment Considerations

Epidermal growth factor (EGFR)-inhibitors have emerged as the primary therapy in advanced solid tumor malignancies because of improvement in survival with overall favorable side effect profile. However, 50–90% of patients treated with EGFR-inhibitors develop a follicular or acneiform rash, which can be symptomatic and source of psychosocial distress, negatively impacting quality of life. As this acneiform rash is a well-recognized cutaneous toxicity of EGFR-inhibitors, a treatment algorithm has been proposed for management based on severity. However, treatment options for EGFR-inhibitor induced rash may not be generalizable to African Americans whose differences in skin biology and sensitivity present pathophysiologic challenges. Herein, we present a case of an African American patient who developed this acneiform rash while on cetuximab. We also review the few cases that have been reported in the literature of EGFR-inhibitor rash in African Americans, highlighting important management considerations in this patient population. J Drugs Dermatol. 2020;19(9):894-896. doi:10.36849/JDD.2020.5275.

Cutaneous Manifestations of EGFR-Inhibitors in African Americans and Treatment Considerations

Epidermal growth factor (EGFR)-inhibitors have emerged as the primary therapy in advanced solid tumor malignancies because of improvement in survival with overall favorable side effect profile. However, 50–90% of patients treated with EGFR-inhibitors develop a follicular or acneiform rash, which can be symptomatic and source of psychosocial distress, negatively impacting quality of life. As this acneiform rash is a well-recognized cutaneous toxicity of EGFR-inhibitors, a treatment algorithm has been proposed for management based on severity. However, treatment options for EGFR-inhibitor induced rash may not be generalizable to African Americans whose differences in skin biology and sensitivity present pathophysiologic challenges. Herein, we present a case of an African American patient who developed this acneiform rash while on cetuximab. We also review the few cases that have been reported in the literature of EGFR-inhibitor rash in African Americans, highlighting important management considerations in this patient population. J Drugs Dermatol. 2020;19(9):894-896. doi:10.36849/JDD.2020.5275.

In vitro effects of three equimolar concentrations of methylprednisolone acetate, triamcinolone acetonide, and isoflupredone acetate on equine articular tissue cocultures in an inflammatory environment

OBJECTIVE To compare the effects of 3 equimolar concentrations of methylprednisolone acetate (MPA), triamcinolone acetonide (TA), and isoflupredone acetate (IPA) on equine articular tissue cocultures in an inflammatory environment. SAMPLE Synovial and osteochondral explants from the femoropatellar joints of 6 equine cadavers (age, 2 to 11 years) without evidence of musculoskeletal disease. PROCEDURES From each cadaver, synovial and osteochondral explants were harvested from 1 femoropatellar joint to create cocultures. Cocultures were incubated for 96 hours with (positive control) or without (negative control) interleukin (IL)-1β (10 ng/mL) or with IL-1β and MPA, TA, or IPA at a concentration of 10^-4, 10^-7, or 10^-10M. Culture medium samples were collected from each coculture after 48 and 96 hours of incubation. Concentrations of prostaglandin E₂, matrix metalloproteinase-13, lactate dehydrogenase, and glycosaminoglycan were determined and compared among treatments at each time. RESULTS In general, low concentrations (10^-7 and 10^-10M) of MPA, TA, and IPA mitigated the inflammatory and catabolic (as determined by prostaglandin E₂ and matrix metalloproteinase-13 quantification, respectively) effects of IL-1β in cocultures to a greater extent than the high (10^-4M) concentration. Mean culture medium lactate dehydrogenase concentration for the 10^-4M IPA treatment was significantly greater than that for the positive control at both times, which was suggestive of cytotoxicosis. Mean culture medium glycosaminoglycan concentration did not differ significantly. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that the in vitro effects of IPA and MPA were similar to those of TA at clinically relevant concentrations (10^-7 and 10^-10M).

The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an open-label, parallel group, randomised controlled trial

BACKGROUND

To our knowledge, the comparative effectiveness of commonly used conservative treatments for carpal tunnel syndrome has not been evaluated previously in primary care. We aimed to compare the clinical and cost-effectiveness of night splints with a corticosteroid injection with regards to reducing symptoms and improving hand function in patients with mild or moderate carpal tunnel syndrome.

METHODS

We did this randomised, open-label, pragmatic trial in adults (≥18 years) with mild or moderate carpal tunnel syndrome recruited from 25 primary and community musculoskeletal clinics and services. Patients with a new episode of idiopathic mild or moderate carpal tunnel syndrome of at least 6 weeks' duration were eligible. We randomly assigned (1:1) patients (permutated blocks of two and four by site) with an online web or third party telephone service to receive either a single injection of 20 mg methylprednisolone acetate (from 40 mg/mL) or a night-resting splint to be worn for 6 weeks. Patients and clinicians could not be masked to the intervention. The primary outcome was the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. We used intention-to-treat analysis, with multiple imputation for missing data, which was concealed to treatment group allocation. The trial is registered with the European Clinical Trials Database, number 2013-001435-48, and ClinicalTrial.gov, number NCT02038452.

FINDINGS

Between April 17, 2014, and Dec 31, 2016, 234 participants were randomly assigned (118 to the night splint group and 116 to the corticosteroid injection group), of whom 212 (91%) completed the BCTQ at 6 weeks. The BCTQ score was significantly better at 6 weeks in the corticosteroid injection group (mean 2·02 [SD 0·81]) than the night splint group (2·29 [0·75]; adjusted mean difference -0·32; 95% CI -0·48 to -0·16; p=0·0001). No adverse events were reported.

INTERPRETATION

A single corticosteroid injection shows superior clinical effectiveness at 6 weeks compared with night-resting splints, making it the treatment of choice for rapid symptom response in mild or moderate carpal tunnel syndrome presenting in primary care.

FUNDING

Arthritis Research UK.

Hypothalamic Pituitary Adrenocortical Axis Suppression following a Single Epidural Injection of Methylprednisolone Acetate

BACKGROUND

Epidural injections (EIs) are the most commonly performed minimally invasive intervention in managing chronic low back pain (CLBP). There is inconsistency in data to accurately predict the degree of hypothalamic-piuitary-adrenal (HPA) axis suppression in patients receiving exogenous steroid therapy, especially in the form of epidural steroid injections (ESIs).

OBJECTIVE

We aim to quantify the degree and duration of HPA axis suppression after a single ESI of 80 mg methyl prednisolone acetate in patients with CLBP.

STUDY DESIGN

A single open-label prospective study.

SETTING

An operating room of a tertiary care hospital.

METHODS

Patients with CLBP and unilateral radicular pain were included in this study. An ESI of 80 mg of methylprednisolone acetate was administered in each patient. Blood samples for cortisol and adrenocorticotropic hormone (ACTH) were collected before the ESI and on days 7, 14, and 28 after the ESI. The patients' pain levels were graded on the numeric rating scale (NRS) at baseline and on days 7, 14, 28, and 60 after the ESI in the pain clinic.

RESULTS

A total of 30 patients were enrolled in this study. The median with interquartile range (IQR) serum cortisol level at baseline and on days 7, 14, and 28 after intervention were found to be 329.55 (208.49 - 399.48) nmol/L, 72.99 (52.95 - 119.82) nmol/L, 194.45 (73.88 - 292.52) nmol/L, and 302.56 (257.68 - 357.43) nmol/L, respectively. A significant discrease in the serum cortisol levels was observed on days 7 (P < 0.001) and 14 (P < 0.001). Twenty-six (87%), 13 (43%), and 2 (7%) patients had serum cortisol levels below normal (<170 nmol/L) on days 7, 14, and 28, respectively. HPA axis suppression was observed in all of the patients for a median (IQR) period of 14 days (range: 11-17 days).

LIMITATIONS

This study was an unblinded observational study. The effect of a single ESI was studied and the sample collection of day 21 serum cortisol and ACTH were passed over.

CONCLUSIONS

HPA axis function was suppressed after the ESI until day 14 and returned to the normal range by postoperative week 4.

KEY WORDS

Epidural injections, steroids, HPA, suppression, cortisol, ACTH.

[Bursitis after vaccination in the shoulder region]

Shoulder pain may develop after vaccination in the deltoid area due to inadvertent injection of the vaccine into the subdeltoid bursa, which may be located close to the skin. As far as we know, such vaccination reactions occur more frequently than officially registered, and doctors may not be aware of the problem. We present two of these cases of a suspected inflammatory reaction in the shoulder bursa after vaccination. Injection of cortisone in the bursa may relieve the reaction to some extent, but chronic shoulder pain may develop.

Subacromial corticosteroid injections transiently decrease suture anchor pullout strength: biomechanical studies in rats

BACKGROUND

Arthroscopic rotator cuff (RC) repair incorporates suture anchors to secure torn RC tendons to the greater tuberosity (GT) bone. RC repair strength depends on the anchor-bone interface and on the quality of the GT. We evaluated the effect of single and multiple corticosteroid injections on the pullout strength of suture anchors.

METHODS

Fifty rats were divided into those receiving saline solution injection (control group), a single methylprednisolone acetate (MTA) injection (MTA1 group), or 3 once-weekly MTA injections (MTA3 group). Rats were killed humanely at 1 or 4 weeks after the last injection. A mini-suture anchor was inserted into the humeral head through the GT. Specimens were tested biomechanically.

RESULTS

At 1 week after the last injection, the mean maximal pullout strength was significantly reduced in the MTA1 group (63.5%) and MTA3 group (56%) compared with the control group (P < .05 for both). Mean stiffness decreased significantly in both treatment groups compared with controls (P < .05). At 4 weeks after the last injection, there was a significant increase in the mean maximal pullout strength after single and triple MTA injections compared with values recorded at the 1-week time point (P < .05). At 4 weeks, the mean maximal pullout strength after a single MTA injection was 92.8% of the pullout strength measured in the control group.

CONCLUSIONS

We showed a significant detrimental effect of corticosteroid exposure on the pullout strength of a suture anchor at 1 week. However, this effect was transient and resolved within a relatively short period. These findings indicate that a waiting period is required between subacromial corticosteroid injection and RC repair surgery that involves the use of suture anchors.

Therapeutic Review of Methylprednisolone Acetate Intra-Articular Injection in the Management of Osteoarthritis of the Knee - Part 1: Clinical Effectiveness

Intra-articular (IA) corticosteroid injections are a common approach in the management of osteoarthritis (OA) of the knee. The effectiveness of injections and particular injection products is often discussed and debated in clinical arenas. The following therapeutic review examines the evidence for intra-articular methylprednisolone acetate (MPA) injections in the management of OA knee. A review of research evidence, published guidelines and clinical literature was undertaken following an electronic database and relevant literature search. The review found that there is limited evidence which indicates that a single dose intra-articular MPA injection can provide short to medium term benefits for pain, with less evidence for beneficial effects on function or stiffness. There is heterogeneity across studies and until recently, most studies had only short to medium term follow-up periods, thus limiting the evidence available on longer term benefit. There was also evidence indicating equivalent overall efficacy of MPA to that of other corticosteroid products. Most guideline recommendations concerning IA injections for OA knee have drawn on evidence from pooled data for several corticosteroid products. The review also found there was limited reporting of the incidence of adverse events in most studies. Overall, MPA shows efficacy for symptom relief in OA knee. At an individual management level, evidence for a limited duration of effect needs consideration in injections decisions. Furthermore, consensus across clinical guidelines suggests that the management of OA knee should be individualized to a person's clinical history, degree of disability, risk factors, quality of life and personal preferences, whereby injecting involves a shared decision and forms part of a multimodal approach. Copyright © 2016 John Wiley & Sons Ltd.

Interventions for treating simple bone cysts in the long bones of children

BACKGROUND

Simple bone cysts, also known as a unicameral bone cysts or solitary bone cysts, are the most common type of benign bone lesion in growing children. Cysts may lead to repeated pathological fracture (fracture that occurs in an area of bone weakened by a disease process). Occasionally, these fractures may result in symptomatic malunion. The main goals of treatment are to decrease the risk of pathological fracture, enhance cyst healing and resolve pain. Despite the numerous treatment methods that have been used for simple bone cysts in long bones of children, there is no consensus on the best procedure. This is an update of a Cochrane review first published in 2014.

OBJECTIVES

To assess the effects (benefits and harms) of interventions for treating simple bone cysts in the long bones of children, including adolescents.We intended the following main comparisons: invasive (e.g. injections, curettage, surgical fixation) versus non-invasive interventions (e.g. observation, plaster cast, restricted activity); different categories of invasive interventions (i.e. injections, curettage, drilling holes and decompression, surgical fixation and continued decompression); different variations of each category of invasive intervention (e.g. different injection substances: autologous bone marrow versus steroid).

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the China National Knowledge Infrastructure Platform, trial registers, conference proceedings and reference lists. Date of last search: April 2016.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials evaluating methods for treating simple bone cysts in the long bones of children.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results and performed study selection. We resolved differences in opinion between review authors by discussion and by consulting a third review author. Two review authors independently assessed risk of bias and data extraction. We summarised data using risk ratios (RRs) or mean differences (MDs), as appropriate, and 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the overall quality of the evidence.

MAIN RESULTS

In this update in 2017, we did not identify any new randomised controlled trials (RCT) for inclusion. We identified one ongoing trial that we are likely to include in a future update. Accordingly, our results are unchanged. The only included trial is a multicentre RCT conducted at 24 locations in North America and India that compared bone marrow injection with steroid (methylprednisolone acetate) injection for treating simple bone cysts. Up to three injections were planned for participants in each group. The trial involved 90 children (mean age 9.5 years) and presented results for 77 children at two-year follow-up. Although the trial had secure allocation concealment, it was at high risk of performance bias and from major imbalances in baseline characteristics. Reflecting these study limitations, we downgraded the quality of evidence by two levels to 'low' for most outcomes, meaning that we are unsure about the estimates of effect. For outcomes where there was serious imprecision, we downgraded the quality of evidence by a further level to 'very low'.The trial provided very low quality evidence that fewer children in the bone marrow injection group had radiographically assessed healing of bone cysts at two years than in the steroid injection group (9/39 versus 16/38; RR 0.55 favouring steroid injection, 95% CI 0.28 to 1.09). However, the result was uncertain and may be compatible with no difference or small benefit favouring bone marrow injection. Based on an illustrative success rate of 421 children with healed bone cysts per 1000 children treated with steroid injections, this equates to 189 fewer (95% CI 303 fewer to 38 more) children with healed bone cysts per 1000 children treated with bone marrow injections. There was low quality evidence of a lack of difference between the two interventions at two years in functional outcome, based on the Activity Scale for Kids function score (0 to 100; higher scores equate to better outcome: MD -0.90; 95% CI -4.26 to 2.46) or in pain assessed using the Oucher pain score. There was very low quality evidence of a lack of differences between the two interventions for adverse events: subsequent pathological fracture (9/39 versus 11/38; RR 0.80, 95% CI 0.37 to 1.70) or superficial infection (two cases in the bone marrow group). Recurrence of bone cyst, unacceptable malunion, return to normal activities, and participant satisfaction were not reported.

AUTHORS' CONCLUSIONS

The available evidence is insufficient to determine the relative effects of bone marrow versus steroid injections, although the bone marrow injections are more invasive. Noteably, the rate of radiographically assessed healing of the bone cyst at two years was well under 50% for both interventions. Overall, there is a lack of evidence to determine the best method for treating simple bone cysts in the long bones of children. Further RCTs of sufficient size and quality are needed to guide clinical practice.

In vivo feasibility of real-time MR-US fusion imaging lumbar facet joint injections

OBJECTIVES

Traditionally, facet joint injections (FJI) are performed under fluoroscopic or computed tomography (CT) guidance, mainly due to the deep anatomical location and the presence of bony landmarks. Fusion imaging technology, which couples the ultrasound scan with the corresponding CT or magnetic resonance (MR) image obtained from the diagnostic examination and reformatted in real time according to the ultrasound scanning plane, allows to combine the panoramic view and the elevated anatomical detail of MR or CT with the ease of use of ultrasound without patient exposure to ionizing radiation.

METHODS

Thirty eight patients (24 females; mean age ± SD: 64 ± 9 years) received MR fusion-assisted ultrasound-guided FJI of 1 ml of a mixture of local anaesthetic and corticosteroid using a ultrasound machine (Logiq E9, GE Healthcare) equipped with a GPS-enhanced fusion imaging technology which couples real-time B-mode images with those of the previous recent diagnostic MR examination. Low-dose CT needle positioning confirmation was performed in the first 28 patients. Patients' pain was recorded using a visual analogue scale (VAS), at baseline and at 2, 4 and 8 weeks.

RESULTS

All fusion imaging-guided injections were performed successfully. Out of 112, 96 FJI had optimal intra-articular needle positioning (accuracy: 85.7%). Patients VAS significantly decreases after the procedure with no differences among who received CT needle positioning control and who did not receive it. No major complications were observed.

CONCLUSIONS

Ultrasound needle guidance with MR fusion assistance allows for safe and effective injection of degenerative facet joint disease.

Brief Report: Synovial Fluid White Blood Cell Count in Knee Osteoarthritis: Association With Structural Findings and Treatment Response

OBJECTIVE

Osteoarthritis (OA) is a disease with a significant inflammatory component. The aim of this analysis was to determine the relationship between synovial fluid (SF) white blood cell (WBC) count and 2 parameters: disease severity and the reduction in knee pain after intraarticular (IA) steroid injection.

METHODS

Subjects with painful knee OA were recruited for participation in an open-label study of IA steroid therapy. Information was obtained about knee pain using the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire, and a proportion of subjects underwent magnetic resonance imaging (MRI). Prior to injection with 80 mg methylprednisolone acetate, the index knee joint was aspirated and the fluid obtained was forwarded for assessment of SF WBC count.

RESULTS

Information on SF WBC count was available for 55 subjects. An increase in WBC count category (≤100, 101-250, and 251-1,000 cells/mm3 ) was associated with an increase in synovial tissue volume (P = 0.028) and with other MRI-based measures of disease severity. Also, with each increase in SF WBC count category, there was a greater reduction in KOOS score after steroid injection (for WBC count of ≤100 cells/mm3 [referent], mean ± SD 12.5 ± 15.2; for WBC count of 101-250 cells/mm3 , mean ± SD 21.3 ± 20.6 [β coefficient 0.279, P = 0.049]; for WBC count of 251-1,000 cells/mm3 , mean ± SD 29.3 ± 15.2 [β coefficient 0.320, P = 0.024]).

CONCLUSION

Although all participants in the analysis had SF WBC counts within the "normal" range, total SF WBC count appears to be a biomarker for synovitis on MRI and may also predict response to antiinflammatory treatment.

Therapeutic Review of Methylprednisolone Acetate Intra-Articular Injection in the Management of Osteoarthritis of the Knee - Part 2: Clinical and Procedural Considerations

The use of an intra-articular methylprednisolone acetate (MPA) injection has been shown to have benefits for symptoms of knee osteoarthritis (OA). However, considerations beyond drug efficacy can influence the appropriateness, clinical effectiveness and potential harm of an injection. A review of research evidence and published literature on clinical and procedural factors influencing the effectiveness and safety of a knee injection has been undertaken. Factors include dose, frequency, contraindications, precautions, drug interactions, side-effects, and procedural and patient-related considerations. An evaluation of evidence indicated that a 40 mg dose provides clinical benefit. No strong predictors of response were evident, with the exception of pain severity. Additional benefit for outcomes from higher doses, local anaesthetic, ultrasound guidance or particular anatomical approaches is yet to be demonstrated. Evidence for dose- and duration-related detrimental effects suggests judicious use and frequency. The evaluation showed that there are a number of contraindications and precautions arising from the drug pharmacology, concurrent medications, comorbidities and adverse events which need consideration and monitoring. There was limited safety evidence concerning anticoagulation. The review found that specialist guidance and limited evidence suggests that injection safety concerning warfarin may be enhanced by ensuring that the international normalized ratio level is within therapeutic range. However, the risk-benefit evaluation concerning non vitamin K antagonist oral anticoagulants remains challenging. Although there is published guidance, a lack of clinical studies, safety evidence and reversibility advocates caution. Overall, the review indicates that injection decisions and procedures need an individualized approach and supporting evidence is limited in many areas. Evaluation and discussion of benefits and risks, peri-procedural and post-injection management, and tailoring to the context and individuals' preferences are important in optimizing the benefits and safety of a knee injection.

The clinical and cost effectiveness of steroid injection compared with night splints for carpal tunnel syndrome: the INSTINCTS randomised clinical trial study protocol

BACKGROUND

Patients diagnosed with idiopathic mild to moderate carpal tunnel syndrome (CTS) are usually managed in primary care and commonly treated with night splints and/or corticosteroid injection. The comparative effectiveness of these interventions has not been reliably established nor investigated in the medium and long term. The primary objective of this trial is to investigate whether corticosteroid injection is effective in reducing symptoms and improving hand function in mild to moderate CTS over 6 weeks when compared with night splints. Secondary objectives are to determine specified comparative clinical outcomes and cost effectiveness of corticosteroid injection over 6 and 24 months.

METHOD/DESIGN

A multicentre, randomised, parallel group, clinical pragmatic trial will recruit 240 adults aged ≥18 years with mild to moderate CTS from GP Practices and Primary-Secondary Care Musculoskeletal Interface Clinics. Diagnosis will be by standardised clinical assessment. Participants will be randomised on an equal basis to receive either one injection of 20 mg Depo-Medrone or a night splint to be worn for 6 weeks. The primary outcome is the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. Secondary outcomes are the BCTQ symptom severity and function status subscales, symptom intensity, interrupted sleep, adherence to splinting, perceived benefit and satisfaction with treatment, work absence and reduction in work performance, EQ-5D-5L, referral to surgery and health utilisation costs. Participants will be assessed at baseline and followed up at 6 weeks, 6, 12 and 24 months. The primary analysis will use an intention to treat (ITT) approach and multiple imputation for missing data. The sample size was calculated to detect a 15 % greater improvement in the BTCQ overall score in the injection group compared to night-splinting at approximately 90 % power, 5 % two-tailed significance and allows for 15 % loss to follow-up.

DISCUSSION

The trial makes an important contribution to the evidence base available to support effective conservative management of CTS in primary care. No previous trials have directly compared these treatments for CTS in primary care populations, reported on clinical effectiveness at more than 6 months nor compared cost effectiveness of the interventions.

TRIAL REGISTRATION

Trial registration: EudraCT 2013-001435-48 (registered 05/06/2013), ClinicalTrials.gov NCT02038452 (registered 16/1/2014), and Current Controlled Trials ISRCTN09392969 (retrospectively registered 01/05/2014).

Can subtenon methylprednisolone acetate be a choice for the acute non-arteritic ischemic optic neuropathy treatment?

Nonarteritic ischemic optic neuropathy is characterized by sudden, painless, unilateral vision loss. A case of an acute NAION patient who was treated with subtenon methyl prednisolone acetate was presented. The patient, a 65-year-old male, presented vision loss for two days. The total ophthalmologic examination, fundus photography, and automated perimetry were applied to the patient before and after 1, 3, and 6 months from injection. The visual acuity increased from 0,1 to 0,3 in the first month and to 0,7 at the last visit, the visual field defect being mostly improved. This case showed that 40 mg of subtenon methyl prednisolone acetate injection was an effective and safe treatment method for acute NAION. However, a large randomized controlled trial is needed to assess the efficacy of subtenon methyl prednisolone acetate as a treatment for NAION.

Medical treatment of horses with deep digital flexor tendon injuries diagnosed with high-field-strength magnetic resonance imaging: 118 cases (2000-2010)

OBJECTIVE

To describe the location and severity of deep digital flexor tendon (DDFT) lesions diagnosed by means of high-field-strength MRI in horses and to identify variables associated with return to activity following medical treatment.

DESIGN

Retrospective case series.

ANIMALS

118 horses.

PROCEDURES

Medical records of horses with DDFT injury diagnosed with MRI over a 10-year period (2000-2010) and treated medically (intrasynovial administration of corticosteroids and sodium hyaluronan, rest and rehabilitation, or both) were reviewed. History, signalment, use, results of lameness examination and diagnostic local anesthesia, MRI findings, and treatment details were recorded. Outcome was obtained by telephone interview or follow-up examination. Horses were grouped by predictor variables and analyzed with logistic regression to identify significant effects.

RESULTS

Overall, of 97 horses available for follow-up (median time to follow-up, 5 years; range, 1 to 12 years), 59 (61%) returned to activity for a mean duration of 22.6 months (median, 18 months; range, 3 to 72 months), with 25 (26%) still sound at follow-up. Of horses with mild, moderate, and severe injury, 21 of 29 (72%), 20 of 36 (56%), and 18 of 32 (56%), respectively, returned to use. Horses treated with intrasynovial corticosteroid injection and 6 months of rest and rehabilitation returned to use for a significantly longer duration than did horses treated without rest. Western performance horses returned to use for a significantly longer duration than did English performance horses.

CONCLUSIONS AND CLINICAL RELEVANCE

Results of the present study suggested that outcome for horses with DDFT injuries treated medically depended on injury severity, presence of concurrent injury to other structures in the foot, type of activity, and owner compliance with specific treatment recommendations. Although some horses successfully returned to prior activity, additional treatment options are needed to improve outcome in horses with severe injuries and to improve long-term prognosis.

HYADD 4 versus methylprednisolone acetate in symptomatic knee osteoarthritis: a single-centre single blind prospective randomised controlled clinical study with 1-year follow-up

OBJECTIVES

The aim of the present study was to compare the clinical results and the quality of life in patients with symptomatic knee osteoarthritis randomised to either a new HA (HYADD 4) or corticosteroid (CS). A separate rationale was to evaluate the safety profile of HYADD 4.

METHODS

All the patients presenting for unilateral symptomatic primary knee osteoarthritis were prospectively randomly assigned to receive 2 injections of either HYADD 4 or CS, and were evaluated before the injections and at 6, 12, 26 and 52 weeks. Primary end point was WOMAC score at 26 weeks; secondary end points were WOMAC score, VAS for pain, and SF-36 score at any time point.

RESULTS

There were 53 females and 22 males in the HYADD 4 group (mean age 71.5±10.6 years), and 50 females and 25 males in the CS group (mean age 68.6±9.9 years). The observed sided effects were mild and their incidence was similar in the two groups. Patients in the HYADD 4 group reported significantly better WOMAC scores at 26 weeks. The patients improved in all considered outcomes after the injections, with a peak of therapeutic effect between 6 and 12 weeks. Patients in the HYADD 4 group obtained significantly better scores than the CS group up to 26 weeks. At the 1-year follow-up no statistically significant differences between treatments were detected.

CONCLUSIONS

HYADD 4 did not have significantly higher side effects when compared to CS injections and provided better short-term (but not long-term) control of symptoms in patients with mild to moderate knee osteoarthritis. Patients with less pain and dysfunction at baseline may be the best candidates for HYADD 4 injections.

Effect of single injection of platelet-rich plasma in comparison with corticosteroid on knee osteoarthritis: a double-blind randomized clinical trial

BACKGROUND

Evidence on the effect of platelet-rich plasma (PRP) in treating osteoarthritis (OA) is insufficient. Therefore, the present study compares the effects of a one-time injection of PRP and corticosteroid (CS).

METHODS

In the present randomized double blind clinical trial, the participants who suffered from knee osteoarthritis (Grades II/III), were randomly divided into two groups: intra articular injection of PRP and CS. Knee injury and osteoarthritis outcome score (KOOS), the 20-Meter-Walk Test (20MW), active and passive ranges of motions (ROM), flexion contracture, and pain intensity based on Visual Analog Scale (VAS) were assessed before, 2-months, and 6-months after interventions.

RESULTS

Forty-one participants (48 knees) were involved in the research (66.7% women; average age of 61.1±7.0 years old). Compared to the group treated with corticosteroid, pain relief (df: 6, 35; F=11.0; P=0.007), symptom free (df:6, 35; F=23.0; P<0.001), activities of daily living (ADL) (df:6, 35; F=10.7; P=0.005) and quality of life (df:6, 35; F=5.2; P=0.02) in the RPR group were significantly higher, but sporting ability was not different between the two groups (df: 6, 35; F=0.6; P=0.55). PRP was significantly more helpful for relieving patients' pain (VAS) compared to corticosteroids (df: 6, 35; F=32.0; P=0.001). It is also notable that using PRP was more helpful in improving the 20MW test than corticosteroid treatment (df: 6, 35; F=7.4; P=0.04) but none of the treatments had any impact on active flexion ROM، passive flexion ROM and flexion contracture (P>0.05).

CONCLUSIONS

Our study demonstrated that one shot of PRP injection, decreased joint pain more and longer-term, alleviated the symptoms, and enhanced the activity of daily living and quality of life in short-term duration in comparison with CS.

Dr Michaels® product family (also branded as Soratinex®) versus Methylprednisolone aceponate - a comparative study of the effectiveness for the treatment of plaque psoriasis

As one of the most common dermatologic chronic-recurrent disease, variable therapeutic options are available today for management of psoriasis. Although topical high potency corticosteroids, alone or in association with salicylic acid or vitamin D analogues, are still considered the best treatment, they do not seem to possess the capability for a long-term control of the disease or prevent recurrences, as their side effects are major contraindications for continuative use. The aim of this study was to investigate whether Dr. Michaels® product family is comparable to methylprednisolone aceponate (MPA) as a viable alternative treatment option for the treatment and management of stable chronic plaque psoriasis. Thirty adults (13 male, 17 female, mean age 40 years) with mild to severe stable chronic plaque psoriasis, were included in the study. Patients were advised to treat the lesions of the two sides of their body (left and right) with two different unknown modalities for 8 weeks; the pack of Dr. Michaels® products on the left side (consisting of a cleansing gel, an ointment and a skin conditioner) and a placebo pack on the right side, consisting of a cleansing gel, methylprednisolone ointment and a placebo conditioner. Assessment was done using the Psoriasis Activity Severity Index (PASI) scores before treatment and after 2, 4, 6 and 8 weeks. The results achieved with the Dr. Michaels® (Soratinex®) product family for the treatment of chronic plaque psoriasis were better than the results achieved with methylprednisolone aceponate (MPA), even though quicker resolution was achieved with the steroid with 45% of patients achieving resolution within 8-10 days in comparison to 5-6 weeks in the Dr. Michaels® (Soratinex®) group. Before therapy, the mean PASI score of the LHS in Dr. Michaels® (Soratinex®) group was 13.8±4.1 SD and 14.2±4.2 SD in the RHS methylprednisolone aceponate (MPA) group. After 8 weeks of treatment 62% of the Dr. Michaels® (Soratinex®) group had achieved resolution whilst in the methylprednisolone aceponate (MPA) group, the figure remained at 45%. The mean PASI score after 8 weeks of treatment was calculated and in the LHS Dr. Michaels® (Soratinex®) group it was 2.8±1.6 SD and 6.8±2.4 SD in the RHS methylprednisolone aceponate group. In the RHS -methylprednisolone aceponate (MPA) group, 22% of patients failed to respond to the treatment in comparison to 6% in the LHS Dr. Michaels® (Soratinex®) group. Based on the results of this study, Dr. Michaels® products are a more effective treatment option, with insignificant side effects, compared to local treatment with methylprednisolone aceponate (MPA).

Interlaminar epidural steroid injections for low back pain in rural Ontario

INTRODUCTION

We sought to document the efficacy of interlaminar epidural steroid injections (ESIs) for the relief of low back pain in a rural population.

METHODS

We conducted a prospective observational cohort study with brief follow-up telephone interviews at 1, 3 and 6 months after interlaminar ESI.

RESULTS

A total of 47 ESIs were administered to the 24 participants. In an intention-to-treat analysis, pain relief was achieved in 78.7%, 55.3% and 27.7% of participants at 1, 3 and 6 months.

CONCLUSION

Interlaminar ESIs, without fluoroscopic guidance, were effective for up to 3 months of symptom relief.

Bilateral hip pain in a young man? It may be worth considering juvenile-onset ankylosing spondylitis (JAS)

A 15-year-old boy with severe bilateral hip joint pain and restriction of mobility presented to the casualty ward. He had earlier been treated for tuberculosis of the hip, with no relief. Our work up revealed a case of severe juvenile-onset ankylosing spondylitis with predominant hip involvement and accompanying sacroiliitis.

Age and Dose Are Major Risk Factors for Liver Damage Associated with Intravenous Glucocorticoid Pulse Therapy for Graves' Orbitopathy

BACKGROUND

High-dose intravenous glucocorticoid (ivGC) pulse therapy, which is commonly used for Graves' orbitopathy (GO), has been associated with acute liver damage (ALD), resulting in a fatal outcome in a few cases. No certain risk factors for ALD have been established. Consequently, a large retrospective cohort study was performed.

METHODS

The relationship between ALD and several potential risk factors was assessed in 1076 consecutive patients with GO given ivGC. ALD was defined as an increase of alanine aminotransferase ≥300 IU/L.

RESULTS

Fourteen cases of ALD were recorded, resulting in a morbidity of 1.3%. Thirteen patients recovered and one died, resulting in a mortality of 0.09%. There was a significant, positive correlation of ALD with age and methylprednisolone acetate (MPA) cumulative dose, and ALD was more common (relative risk [RR]=2.8; p=0.05) in patients aged ≥53 years (9/420; 2.14%) than in those aged <53 years (5/656; 0.76%). In patients aged ≥53 years, there was a significant positive correlation of ALD with MPA cumulative dose, and with MPA dose per infusion. Thus, the frequency of ALD in this age group was greater (RR=3.48; p=0.04) in patients with a MPA dose per infusion ≥0.7 g (5/111, 4.5% vs. 4/308, 1.29%). Regardless of age, no cases of ALD were observed for MPA doses per infusion <0.57 g.

CONCLUSIONS

Age and MPA dose are significant risk factors for ALD, with the following practical implications. First, the total MPA cumulative dose should not exceed 8.5 g (the average dose in patients without ALD). Second, in patients aged ≥53 years, selection and observation should be quite strict. However, being aged ≥53 years should not be seen as an absolute contraindication to ivGC, especially in patients with severe GO, considering that the risk of ALD, although statistically significant, was relatively low. Third, the MPA dose should not exceed 0.57 g per infusion, a measure to be applied regardless of age.

TOPICAL CORTICOSTEROIDS BUT NOT CALCINEURIN INHIBITORS INDUCED ATROPHY AFTER FOUR WEEKS

Reflectance confocal microscopy (RCM) is a non-invasive, in vivo technique for real-time imaging of the epidermis and superficial dermis at the cellular resolution. We performed a pilot study focusing on the evaluation of the effect of topical corticosteroids and calcineurin inhibitors on the epidermis of patients with atopic dermatitis (AD). The effect was assessed by RCM. A total of 45 patients with AD took part in the study. Patients were selected according to the standardized protocol and divided into two groups. Twenty-three patients used methylprednisolone aceponat topically on the skin with lesions of AD once a day for three months (group A). Twenty-one patients applied topical tacrolimus on the skin with lesions of AD twice a day for three months (B). RCM imaging was performed on the day of intiating the study (T0), then after one (T1), two (T2) and three months (T3). In group A, there was a visible decrease of the stratum corneum and the epidermis thickness which was statistically significant. In comparison, in group B, such changes were not noted and the differences between the groups in time course were statistically significant. In group A, an increase in the percentage of blurred keratinocytes in the stratum spinosum was also recorded, especially between the first (T0) and the second visit (T1). RCM is a useful method for evaluating the changes in epidermis due to the different topical treatment in patients with AD.

Effectiveness of Parasagittal Interlaminar Epidural Local Anesthetic with or without Steroid in Chronic Lumbosacral Pain: A Randomized, Double-Blind Clinical Trial

BACKGROUND

Epidural injections (EI) are the most commonly performed minimally invasive intervention to manage chronic low back pain (CLBP) with lumbosacral radicular pain (LRP). Local anesthetic (LA) and/or steroids are frequently used injectates for EI and are reported with variable effectiveness. The majority of earlier studies have used either caudal, transforaminal (TF), or undefined interlaminar approaches for EI. The parasaggital interlaminar (PIL) approach route is reported to have good ventral epidural spread and comparable effectiveness to the TF route. However, there is a lack of head-to-head comparative effectiveness research of LA with or without steroid for managing CLBP with LRP using a PIL approach.

OBJECTIVE

To compare the effectiveness of EI of LA alone and LA with steroid using a PIL approach for managing CLBP with LRP.

STUDY DESIGN

Randomized, double blind, active control one year follow-up study.

SETTING

Interventional pain management clinic in a tertiary care center in India.

METHODS

Sixty-nine patients were randomized to receive fluoroscopic guided EI of either 8 mL of 0.5% lidocaine (group L, n = 34) or 6 mL of 0.5% lidocaine mixed with 80 mg (2 mL) of methylprednisolone acetate (group LS, n = 35). Patients were evaluated for pain intensity using 0 - 10 numerical rating scale (NRS) and functional disability using Modified Oswestry Disability Questionnaire (MODQ) at baseline; and 2 weeks, one, 2, 3, 6, 9, and 12 months after injection. Patients with inefficacy with the initial injection or response deterioration received an additional injection of the same injectate and dose. Patients were evaluated for achieving effective pain relief (EPR, i.e., ≥ 50% from baseline), overall NRS and MODQ, number of injections, and presence of ventral and perineural spread over one year follow-up. Primary outcome was proportion of patients achieving EPR at 3 months.

RESULTS

A significantly higher proportion of patients achieved EPR at 3 months in group LS [30 (86%, 90% CI 73% - 93%)] as compared to group L [17 (50%, 90% CI 36% - 64%)] (P = 0.02). Similar results were obtained at 6, 9, and 12 months, respectively. The probability of achieving EPR was significantly higher in group LS at various time-points during the one year follow-up as compared to group L (P = 0.01) A significant reduction in NRS and improvement in MODQ were observed at all time-points post-intervention compared to baseline (P < 0.001) in both groups. NRS and MODQ scores were significantly lower in group LS as compared to group L at all time intervals post baseline. On average patients in group L received 2.0 (0.85) and group LS received 1.7 (0.71) injections annually (P = 0.07). Ventral epidural spread was comparable in both groups (97%). No major complications were encountered in either group; however, intravascular spread of contrast was noted during 2 injections (one in each group) requiring relocation.

LIMITATIONS

A single center study, lack of documentation of adjuvant therapies like individual analgesic medication, and lack of placebo group.

CONCLUSIONS

Using a PIL approach and the addition of steroid to LA for EI may provide superior effectiveness in terms of extent and duration of pain relief for managing CLBP with unilateral LRP, even though, local anesthetic alone also was effective.

TRIAL REGISTRATION

CTRI/2014/04/004572

Topical glucocorticoid or pimecrolimus treatment suppresses thymic stromal lymphopoietin-related allergic inflammatory mechanism in an oxazolone-induced atopic dermatitis murine model

Congenitally or early impaired skin barrier as the first event starting the 'atopic march' in atopic dermatitis (AD) patients can increase allergen penetration that results in sensitization, even in the airways, followed by asthma and allergic rhinitis. Thymic stromal lymphopoietin (TSLP) is a cytokine existing in high levels in AD skin and is considered as a novel therapeutic target for atopic disease. We generated oxazolone (Ox)-induced AD-like (Ox-AD) hairless mice and divided them into four groups according to the therapeutic challenges: topical glucocorticoid, pimecrolimus, emollient, and control (acetone-only treated). We assessed the functional studies of skin barrier, epidermal expressions of differentiation markers, IL-1α, TNF-α, proteinase-activated receptor-2 (PAR-2), TSLP and antimicrobial peptides (AMP), and serum IgE in each group. Topical glucocorticoid or pimecrolimus treatment improved AD-like skin lesions and barrier functions, and restored the epidermal expression of differentiation markers, IL-1α, TNF-α, PAR-2, and TSLP, in Ox-AD mice. The improvement was relatively better with the glucocorticoid than pimecrolimus. Epidermal AMP expression was restored by topical glucocorticoid, but not pimecrolimus. Our result showed that topical glucocorticoid or pimecrolimus improved the AD-like skin lesions and barrier impairment by suppressing TSLP-related allergic inflammation.

Intravenous glucocorticoid therapy for Graves' ophthalmopathy and acute liver damage: an epidemiological study

OBJECTIVE

Intravenous glucocorticoid (i.v.GC) pulse therapy for Graves' ophthalmopathy (GO) can be associated with acute liver damage (ALD), which was roughly estimated to occur in ∼1% of patients, with an overall mortality of 0.4%. The aim of this study was to evaluate the frequency of ALD after the introduction of a series of exclusion criteria and preventive measures.

DESIGN

Retrospective evaluation of all consecutive patients candidate to i.v.GC over a period of 5 years.

METHODS

The study includes 376 GO patients candidate to i.v.GC. Several liver tests were performed before, during, and after i.v.GC. To prevent ALD morbidity and mortality, the following measures were applied: i) exclusion of patients with active viral hepatitis and/or severe liver steatosis; ii) reduction in the GC dose, frequency, and number of pulses; and iii) administration of oral GC after i.v.GC, and also during i.v.GC in patients positive for nonorgan-specific autoantibodies (to prevent autoimmune hepatitis due to immune rebound). ALD was defined as an increase in alanine aminotransferase ≥ 300 U/l.

RESULTS

A total of 353 patients were given i.v.GC and 23 were excluded for various conditions. ALD was detected in 4/376 patients candidate to i.v.GC, resulting in a morbidity of 1.06%. One patient recovered spontaneously and three after additional treatment with oral GC, given to re-establish immune suppression in the suspect of an autoimmune hepatitis.

CONCLUSIONS

ALD related to i.v.GC is a relatively rare adverse event. Provided an accurate selection of patients and a series of preventive measures are applied, i.v.GC is a safe treatment for the liver.

Unilateral and pruritic papules: segmental Darier-White disease

Darier-White disease is an uncommon disorder, which presents in a localized pattern in about 10% of patients, usually without nail, mucosa, or acral involvement. Type-1 is the most common of the segmental Darier-White disease types: papules have unilateral distribution along Blaschko lines. A 36-year-old woman diagnosed with type-1 segmental Darier-White disease is reported herein.

Interventions for treating simple bone cysts in the long bones of children

BACKGROUND

Simple bone cysts, also known as a unicameral bone cysts or solitary bone cysts, are the most common type of benign bone lesion in growing children. Cysts may lead to repeated pathological fracture (fracture that occurs in an area of bone weakened by a disease process). Occasionally, these fractures may result in symptomatic malunion. The main goals of treatment are to decrease the risk of pathological fracture, enhance cyst healing and resolve pain. Despite the numerous treatment methods that have been used for simple bone cysts in long bones of children, there is no consensus on the best procedure.

OBJECTIVES

To assess the effects (benefits and harms) of interventions for treating simple bone cysts in the long bones of children, including adolescents.We intended the following main comparisons: invasive (e.g. injections, curettage, surgical fixation) versus non-invasive interventions (e.g. observation, plaster cast, restricted activity); different categories of invasive interventions (i.e. injections, curettage, drilling holes and decompression, surgical fixation and continued decompression); different variations of each category of invasive intervention (e.g. different injection substances: autologous bone marrow versus steroid).

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2013), the Cochrane Central Register of Controlled Trials (CENTRAL, 2013 Issue 12), MEDLINE (1946 to 12 December 2013), EMBASE (1974 to 12 December 2013) and the China National Knowledge Infrastructure Platform (31 December 2013). We also searched trial registers, conference proceedings and reference lists.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials evaluating methods for treating simple bone cysts in the long bones of children.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results and performed study selection. We resolved differences in opinion between review authors by discussion and by consulting a third review author. Two review authors independently assessed risk of bias and data extraction. We summarised data using risk ratios (RRs) or mean differences (MDs), as appropriate, and 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the overall quality of the evidence.

MAIN RESULTS

The only included trial was a multicentre randomised controlled trial (RCT) conducted at 24 locations in North America and India that compared bone marrow injection with steroid (methylprednisolone acetate) injection for treating simple bone cysts. Up to three injections were planned for participants in each group. The trial involved 90 children (mean age 9.5 years) and presented results for 77 children at two-year follow-up. Although the trial had secure allocation concealment, it was at high risk of performance bias and from major imbalances in baseline characteristics. Reflecting these study limitations, we downgraded the quality of evidence by two levels to 'low' for most outcomes, meaning that we are unsure about the estimates of effect. For outcomes where there was serious imprecision, we downgraded the quality of evidence by a further level to 'very low'.The trial provided very low quality evidence that fewer children in the bone marrow injection group had radiographically assessed healing of bone cysts at two years than in the steroid injection group (9/39 versus 16/38; RR 0.55 favouring steroid injection, 95% CI 0.28 to 1.09). However, the result was uncertain and may be compatible with no difference or small benefit favouring bone marrow injection. Based on an illustrative success rate of 421 children with healed bone cysts per 1000 children treated with steroid injections, this equates to 189 fewer (95% CI 303 fewer to 38 more) children with healed bone cysts per 1000 children treated with bone marrow injections. There was low quality evidence of a lack of difference between the two interventions at two years in functional outcome, based on the Activity Scale for Kids function score (0 to 100; higher scores equate to better outcome: MD -0.90; 95% CI -4.26 to 2.46) or in pain assessed using the Oucher pain score. There was very low quality evidence of a lack of differences between the two interventions for adverse events: subsequent pathological fracture (9/39 versus 11/38; RR 0.80, 95% CI 0.37 to 1.70) or superficial infection (two cases in the bone marrow group). Recurrence of bone cyst, unacceptable malunion, return to normal activities, and participant satisfaction were not reported.

AUTHORS' CONCLUSIONS

The available evidence is insufficient to determine the relative effects of bone marrow versus steroid injections, although the bone marrow injections are more invasive. Noteably, the rate of radiographically assessed healing of the bone cyst at two years was well under 50% for both interventions. Overall, there is a lack of evidence to determine the best method for treating simple bone cysts in the long bones of children. Further RCTs of sufficient size and quality are needed to guide clinical practice.

Transverse abdominal plane neurostimulation for chronic abdominal pain: a novel technique

Management of chronic abdominal pain can be challenging. Sometimes patients fail to get adequate response from multiple medications and nerve blocks. We present a patient case report of chronic abdominal pain with a history of multiple surgeries managed successfully by neuromodulation of the transverse abdominis plane (TAP). The TAP block is a procedure in which local anesthetic is injected into the abdominal fascial plane that carries sensory nerves to the abdominal wall in order to block pain sensation. It has been shown to reduce postoperative pain and analgesic dependence after abdominal and gynecological surgeries. A 60-year-old woman presented to us for chronic abdominal pain for which medications provided little relief. She had an extensive history of abdominal surgeries and was also treated for lower back pain with surgery and less invasive procedures in the past. Under our care, she underwent 2 TAP blocks with almost complete resolution of her abdominal pain. Her pain, however, came back within a few of weeks of the procedures. Since our patient found pain relief from the TAP blocks, we proceeded with neurostimulation of the TAP for long-term pain relief. We placed a dorsal column stimulator 16 contact lead for lower back and leg pain and 8 contact leads placed in the TAP under ultrasound guidance. She has had multiple follow-ups since her TAP lead placement procedure with continued and near complete resolution of her abdominal pain. The TAP lead stimulation was helping her abdominal pain and the dorsal column lead stimulation was helping her back and leg pain.

Cytotoxic effect of commercially available methylprednisolone acetate with and without reduced preservatives on dorsal root ganglion sensory neurons in rats

BACKGROUND

Epidural and intrathecal injections of methylprednisolone acetate (MPA) have become the most commonly performed interventional procedures in the United States and worldwide in the last 2 decades. However neuraxial MPA injection has been dogged by controversy regarding the presence of different additives used in commercially prepared glucocorticoids. We previously showed that MPA could be rendered 85% free of polyethylene glycol (PEG) by a simple physical separation of elements in the suspension.

OBJECTIVE

The objective of the present study was to explore a possible cytotoxic effect of commercially available MPA (with intact or reduced preservatives) on rat sensory neurons.

METHODS

We exposed primary dissociated rat dorsal root ganglia (DRG) sensory neurons to commercially available MPA for 24 hours with either the standard (commercial) concentration of preservatives or to different fractions following separation (MPA suspension whose preservative concentration had been reduced, or fractions containing higher concentrations of preservatives). Cells were stained with the TUNEL assay kit to detect apoptotic cells and images were taken on the Bio-Rad Laser Sharp-2000 system. We also detected expression of caspase-3, as an indicator of apoptosis in cell lysates.

RESULTS

We exposed sensory neurons from rat DRG to different concentrations of MPA from the original commercially prepared vial. TUNEL assay showed dose-related responses and increased percentages of apoptotic cells with increasing concentrations of MPA. Increased concentrations of MPA caused 1.5 - 2 times higher caspase-3 expression in DRG sensory neurons than in control cells (ANOVA, P = 0.001). Our results showed that MPA with reduced preservatives caused significantly less apoptosis observed with TUNEL assay labeling (P < 0.001) and caspase-3 immunoblotting (P = 0.001) than in neurons exposed to MPA from a commercially prepared vial or "clear phase" that contained higher concentrations of preservatives. Even though MPA with reduced preservatives caused 12.5% more apoptosis in DRG sensory neurons than in control cells, post hoc analysis showed no differences between these 2 groups.

LIMITATIONS

Our data was collected from in vitro isolated rat DRG neurons. There is a possibility that in vivo neurons have different extents of vulnerability compared to isolated neurons.

CONCLUSIONS

Results of the present study identified a cytotoxic effect of commercially available MPA with preservatives or with a "clear phase" containing higher concentrations of preservatives on primary isolated rat DRG sensory neurons. This was shown by TUNEL positive assay and by increased caspase-3 expression as one of the final executing steps in apoptotic pathways in DRG neurons. However, our results showed no statistically significant difference between the control cells (saline-treated) and cells treated with MPA with reduced concentrations of preservatives, pointing out that either PEG or myristylgamma-picolinium chloride (MGPC) or their combination have harmful effects on these cells. Reduction of concentrations of preservatives from commercially available MPA suspensions by using the simple method of inverting vials for 2 hours could be considered useful in clinical practice to enhance the safety of this depot steroid when injected neuraxially.

Phytodermatitis to Euphorbia trigona

A 56-year-old Caucasian woman presented with acute onset of dermatitis on her face accompanied by intense itching. The patient reported that the condition began after cleaning a decorative plant, Euphorbia trigona, and contact with some drops of the plant's latex sap released upon cutting its leaves. The clinical examination revealed erythema and edema of the infraorbital and perioral regions (Figure 1). The patient was in otherwise good general health, had no personal or family history of systemic or skin disease, and was not receiving any concomitant medications. Therapy with topical methylprednisolone aceponate 0.1% cream once daily was initiated and systemic desloratadine 5 mg tablets once daily was administered for the intense itch. Seven days after the introduction of the treatment a significant improvement was noticed (Figure 2). Patch testing with the leaves of the plant as well as with the latex sap was undertaken in order to prove the causative role (Figures 3 and 4). Strongly positive reactions with bulla formation were observed on day 2 and 3, most likely suggesting acute irritation instead of true delayed hypersensitivity.

[Exudative onycholysis and acute bacterial paronychia related to BIBF-1120 and paclitaxel: response to topical therapy]

A case of a 50 years-old breast cancer patient treated with weekly paclitaxel and BIBF 1120 is reported herein. At the end of the twelfth cycle of chemotherapy, the patient developed distal onycholysis with intense hyponychium serous exudates, pain and malodor in all her fingernails. It was treated with topical fusidic acid and 1% methylprednisolone aceponate two times daily, with an excellent clinical response from the first three days of treatment. Bacterial paronychia with nail plate loss of the fifth left fingernail was observed a week after the topical therapy was started, with positive cultures for Methicillin susceptible Staphylococcus aureus. There are few reported cases of exudative onycholysis associated with chemotherapy. However, these are especially related to paclitaxel. No recurrences of nail disturbances were observed weeks after the end of chemotherapy. Topical corticosteroids and fusidic acid could be considered as a therapeutic option when exudative onycholysis related to paclitaxel is established

Outcomes of greater occipital nerve injections in pediatric patients with chronic primary headache disorders

BACKGROUND

Chronic migraine is common in pediatrics and generally disabling. In adults, infiltration of the area around the greater occipital nerve can provide short- to medium-term benefit in some patients. This study reports the efficacy of greater occipital nerve infiltrations in pediatric patients with chronic primary headache disorders.

METHODS

Retrospective chart review of patients <18 years with a chronic primary headache disorder undergoing a first-time injection. Infiltrations were unilateral and consisted of a mixture of methylprednisolone acetate, adjusted for weight, and lidocaine 2%.

RESULTS

Forty-six patients were treated. Thirty-five (76%) had chronic migraine, 9 (20%) new daily persistent headache (NDPH), and 2 (4%) a chronic trigeminal autonomic cephalalgia. Medication overuse was present in 26%. Ages ranged from 7 to 17 years. Follow-up data were available for 40 (87%). Overall, 53% (21/40) benefitted, and 52% (11/21) benefitted significantly. Benefit onset ranged from 0 to 14 days, mean 4.7 (SD 4.3), with mean benefit duration of 5.4 (SD 4.9) weeks. In chronic migraine, 62% (18/29) benefitted, and 56% (10/18) significantly benefitted. In NDPH, 33% (3/9) benefitted; 33% (n = 1) significantly. Neither child with a chronic trigeminal autonomic cephalalgia benefitted. In logistic regression modeling, medication overuse, age, sex, and sensory change in the distribution of the infiltrated nerve did not predict outcome. There were no serious side effects.

CONCLUSIONS

Greater occipital nerve injections benefitted 53% of pediatric patients with chronic primary headache disorders. Efficacy appeared greater in chronic migraine than NDPH. Given the benign side effect profile, a greater occipital nerve infiltration seems appropriate before more aggressive approaches.

Carbapenem-resistant Klebsiella pneumoniae sepsis in corticosteroid receipt mice: tigecycline or colistin monotherapy versus tigecycline/colistin combination

This study compared the effect of monotherapy of colistin, tigecycline, and their combination in sepsis model of mice. OXA-48 producing Carbapenem-resistant Klebsiella pneumoniae (CRKP) strain was used in Balb/c mice. The mice were divided into competent and Methylprednisolone acetate (MPA)-treated groups. Each group was sub-divided into (1) colistin or (2) tigecycline monotherapy and (3) colistin/tigecycline combination therapy. After 3 hours of intraperitoneal bacterial inoculation, antimicrobials were administered, and mice were sacrificed at 24 and 48 hours Time-kill curve study demonstrated that colistin sulphate had early bactericidal activity following re-growth. In competent and MPA-treated groups of mice at 24 hours, bacterial counts in liver samples significantly lowered compared to control, however, there were no statistically differences between monotherapy and combination therapy subgroup. Bacterial count in lung samples of competent group was significantly lesser than control for all three antimicrobial subgroups at 24 hours Colistin plus tigecycline combination therapy was not superior against colistin or tigecycline monotherapy.

Vascular complications of fungal meningitis attributed to injections of contaminated methylprednisolone acetate

IMPORTANCE

Fungal meningitis due to injections of contaminated methylprednisolone acetate can present with vascular sequelae in immunocompetent individuals. This is particularly germane to neurologists because better recognition of the clinical characteristics of patients with fungal meningitis and ischemic stroke will provide more timely and efficient care.

OBSERVATIONS

In a case series, 3 patients presented to Vanderbilt University Medical Center in Nashville, Tennessee, with acute ischemic stroke and later received a diagnosis of fungal meningitis attributed to epidural injections of contaminated methylprednisolone. Of these 3 patients, 2 were women, and the mean age for all 3 was 75.3 years. Their medical records and imaging scans were reviewed. All 3 patients presented with acute ischemic strokes and had a history of epidural spinal injections of methylprednisolone for low back pain. All 3 patients had 1 or more traditional risk factors for stroke. There were differing vascular patterns of presentation: 2 patients presented with small-vessel (lacunar) infarctions, whereas 1 patient presented with a large-vessel infarct. Of these 3 patients, 2 died and underwent an autopsy, which revealed Exserohilum rostratum as the presumed cause of death. For 2 cases, fever and meningeal signs were absent at presentation.

CONCLUSIONS AND RELEVANCE

Patients with fungal meningitis may present with ischemic stroke detected on initial imaging scans. A definitive diagnosis should not delay early antifungal treatment.

Efficacy of a Dermoxen® lenitiva for pruritus genitalis in a randomized, double blind trial

BACKGROUND

Pruritus can be defined as an unpleasant cutaneous sensation associated with the immediate desire to scratch. In particular external intimate zone could be hit by pruritus genitalis because of several reasons (bacterial infection, fungal infection, stress, bad intimate behavior, synthetic intimate clothes).

AIM

The aim of the study was to compare the efficacy of Dermoxen® Lenitiva cream versus a methylprednisolone aceponate 0.1% based cream in treating pruritus of the external genitalia.

PATIENTS AND METHODS

Independent, randomized, double-blind, controlled trial in two University affiliated Italian Hospitals. 80 women, affected by aspecific pruritus genitalis with negative vaginal swab for bacterial or fungal infections or other pathogenic causes of itching, were selected and blindly treated by Dermoxen® Lenitiva cream or methylprednisolone aceponate 0.1% based cream. The main outcome measures were: the reduction of sensation of pruritus, evaluated by a visual analog scale (VAS) pain score, and improvement of intimate wellness sensation, and comfort during sexual intercourse, frequency and severity of adverse reactions.

RESULTS

Significant reduction of itching sensation was verified for each treatment.

CONCLUSIONS

Based on our results, DermoXen® Lenitiva vaginal cream showed efficacy so as methylprednisolone aceponate 0.1% based cream for itching treatment on external female genitalia and improved intimate comfort and comfort in sexual intercourse.

Notes from the field: Department of Defense response to a multistate outbreak of fungal meningitis--United States, October 2012

On October 1, 2012, the Department of Defense (DoD) learned of a multistate outbreak of fungal meningitis in persons who received injections of methylprednisolone acetate (MPA) from a single compounding pharmacy. Ten patients with fungal meningitis after epidural steroid injection (ESI) were initially identified in Tennessee and North Carolina. No military treatment facilities had received MPA from this pharmacy. However, clinics receiving implicated MPA lots were located throughout the United States, and active duty military service members and other DoD health-care beneficiaries could have been exposed through health-care services purchased outside of the DoD health-care system. Therefore, a timely method was needed to determine whether exposure to implicated MPA had occurred among DoD personnel who used purchased care.

Abnormal vaginal bleeding after epidural steroid injection: a paired observation cohort study

OBJECTIVE

The use of epidural steroid injections has increased dramatically, but knowledge of potential adverse effects is lacking. An association between steroid injection and subsequent abnormal vaginal bleeding has been suspected clinically, but evidence has been limited to anecdotal reports.

STUDY DESIGN

Paired observational retrospective cohort study using electronic medical records from a large integrated health care system. Participants were all nonhysterectomized women who underwent epidural steroid injections in 2011. For each steroid injection, encounters for abnormal vaginal bleeding during the 60 days preceding and 60 days after the injection were compared as paired observations. For women found to have bleeding, medical records review was performed to examine menopausal status and bleeding evaluation outcomes.

RESULTS

Among 8166 epidural steroid injection procedures performed on 6926 nonhysterectomized women, 201 (2.5%) procedures were followed by at least 1 outpatient visit for abnormal vaginal bleeding. Women were 2.8 times more likely to present with abnormal vaginal bleeding during the postinjection period compared with the preinjection period (P < .0001). Of the 197 women with postinjection bleeding, 137 (70%) were premenopausal and 60 (30%) were postmenopausal. Postinjection bleeding prompted endometrial biopsy evaluation in 103 (52%) cases, with benign findings for 100% of premenopausal women (59/59) and 95% of postmenopausal women (42/44).

CONCLUSION

Epidural steroid injections are associated with subsequent abnormal vaginal bleeding for both premenopausal and postmenopausal women. Women undergoing epidural steroid injection should be advised of abnormal bleeding as a potential adverse effect and providers should be aware of this association when evaluating abnormal bleeding.

Cotton-made cellulose support for anti-allergic pajamas

The cotton used to produce an interlock knitted fabric is alkaline boiled, bleached and after drying, it is grafted with monochlorotriazinyl-beta-cyclodextrin (MCT-β-CD) as a support of an inclusion compound (IC) with natural anti-allergic active principles, in order to improve the curative properties and the comfort. Are used: extract of Viola tricolor Herb (VtH), solution of propolis (P) and of menthol (M), as well as the pharmacologic products: advantan (AD), hydrocortisone (HYD) and pimechrolimus (PI). The dimensions of the active compound molecules were established with software. The textile material grafted with MCT-β-CD and with active principles absorbed in the cyclodextrin cavity is investigated by EDX. The anti-microbial activity of VtH, P and M was tested. Tactile determinations of softness were performed with human appraisers. By assembling the anti-allergic knitted fabric with untreated fabric, therapeutic pajamas were obtained. The manner to process and manufacture the pajamas for patients with contact and atopic (DA) dermatitis (DC) is presented.

Ultrasound Doppler score correlates with OMERACT RAMRIS bone marrow oedema and synovitis score in the wrist joint of patients with rheumatoid arthritis

PURPOSE

MRI is considered the standard of reference for advanced imaging in rheumatoid arthritis (RA). However, in daily clinical practice ultrasound (US) imaging with Doppler information is more versatile and often used for fast and dynamic assessment of joint inflammation. The aim was to compare low-field MRI scores with the US Doppler measurements in the wrist joint of patients with RA.

MATERIAL AND METHODS

Fifty consecutive patients with RA (46 women & 4 men) completed both low-field dedicated extremity MRI (E-scan®, Esaote) and a high-end US (Sequioa®, Siemens) imaging of the wrist before initiating either biological treatment (n = 26) or intraarticular injection of Depomedrole® (n = 24). Mean age was 56 years (range 21 - 83 years); mean disease duration 87.2 months (range 4 - 349 months), mean DAS 28 4,8 (range 2 - 7). MRI was scored according to the OMERACT RAMRIS recommendations and US Doppler colour-fractions were determined.

RESULTS

Using Spearman's rho, we found a relatively good to moderate correlation between the US colour-fraction and the total OMERACT bone marrow oedema and synovitis scores on MRI (r = 0.6; p < 0.001 and r = 0.4; p < 0.006 respectively). There was a trend but no significant correlation with the total OMERACT erosion score (r = 0.3; p = 0.06).

CONCLUSION

Within limits, the OMERACT RAMRIS scores of inflammation in RA patients (bone marrow oedema and synovial enhancement) are comparable to the US colour-fraction measurements using a high-end US scanner. Both imaging modalities detect inflammation although showing different aspects of the inflammatory process in the wrist joint. The higher correlation between US colour-fractions and MRI bone marrow oedema indicates a potential importance of US Doppler in monitoring inflammatory disease changes in RA.