Τρίτη 9 Ιανουαρίου 2018
Erratum: Tinea Capitis in Children: A Report of Four Cases Trichoscopic with Trichoscopic features
Indian Journal of Paediatric Dermatology 2018 19(1):91-91
Modification of the Fitzpatrick system of skin phototype classification for the Indian population, and its correlation with narrowband diffuse reflectance spectrophotometry
Summary
Background
The Fitzpatrick classification for skin phototyping is widely used, but its usefulness in dark-skinned populations has been questioned by some researchers. Recently, skin colour measurement has been proposed for phototyping skin colour objectively.
Aims
To modify the Fitzpatrick system of skin phototyping for the Indian population and to study its correlation with skin colour using narrowband diffuse reflectance spectrophotometry
Methods
Answer choices for three items (eye colour, hair colour, colour of unexposed skin) out of 10 in the original Fitzpatrick questionnaire were modified, followed by self-administration of the original and the modified Fitzpatrick questionnaire by 70 healthy Indian volunteers. Skin colour (melanin and erythema indices) was measured from two photoexposed and two photoprotected sites using a narrowband reflectance spectrophotometer.
Results
The mean ± SD scores for the original and modified Fitzpatrick questionnaires were 25.40 ± 4.49 and 23.89 ± 4.82, respectively (r = 0.97, P < 0.001). The two items related to tanning habits were deemed irrelevant based on the subjects' response and were removed from the modified questionnaire. The Melanin Index (MI) of all sites correlated moderately well with both the modified (r = 0.61–0.64, P < 0.001) and original Fitzpatrick questionnaire scores (r = 0.64–0.67, P < 0.001), while the Erythema Index showed poor correlation with both. An MI value of ≧42 was found to be the cut-off between skin phototypes I–III and IV, and ≥ 47 between IV and V–VI.
Conclusions
Our modification of the Fitzpatrick questionnaire makes it more relevant to the Indian population. Spectrophotometry can be a useful objective tool for skin phototyping.
Dermoscopic characterization of cutaneous lymphomas: a pilot survey
Abstract
Background
While substantial dermoscopic analysis of melanocytic lesions has been performed, dermoscopic characterization of cutaneous lymphoid proliferations has been limited. Cutaneous lymphoma, particularly early mycosis fungoides (MF) and its variants, is often challenging to clinically and pathologically distinguish from inflammatory processes of the skin. This study aimed to survey the dermoscopic findings of cutaneous lymphomas and to discern whether any patterns might potentially serve as specific signatures.
Methods
Fifteen patients with an established diagnosis of cutaneous lymphoma were prospectively recruited and seen in the university multidisciplinary cutaneous lymphoma program with MF, an MF- variant, CD30-positive lymphoproliferative disorder, or cutaneous B-cell lymphomas and were included in our study. Dermoscopic findings, histologic features, clinical characteristics, and demographic data were analyzed.
Results
Patch stage MF was characterized by interconnected white structureless patches encircling small fine linear vessels, yielding an overall trabeculated to fenestrated pattern under dermoscopy. Corresponding histopathologic findings for these patterns included epidermotropism, atypical pleomorphic cells, and lichenoid infiltrates. Folliculotropic mycosis fungoides (FMF) was characterized by folliculocentric erosions surrounded by dotted and fine linear vessels, loss of terminal follicles, comedo-like openings, and interconnected regular-appearing structureless patches. Corresponding histopathologic findings in these FMF cases were typical of FMF. Notably, these changes were not appreciated in lymphomatoid papulosis. Primary cutaneous follicle center B cell lymphoma showed crystalline structures and vascular pseudopods.
Conclusions
Cutaneous lymphomas appear to demonstrate characteristic dermoscopic patterns, reflective of the specific lymphoma type and its corresponding histopathology, which have not been seen in inflammatory skin conditions, such as psoriasis and eczematous dermatitis.
The early repigmentation pattern of vitiligo is related to the source of melanocytes and by the choice of therapy: a retrospective cohort study
Abstract
Background
Patients with vitiligo present with different repigmentation patterns in the early recovery stage.
Objectives
To analyze the relationships between early repigmentation patterns in vitiliginous patches, their clinical characteristics, and therapeutic choices.
Methods
Patients with vitiligo seen in the Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University from 2010 to 2015, were included, and their clinical records, especially photographs and medical treatments, were reviewed.
Results
One hundred and sixteen patients were included in this study, and 326 lesions with different degrees of depigmentation, locations, stages, distributions, therapies, and repigmentation patterns were included and analyzed. Perifollicular repigmentation occurred more frequently in lesions with complete depigmentation (P = 0.005), in non-sun exposed areas (P < 0.001), a stable stage (P = 0.008), and lesions treated with narrow band ultraviolet B (NB-UVB) (P < 0.001, despite lesion distributions). Marginal repigmentation is more frequent in lesions with complete depigmentation (P = 0.016), lesions treated without NB-UVB (P = 0.002), and facial lesions treated with topical vitamin D analogs (TVDAs) monotherapy (P = 0.022). Diffuse repigmentation is the predominant pattern in lesions with incomplete depigmentation (P < 0.001), in sun-exposed areas (P < 0.001), progressive stage (P = 0.044), and truncal lesions treated with TVDAs (P < 0.001).
Conclusions
The different repigmentation patterns of vitiligo lesions depend on the different source and status of melanocytes and their abilities to produce melanin on the choice of therapy.
Efficacy and safety of noncultured melanocyte-keratinocyte transplant procedure for vitiligo and other leukodermas: a critical analysis of the evidence
Abstract
Vitiligo is an acquired pigmentary skin of depigmentation occurring secondary to melanocyte destruction. Vitiligo and other leukodermas have a profound impact on quality of life. Current therapies include medical options, such as phototherapy, topical and systemic corticosteroids, topical calcineurin inhibitors, immunomodulators, and antioxidiants, and surgical options. Surgical options provide melanocytic cells to previously depigmented areas and use either tissue grafting or cellular grafting methods. Topical treatments are often insufficient, and many of the current surgical procedures have shown variable response rates. In this review, we discuss the process of the cellular grafting melanocyte-keratinocyte transplantation procedure (MKTP) and critically analyze its efficacy and safety in the treatment of vitiligo and other leukodermas. PubMed was searched for studies (2001–2017) describing the use of MKTP in patients with vitiligo or other leukodermas. Articles or trials discussing the use of MKTP for these patients were selected for in-depth review. Clinically relevant results regarding efficacy and safety of MKTP in vitiligo and leukoderma patients were analyzed. Numerous trials and case series/reports have demonstrated tolerability and efficacy of MKTP with repigmentation for patients with refractory, stable vitiligo. However, the response rates have been variable, likely influenced by vitiligo type and affected areas. Future research and clinical reporting will provide more insight on which phenotypes may benefit from MKTP.
Hypopigmented mycosis fungoides: a 20-case retrospective series
Abstract
Background
Hypopigmented mycosis fungoides (hMF) is a rare subtype of mycosis fungoides. The aim of this study was to identify the clinical–epidemiological profile of our patient group and also to provide additional information about treatment responses and prognosis.
Methods
This is a cross-sectional retrospective observational study, with exploratory analysis. The outcome variables were disease progression and related death.
Results
Twenty patients with hMF were selected from a group of 102 patients diagnosed with MF. There was no gender difference (10 females and 10 males). Mean age at diagnosis was 43.85 years, and most patients had mixed or black skin color. The mean time between the onset of the lesions and the diagnosis was 66.75 months. Patients were equally distributed in stages IA (50%) and IB (50%). Photochemotherapy (psoralen and ultraviolet A) was the predominant therapeutic modality. The mean follow-up time was 7.25 years. In 10%, disease progression was observed. Death related to the disease occurred in one patient.
Conclusions
The clinical and epidemiological profile of patients with hypopigmented MF found in our sample is in agreement with what is described in the literature, with the exception of the age at diagnosis, higher than expected. Diagnostic delay time, despite long, is also consistent with the medical literature; however, in this sample, we had two cases of disease progression, with death of one patient, despite the treatment, which is extremely important since hypopigmented MF is usually associated with good prognosis.
Evaluation of ICAM-1 expression and vascular changes in the skin of patients with plaque, pustular, and erythrodermic psoriasis
Abstract
Background
Psoriasis is a chronic inflammatory disease. Pustular, erythrodermic, and extensive plaque psoriasis are responsible for systemic complications. Systemic capillary leak syndrome is the complication with greater progression to death and occurs due to vascular changes.
Purpose
The aim of this study was to evaluate vascular changes through the expression of CD34 and ICAM-1 in plaque, pustular, and erythrodermic psoriasis.
Methods
The sample consisted of seven patients with erythrodermic psoriasis, 24 with moderate-severe plaque psoriasis, 14 with mild plaque psoriasis and 13 with pustular psoriasis. Patients were submitted to physical examination and skin biopsy for histopathological examination and immunohistochemical analysis with anti-CD34 and anti-ICAM-1 antibodies. Subsequently, tissue fragments were organized by groups using the Tissue Macroarray (TMA) technique to perform immunohistochemistry.
Results
In 58 patients, analysis of vessels using anti-CD34 demonstrated vascular immunostaining in superficial dermis and between dermal papillae. There were more blood vessels in erythrodermic psoriasis, followed by plaque psoriasis. In erythrodermic psoriasis, there were small and few tortuous blood vessels with great dilatation, while plaque psoriasis presented larger vessels that were less dilated and more tortuous. There was an intense and localized expression of ICAM-1 in endothelial and lymphocytic cells in all groups, with significant differences.
Conclusions
Vascular alterations are important in psoriasis, with an increase in the number of blood vessels and ICAM-1 overexpression, especially in erythrodermic form. Therefore, vascular changes and the expression of intercellular adhesion molecules could help to diagnose the erythrodermic form of psoriasis.
Clinico-etiologic profile of hand dermatitis and patch response of patients at a tertiary hospital in Lagos, Nigeria: results of a prospective observational study
Abstract
Background
Hand dermatitis is an acute or chronic inflammation of the skin of the hands from a multifactorial cause which may be endogenous, exogenous, or a combination of both. With a wide range in severity and recurrent periods of flares, it has significant impact on the quality of life of its sufferers. A history of atopy predisposes patients to hand dermatitis, but contact dermatitis, either allergic or irritant, is the more commonly implicated factor in the etiology of hand dermatitis. Patch testing is an important tool in identifying the allergen responsible for allergic hand dermatitis, and this knowledge will contribute to improved management.
Aim and Objectives
This study was undertaken to evaluate the clinical and etiologic profile and review the patch responses of patients who presented with hand dermatitis at a foremost tertiary skin clinic in the most populous state of the most populous country in Africa.
Methods
A prospective, observational study in which consecutive walk-in patients who fulfilled the inclusion criteria were enrolled. Ethical clearance was obtained. Study tools included self-administered questionnaires, physical examination, and patch tests (European Hermal series), amongst others. The patch tests were carried out. Results were documented, and treatment was individualized based on clinical and investigation findings. The results were collated and analyzed with SPSS® 17.0 edition (SPSS II).
Results
Hand dermatitis was seen in 177 (13.3%) patients who presented during the study period. The mean age was 34.6 + 17.4 years. Almost two-thirds of patients (119; 67.2%) had chronic hand dermatitis, while 53 (32.8%) presented acutely. Patch responses were positive in 65 (36.7%) patients with paraphenylenediamine identified as the most frequent cause. Respondents had at least one (+) response to 20 of the 28 allergens, while there was no response to eight of the allergens in the European series.
Conclusion
The study reveals that hand dermatitis is present in a younger age group and a variety of subtypes coexist. Locally sourced allergens are needed to improve the yield of patch responses.
Nail changes in alopecia areata: an update and review
Abstract
Nail changes are a common feature of alopecia areata (AA) and are a significant source of cosmetic disfigurement and functional impairment. This review provides an update of the prevalence, clinical and histopathological features, pathogenesis, differential diagnosis, clinical course, prognosis, and management of nail changes in patients with AA. Searches for peer-reviewed journal articles were conducted using the PubMed/MEDLINE database with the search terms "nail changes alopecia areata," "alopecia areata nails," and specific searches on "trachyonychia alopecia areata" and "pitting alopecia areata." Other sources of articles included the reference lists of retrieved articles. Nail changes are a common feature of AA, with an average prevalence of 30%, and can cause significant disfigurement and loss of function. Pitting and trachyonychia were by far the most common manifestations of AA, with an average prevalence of 20 and 8%, respectively. Red spotted lunulae, onycholysis, and punctate leukonychia were other reported findings. Other etiologies, such as onychomycosis or lichen planus, may coexist with or confound the diagnosis. There is limited published data on the clinical manifestations of AA-associated nail changes and therapeutic options. Larger controlled trials are necessary to guide treatment decisions.
Giant panda foraging and movement patterns in response to bamboo shoot growth
Abstract
Diet plays a pivotal role in dictating behavioral patterns of herbivorous animals, particularly specialist species. The giant panda (Ailuropoda melanoleuca) is well-known as a bamboo specialist. In the present study, the response of giant pandas to spatiotemporal variation of bamboo shoots was explored using field surveys and GPS collar tracking. Results show the dynamics in panda-bamboo space-time relationships that have not been previously articulated. For instance, we found a higher bamboo stump height of foraged bamboo with increasing elevation, places where pandas foraged later in spring when bamboo shoots become more fibrous and woody. The time required for shoots to reach optimum height for foraging was significantly delayed as elevation increased, a pattern which corresponded with panda elevational migration patterns beginning from the lower elevational end of Fargesia robusta distribution and gradually shifting upward until the end of the shooting season. These results indicate that giant pandas can respond to spatiotemporal variation of bamboo resources, such as available shoots. Anthropogenic interference of low-elevation F. robusta habitat should be mitigated, and conservation attention and increased monitoring should be given to F. robusta areas at the low- and mid-elevation ranges, particularly in the spring shooting season.
Comparative evaluation of skin moisture after topical application of 10% and 30% lactobionic acid
Summary
Background
Dry skin is characterized by symptoms such as itching, redness, excessive exfoliation. These symptoms cause discomfort and contribute to secondary bacterial infections. Dry skin treatments are based on topical applications of various formulations. Among many of them are polyhydroxy acids, which recently gained more attention.
Aims
The aim of this study was a comparative assessment of hydration level (corneometric) after application of lactobionic acid (LA) in the form of peel at concentrations of 10% and 30%.
Material and Methods
The study involved 10 Caucasian individuals aged 26-73 years. Eight treatments were performed at weekly intervals. The peels were applied using the "Split face" method—on the left side of the face 10% LA, and the right side 30% LA which consisted of specified concentration of LA, deionized water, xanthan gum, ethoxydiglycol. The test subjects received a 5% LA cream for overnight use. The cream consisted of deionized water, LA, isopropyl palmitate, ascorbyl palmitate, methylparaben. The products for this study were provided by Grehen Ltd. Celestynów, Poland. Prior to each procedure, the skin hydration level was measured using Corneometer CM 825 from Courage + Khazaka electronic GmbH.
Results
There was a statistically significant improvement in hydration level after 8 treatments for all measuring points and both concentrations. The difference of the skin hydration level between 10% LA and 30% LA could not be determined.
Conclusions
Lactobionic acid is a highly moisturizing agent. There was no significant difference in moisturizing effect between 10% LA concentration and 30% LA concentration.
Genetic association of HCRTR2, ADH4 and CLOCK genes with cluster headache: a Chinese population-based case-control study
Cluster headache (CH), a rare primary headache disorder, is currently thought to be a genetic susceptibility which play a role in CH susceptibility. A large numbers of genetic association studies have confirme...
Suppression of pathergy in pyoderma gangrenosum with infliximab allowing for successful tendon debridement
Pyoderma gangrenosum (PG) is an inflammatory condition that causes neutrophilic infiltration of the skin and characteristic skin ulceration.1 More than half of patients develop PG in association with an underlying systemic disease.1 Its pathophysiology is complicated and not fully understood.1 PG can affect any part of the body, but it commonly affects the legs.2 The diagnosis of PG can be challenging and is often one of exclusion.3 PG exhibits pathergy, which is the development or worsening of a lesion at the site of trauma, and the presence of pathergy can help support the diagnosis of PG.
Removal of forearm lentigines in dyschromatosis universalis hereditaria with a 755-nm Q-switched alexandrite laser
Characterized by hyperpigmented and hypopigmented macules forming a reticulate pattern, dyschromatosis universalis hereditaria (DUH) was first described by Toyamo in Japan. Subsequent cases have been reported from other areas including Europe, China, Saudi Arabia, Tunisia, India, and Nigeria.1 A variable autosomal inheritance has been described, and a few sporadic cases have been reported. Spontaneous regression has not been recorded. Only one case involving treatment modality was reported in 2011.
Exposed hardware in a patient with invasive keratinocyte carcinoma
The care of patients with aggressive keratinocyte carcinomas (KCs), including squamous cell carcinoma (SCC) and basal cell carcinoma, is often multidisciplinary and includes dermatologic surgeons, plastic surgeons, otolaryngologists, and other surgical subspecialties. Complex reconstructions might require osteosynthetic material, such as porous polyethylene plates and mesh. Complications of titanium implants include infection, poor wound healing, fistula formation, hardware exposure, and hardware malfunction, which might necessitate hardware removal.
Cutaneous Langerhans cell histiocytosis with gastrointestinal involvement treated with dabrafenib
Langerhans cell histiocytosis (LCH) is a rare disorder characterized by an abnormal clonal proliferation of histiocytes, with adult-onset LCH accounting for an estimated 30% of cases.1 The clinical spectrum of LCH varies widely, from asymptomatic single-organ involvement to severe and potentially fatal multisystem disease. Although cutaneous lesions are frequently encountered, gastrointestinal involvement in LCH is exceedingly rare, especially in the adult population.
Dementia, diarrhea, desquamating shellac-like dermatitis revealing late-onset cobalamin C deficiency
We present a case of late-onset cobalamin C deficiency presenting with a unique shellac-like erosive desquamation and mental status changes that was dramatically responsive to treatment. We discuss cobalamin C deficiency and compare the cutaneous findings with other similar nutritional deficiency states. The brown shellac-like desquamation should prompt dermatologists to consider this diagnosis in the setting of a suspected nutritional deficiency.
Herpes zoster infection after topical steroid use in the setting of tumid lupus erythematosus
Topical corticosteroids are commonly used in the treatment of a wide range of skin manifestations of systemic lupus erythematosus (SLE). Patients with SLE are also known to have an increased risk of herpes zoster (HZ). Here we present a rare case of recurrent HZ induced by topical corticosteroid use for the treatment of tumid lupus in the background of systemic lupus. We also review the literature on topical corticosteroid use and varicella zoster infection. For the literature review, search terms both as keywords and subject headings, included topical corticosteroids, topical steroids, corticosteroids AND systemic lupus erythematosus, lupus, cutaneous lupus AND herpes zoster, herpes virus, varicella zoster, shingles.
Chronic granulomatous reaction in patients receiving vaccine immunotherapy for metastatic melanoma
Various agents such as melanoma-associated antigen 3 (MAGE-3), interleukin-2 (IL-2), gp100, and toll-like receptor agonists have been investigated as therapies for melanoma because of their ability to stimulate an immune response against melanocytes. We report on 3 patients with metastatic melanoma who, after receiving immunotherapy injections, had persistent subcutaneous nodules at their injection sites. One patient's nodules were shown to be a granulomatous reaction on histopathology.
Arsenical keratosis secondary to Fowler solution
Chronic arsenic exposure is rare in developed nations. The few cases of arsenical keratosis in the United States have primarily been attributed to occupational and medicinal exposures.1 Here, we describe a case of an elderly man in whom arsenical keratoses and cutaneous cancers developed decades after being treated with oral Fowler solution, for the treatment of acne during adolescence.
Successful treatment of mucous membrane pemphigoid with bortezomib
Mucous membrane pemphigoid (MMP) is a rare, autoantibody-mediated disease characterized by mucocutaneous blistering including oral, ocular, laryngeal, and skin involvement. Treating MMP is challenging, with few effective therapies available. We report successful treatment of a patient with treatment-refractory MMP with the proteasome inhibitor, bortezomib.
Sporotrichosis in the nail—An unusual location and presentation
Sporotrichosis, or rose gardener's disease, is caused by the dimorphic fungus Sporothrix schenckii and is the most common subcutaneous mycosis.1 The disease typically occurs in one of 3 main forms: lymphocutaneous (most commonly), fixed cutaneous, or disseminated cutaneous.1 We report an unusual case of Sporothrix, presenting in a 67-year-old man with painful, hyperpigmented fingernails.
Paraneoplastic pemphigus mimicking toxic epidermal necrolysis: An underdiagnosed entity?
Paraneoplastic pemphigus (PNP) is an autoimmune blistering syndrome with 5 well-described clinicopathologic phenotypes. Nguyen et al categorized these subtypes as pemphigus-like, pemphigoid-like, erythema multiforme-like, graft-vs-host-disease–like, and lichen planus–like.1 However, there is increasing recognition of PNP simulating Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Herein, we propose SJS/TEN-like PNP as a distinct subtype of PNP. We present 2 new cases of SJS/TEN-like PNP and review the previously reported cases of this subtype.
Acquired lymphangioma circumscriptum of the genitals in an individual with chronic hidradenitis suppurativa
Acquired lymphangioma circumscriptum (LC), also known as localized LC, is characterized by small, clear, fluid-filled, clustered vesicles and papules that resemble a gelatinous mass of "frog spawn" on the surface of the skin. We present a case of genital LC associated with hidradenitis suppurativa (HS), which is significant because it represents a rare causal relationship.
New-onset acrokeratoelastoidosis in an immunosuppressed patient
Acrokeratoelastoidosis (AKE), is a rare keratoderma characterized by small, round, skin-colored papules on the palms and soles.1 It was first described in 1952 by Brazilian dermatologist Oswaldo Costa and commonly presents before the age of 20.2 The primary etiology is unknown, and both autosomal dominant and sporadic forms have been reported in the dermatology literature.1,3 We present the case of an immunosuppressed patient who subsequently had papules on the hands, originally diagnosed as verruca palmoplantaris, that were later found to be consistent with AKE.
Hemorrhagic vesiculobullous eruption on the palms and the soles as presentation of dyshidrosiform bullous pemphigoid
Dyshidrosiform bullous pemphigoid (DP) is an unusual localized variant of bullous pemphigoid (BP), first described by Levine et al1 in 1979. It presents with a persistent and recurrent vesicobullous eruption, sometimes hemorrhagic, localized to the soles and/or palms. Since the clinical manifestations of DP are similar to those of pompholyx or bullous tinea pedis, which are more common and benign dermatologic diseases, a proper diagnosis could be delayed. We report the case of an 82-year-old man affected by DP who was treated for months for pompholyx and bullous tinea pedis with dermatophytid reaction.
Prurigo pigmentosa: Case series and differentiation from confluent and reticulated papillomatosis
Prurigo pigmentosa (PP) is an uncommon, acquired inflammatory disorder with a predilection for young adults of Asian descent.1 This condition is manifested by highly pruritic, reticulated, and erythematous papules that resolve with hyperpigmentation.2 Multiple cases of PP have been reported since its initial description in 1971 by Nagashima et al3; however, this dermatosis is still underdiagnosed or misdiagnosed.3-6 The most significant challenge limiting the identification of PP is successful distinction from confluent and reticulated papillomatosis (CARP).
In vitro examination of an oleosome-based sun protection product on the influence of UVB-induced inflammation markers in human epidermal skin equivalent tissue model
Publication date: February 2018
Source:Journal of Photochemistry and Photobiology B: Biology, Volume 179
Author(s): James V. Gruber, Robert Holtz, Soo In Yang
In vitro human epidermal skin equivalent tissues (MatTek EpiDerm™) were employed to examine the influence of UVB radiation on various established inflammation markers in the presence of topically applied sunscreens. MatTek EpiDerm™ tissues were treated with 2.0mg/cm2 of an Experimental oleosome-based SPF 30 product or a commercial SPF 30 beach product. Tissues were irradiated with 300mJ/cm2 of UVB radiation. Inflammatory cytokines IL-1α, IL-6 and IL-8 as well as arachidonic acid cascade marker PGE2 were examined via ELISA-based antibody detection. Untreated tissues irradiated with 300mJ/cm2 of UVB radiation showed statistically significant upregulation of IL-1α, IL-6 and IL-8 as well as PGE2. Application of both the experimental oleosome-based SPF 30 formulation and the commercial SPF 30 formulation demonstrated an ability to prevent the upregulation of all four markers when applied prior to irradiation. The experimental oleosome-based SPF 30 product contained approximately 80% less sunscreen actives than the commercial formulation. This study demonstrates that in vitro reconstructed human tissues can be used to study the influences of sun screen actives in the presence of UVB radiation. The results support previously reported clinical results that demonstrated that oleosome-based sun care formulations can function with high protection effects with significantly less sun care actives.
Review of quality of life studies in women with alopecia
Alopecia is a dermatologic condition that affects the pilosebaceous unit in both men and women. In addition to a thorough medical history and physical examination, a host of diagnostic tools may be warranted to differentiate nonscarring and scarring alopecias. Female pattern hair loss represents the most common form of hair loss experienced by up to 40% of women by a certain age. Although alopecia is a benign disorder, even the most negligible amount of hair loss can be devastating to a patient's self-esteem, self-image, and overall quality of life.
Defining Normal Parameters for the Male Nipple-Areola Complex: A Prospective Observational Study and Recommendations for Placement on the Chest Wall
Abstract
Background
The nipple-areola complex (NAC) is important aesthetically and functionally for both sexes. Methods for positioning the NAC in males are less well established in the literature compared to females but are just as important. Objectives
This study aims to determine the normal parameters for the male NAC, to review literature, and to present a reliable method for preoperative placement. Methods
Normal male patients, with no prior chest wall conditions, were prospectively recruited to participate. General demographics and chest wall dimensions were recorded—sternal notch to nipple (SNND), internipple (IND), anterior axillary folds distances (AFD), NAC, and chest circumference were measured. Comparisons were made using t test and ANOVA. Results
One hundred and fifty-eight patients were recruited (age range, 18-90 years); mostly (86.7%) with normal or overweight BMI. The IND averaged 249.4 mm, the SNND averaged 204.2 mm, and the AFD averaged 383.8 mm. Areola diameter averaged 26.6 mm and for the nipple, 6.9 mm. The IND:AFD ratio was 0.65. There was no statistical difference in the IND:AFD ratio, SNND, or NAC parameters comparing different ethnic groups. The SNND increased with greater BMI (P ≤ 0.001). Using these data, we suggest ideal NAC dimensions and devised a simple method for positioning of the NAC on the male chest wall. Conclusions
This is the largest study, with the widest range in age and BMI, to date on this topic. Although fewer men than women undergo surgery to the breast, there is a growing awareness for enhancing the appearance of the male chest wall. Level of Evidence: 4
Foreign Body Reaction Mimicking Sarcoma
Foreign body reaction can sometimes mimic the features of sarcoma. A 42-year-old patient was referred to our department for a rapidly growing subcutaneous mass in the posteromedial aspect of the lower leg. Ultrasonography and magnetic resonance imaging were highly suggestive for soft tissue sarcoma. The patient underwent surgical resection. The histho-pathologic diagnosis found that the supposed sarcoma was an inflammatory pseudo-tumor, also referred to as "gossypiboms". Surgeons must be aware that, in some cases, the imaging cannot reliably distinguish between sarcoma and foreign body reaction.Split Tolerance in a Murine Model of Heterotopic En Bloc Chest Wall Transplantation
Background: Congenital and acquired chest wall deformities represent a significant challenge to functional reconstruction and may impact feasibility of heart transplantation for patients with end-stage organ failure. In the recent past, the concept of replacing like-with-like tissue by using vascularized composite allografts (VCA) has been enthusiastically employed for reconstruction of complex tissue defects. Methods: In this study, we introduce a novel murine model for en bloc chest wall, heart, and thymus transplantation and thereby the use of complex tissue allografts for reconstruction of both chest wall defects and also end-stage organ failure. Additionally, this model allows us to study the features of combined vascularized bone marrow (VBM), thymus, and heart transplantation on allograft survival and function. Heterotopic chest wall, thymus, and heart transplants were performed in untreated syngeneic and allogeneic combinations and in allogeneic combinations treated with costimulation blockade (CTLA4-Ig and MR-1). Results: Indefinite (ie, 150 d, N = 3) graft survival was observed in syngeneic controls. In untreated recipients of allogeneic grafts, the skin component was rejected after 10 (±1) days, whereas rejection of the heart occurred after 13 (± 1) days (N = 3). Costimulation blockade treatment prolonged survival of the heart and chest wall component (130 d, N = 3) as well as the VBM niche as evidenced by donor-specific chimerism (average: 2.35 ± 1.44%), whereas interestingly, the skin component was rejected after 13 (±1) days. Conclusion: Thus, this novel microsurgical model of VCA combined with solid organ transplantation is technically feasible and results in split tolerance when treated with costimulatory blockade.Aesthetic Refinements after Radial Free Flap Phalloplasty: Optimizing the Donor Site and the Phallus
Background: Phalloplasty with radial forearm flap is the gold standard for female-to-male sex reassignment surgery. However, it leaves a stigmatizing forearm scar, and as the new phallus is created with the forearm's skin and fat, it does not look like that of a biological man. The aesthetic appearance of the donor site and the neophallus can be optimized after phalloplasty. In this study, we review refinement techniques (RTs) performed after radial forearm flap phalloplasty. Methods: We present a historical cohort of patients who underwent the following RTs: forearm fat grafting and localized laser in the forearm's scars, and micropigmentation of the neophallus. Patient's aesthetic satisfaction was evaluated using the Patient and Observer Scar Assessment Scale for the forearm's refinements and the Male Genital Self-Image Scale for the neophallus. Results: Between January 2014 and January 2016, 8 patients underwent forearm fat grafting with localized laser, and 7 patients micropigmentation of the neophallus after radial flap phalloplasties. All Patient and Observer Scar Assessment Scale parameters showed a statistically significant reduction between preoperative and postoperative values. Male Genital Self-Image Scale survey showed that all patients felt positively about their genitals after micropigmentation. Patients who underwent refinement procedures were highly satisfied with the aesthetic outcome and felt more confident. They also claim that they would choose to have the refinement procedure done again. Conclusions: The proposed RTs are minimally invasive interventions to complement and enhance female-to-male sex reassignment surgery with very few complications and excellent aesthetic results of both the forearm scars and the constructed phallus.The Superiorly Based Partial Rectus Abdominis and External Oblique Flap: A New Technique for Breast Asymmetry Reconstruction
Summary: Breast asymmetry has a wide spectrum of presentations with several employable strategies for surgical correction. Historically, the external oblique muscle has proven to be a versatile flap option for the reconstruction of both local and distant defects. It has also been described for use in breast reconstruction for coverage of the lower pole of implant prostheses. The external oblique muscle flap can be harvested in several ways to capture overlying fat and skin. In this study, we describe the use of a superiorly based partial rectus and external oblique flap for surgical correction of lower pole breast hypoplasia. This flap provides vascularized autologous volume to the lower pole of the breast with minimal donor morbidity. Other advantages of this flap are that it can increase the nipple to inframammary fold distance and lower the inframammary fold. This technique represents an evolution of an under-utilized flap and is the first study describing the use of the external oblique flap in the management of breast asymmetry.Laterality and Left-sidedness in the Nose, Face, and Body: A New Finding
Background: Asymmetry is a common occurrence in bilaterian animals, particularly human beings. Through examination of patients and their photographs during rhinoplasty, we noted wider left-sided nasal and facial features in most patients. This observation led us to hypothesize that this might be consistent to the whole body. Methods: We conducted a study in 3 parts to test the question above. First, we analyzed operating notes of 50 rhinoplasty patients to determine the wider side of the upper, middle, and lower thirds of the nose. Second, we analyzed the width of the face and chest wall in 31 patients to discern any correlation between facial and bodily asymmetry. Third, computerized tomographic scans of the thorax and body of 48 patients were studied to measure the width of the hemithorax and hemipelvic bone. Results: (1) Upper vault width was wider on left side (78%). Left middle vault width was wider (88%). The lower lateral cartilage, lateral crura convexity was more prominent on left side (48%), and a wider scroll area was found and trimmed in 21 (left) and 0 (right) cases. The alar base was wider on left side (56%). (2) In the body and face analysis, 64.5% had a wider left-sided face and body. (3) In the computed tomographic scan analysis, same-sided thorax and pelvis asymmetry was seen (85.35%), 33 and 7 of which were left- and right-sided, respectively. Conclusion: We observed generalized asymmetry of the face and body with left-sided predominance.Late-Onset Inflammatory Response to Hyaluronic Acid Dermal Fillers
Objective: Even though injectable hyaluronic acid (HA)–based fillers are considered safe, rare complications, such as late-onset inflammatory reactions have been reported. Possible causes and effective treatments have not been formally described, so this work aims to discuss these and offer a formal protocol for treatment. Methods: This article presents 5 clinical cases of late-onset inflammatory response occurring at least 3 months after uneventful injection of HA dermal filler. Results: Inflammation appeared spontaneously, usually 4–5 months after the last injection, but in 1 patient, almost 14 months later. One patient was injected at the same time with fillers manufactured by 2 different technologies. In this case, all areas treated with the same filler showed diffuse swelling of inflammatory nature, whereas the lips, treated with the second filler brand, remained unaffected. Four patients reported a flu-like illness or gastrointestinal upset a few days before the onset of dermal filler inflammation. Conclusion: Late-onset inflammatory reactions to HA fillers may be self-limiting but are easily and rapidly treatable with oral steroids, and with hyaluronidase in the case of lumps. It is likely these reactions are due to a Type IV delayed hypersensitivity response. Delayed inflammation associated with HA fillers is nonbrand specific. However, the case where 2 different brands were injected during the same session, but only 1 brand triggered a hypersensitivity reaction, suggests that the technology used in the manufacturing process, and the subsequent differing products of degradation, may have an influence on potential allergic reactions to HA fillers.Successfully Closing an Acquired Palatal-fistula Using a Turnover Flap from a Previously Transferred Forearm-free-flap
Summary: Palatal fistula between the oral and nasal cavities occurs in about 20% of palatal repairs after oncologic resection. Although healing by secondary intention may be employed as an initial strategy, persistent nonhealing symptomatic fistula necessitates intervention. Folded free flap used for primary repair of palatectomy defects enables placement of epithelialized tissue on both the oral and nasal cavities. In case of acquired palatal fistula, a turnover flap can be easily created, based on the free margin of the folded forearm free flap to serve as a reconstructive lifeboat.Changes in Sunken Eyes Combined with Blepharoptosis after Levator Resection
Background: This study aims to report the changes in sunken eyes combined with blepharoptosis after levator resection. Methods: Analysis involved 60 eyes from 32 patients with sunken eyes combined with blepharoptosis. Advancement of the levator aponeurosis and the Müller's muscle complex (levator resection) was performed in these patients. Area of upper eyelid sulcus (AES) was defined as the area of the upper eyelid shadow. The digital images were converted to black and white using image-processing software (Adobe Photoshop), and the AES was calculated using ImageJ software. In addition, margin reflex distance, eyebrow height (EBH), and AES were measured before and 3 months after surgery to assess the changes in the eyelids. Results: Preoperative AES was significantly correlated to age (PNovel Pressure-Sensing Smart Insole System Used for the Prevention of Pressure Ulceration in the Insensate Foot
Summary: Wounds of the foot challenge reconstructive surgeons to manage multiple factors: sensibility, stability, and durability. In this article, we focus on the insensate foot, which poses challenges to wound prevention with its propensity to develop pressure ulceration. The authors present the innovative use of a pressure-sensing smart insole system (SurroSense Rx, Orpyx Medical Technologies Inc., Calgary, Canada) in the management of the insensate foot in a patient following foot reconstruction. The pressure-sensing smart insole system provided unique feedback to both patient and provider in ways that contributed to the prevention of pressure ulcer recurrence, as well as highlight the importance of prescribed footwear in both the affected and unaffected foot. Wearable real-time monitoring and feedback faces the challenge of patient adherence. Future studies are indicated to examine the specific behaviors that are associated with favorable outcomes and long-term behavior changes.Autologous Fat Transfer for Facial Rejuvenation: A Systematic Review on Technique, Efficacy, and Satisfaction
Background: Parallel to the steady decline in surgical aesthetic procedures to the face, dermal fillers seem to have gained a more prominent place in facial rejuvenation over the last couple of years. As a dermal, facial filler, autologous fat transfer (AFT) seems to have real potential because of the biocompatibility of adipose tissue besides being a procedure with few and primarily minor complications. This systematic review aims to evaluate the available evidence regarding the safety and effectiveness of AFT for facial rejuvenation. Method: A systematic review after the Preferred-Reporting-Items-for-Systematic-Reviews-and-Meta-Analysis (PRISMA) statement was conducted. MEDLINE, Embase, and Cochrane Library were searched up to December 2016, with no language restrictions imposed. Case series, cohort studies, and randomized controlled trials (RCTs) reporting on relevant outcomes were included. Results: Eighteen clinical articles were included, reporting on 3,073 patients in total over a mean follow-up period of 13.9 months. Meta-analysis showed an overall complication rate of 6% (95% CI 3.0–14.0), with hematoma/ecchymosis (5%), fat necrosis/oil cysts (2%), and irregular fat distribution and scars (both 2%) being among the most reported. No major complications were reported, and the overall patient satisfaction rate was 81%. Conclusion: Although the evidence in this systematic review is still limited and plagued by heterogeneity between studies, AFT seems to be a promising method in facial rejuvenation with fewer complications than other fillers and high patient satisfaction rates. Further large-cohort, preferably multicenter, RCTs should substantiate these results through quantifiable volumetric assessment tools and validated patient questionnaires, while adhering to predetermined nomenclature in terms of complications.Consensus Recommendations for Treatment Strategies in Indians Using Botulinum Toxin and Hyaluronic Acid Fillers
Background: Indians constitute one of the largest population groups in the world. Facial anthropometry, morphology, and age-related changes in Indians differ from those of other ethnic groups, necessitating a good understanding of their facial structure and the required aesthetic treatment strategies. However, published recommendations specific to Indians are few, particularly regarding combination treatment. Methods: The Indian Facial Aesthetics Expert Group (19 dermatologists, plastic surgeons, and aesthetic physicians with a mean 15.5 years' aesthetic treatment experience) met to develop consensus recommendations for the cosmetic facial use of botulinum toxin and hyaluronic acid fillers, alone and in combination, in Indians. Treatment strategies and dosage recommendations (agreed by ≥ 75% of the group) were based on results of a premeeting survey, peer-reviewed literature, and the experts' clinical experience. Results: The need for combination treatment increases with age. Tear trough deficiency is the most common midface indication in Indian women aged 20–40 years. In older women, malar volume loss and jowls are the most common aesthetic concerns. Excess medial soft tissue on a relatively smaller midface precedes age-related sagging. Hence, in older Indians, fillers should be used peripherally to achieve lift and conservatively in the medial zones to avoid adding bulk medially. The shorter, wider lower face requires 3-dimensional correction, including chin augmentation, to achieve increased facial height and the oval shape desired by most Indian women. Conclusions: These recommendations give physicians treating Indians worldwide a better understanding of their unique facial characteristics and provide treatment strategies to achieve optimal aesthetic outcomes.Orthognathic Relevant Scales of FACE-Q: Translation and Validation for Hong Kong Chinese Patients
Background: A validated questionnaire is needed to study a more holistic outcome assessment including postsurgical aesthetic satisfaction and psychosocial changes in orthognathic patients. The aim of this study was to determine the reliability and validity of 9 orthognathically relevant translated FACE-Q scales among Hong Kong Chinese orthognathic patients. Methods: Two hundred fifty adult Cantonese-speaking patients of 18 years or older who underwent orthognathic treatment were recruited in the Prince Philip Dental Hospital of Hong Kong. Nine of an overall of 40 independent FACE-Q scales were selected and translated into Hong Kong Chinese. The reliability, validity, and test–retest reliability were examined using Cronbach's alpha, paired t test and Pearson's correlation coefficients. Results: The Hong Kong Chinese version of the 9 FACE-Q scales was obtained by forward-backward translation. One hundred eight male (mean age, 25.57 ± 4.49) and 142 female (mean age, 24.61 ± 4.54) patients were recruited for the reliability and validation process. The internal consistency (0.89–0.97) and the test–retest reliability (0.73–0.90) were found to be high. The validity of the translated questionnaires was comparable with that of the original FACE-Q. Conclusion: The results presented here prove that the 9 translated FACE-Q scales are reliable and valid instruments for research and clinical purposes in Hong Kong Chinese orthognathic patients.Complete Lower Lip Reconstruction with a Large Lip Switch Flap and a Composite Modiolus Advancement Flap
Summary: Total loss of the lower lip is debilitating and poses a reconstructive challenge. Aiming to restore oral continence and function and also cosmetic appearance, a successful reconstruction has a huge impact on the quality of life for the individual patient. Early sources of local tissue rearrangement for lip reconstruction date back 3000 years, with earliest reports of lip switch procedures more than 2 centuries ago in Europe, when noma was still endemic in Europe, indicating that the anatomy was better understood by the barber surgeons of the past than we like to acknowledge. We are still faced with such challenging cases all over the world where resources are limited. Our current understanding of perforator anatomy and blood supply makes more frequent revisits to flaps of the past with modern advances. Innovative solutions are imperative for salvage, and old ideas tend to reappear when they prove to be useful. Herein, we describe in open access a new reconstructive method where we combined a large lip switch flap together with a composite advancement modiolus flap to reconstruct a whole lower lip and the donor defect of the upper lip all at once, a procedure that is simple to perform and works in settings where it is greatly needed.Ultrasound Diagnosis and Treatment of Breast Lumps after Breast Augmentation with Autologous Fat Grafting
Background: Breast augmentation with autologous fat has been performed in Japan for over 30 years. However, complications include breast lumps and oil cysts. Such breast lumps greatly reduce patient satisfaction, and are currently difficult to diagnose and treat for many cosmetic surgery clinics. This study aimed to elucidate the effectiveness of ultrasound diagnosis and treatment of patients with breast lumps after breast augmentation with autologous fat grafting. Methods: We used diagnostic and therapeutic ultrasound to examine 256 patients with breast lumps between April 2012 and April 2017. We determined the nature, size, and location of the maximal lump. Breast lumps were classified into five types: cystic, complex, solid, calcification, and unclassifiable. The method of treatment (including fine-needle aspiration, VASER liposuction, lumpectomy, and extended lumpectomy) was selected according to the lump type, and the efficacy of treatment was determined by postoperative palpation and ultrasound. Results: A total of 198 patients (198/256, 77%) requested treatment. Cystic lumps (79/256, 31%) were treated by fine-needle aspiration. VASER liposuction was used to treat complex (64/256, 25%) and solid lumps (50/256, 19%). Calcification (58/256, 23%) and unclassifiable lumps (5/256, 2%) were removed via periareolar incision. There were no serious complications. In all cases, the lumps were no longer palpable after treatment, and ultrasound showed that they had either contracted or disappeared. Conclusions: The appropriate treatment for breast lumps after breast augmentation with autologous fat grafting must be selected according to the nature of the lumps. Ultrasound is essential for diagnosing the breast lump type and determining the best treatment.Quantification of Collagen Organization after Nerve Repair
Background: Clinical outcomes after nerve injury and repair remain suboptimal. Patients may be plagued by poor functional recovery and painful neuroma at the repair site, characterized by disorganized collagen and sprouting axons. Collagen deposition during wound healing can be intrinsically imaged using second harmonic generation (SHG) microscopy. The purpose of this study was to develop a protocol for SHG imaging of nerves and to assess whether collagen alignment can be quantified after nerve repair. Methods: Sciatic nerve transection and epineural repair was performed in male rats. The contralateral nerves were used as intra-animal controls. Ten-millimeter nerve segments were harvested and fixed onto slides. SHG images were collected using a 20× objective on a multiphoton microscope. Collagen fiber alignment was calculated using CurveAlign software. Alignment was calculated on a scale from 0 to 1, where 1 represents perfect alignment. Statistical analysis was performed using a linear mixed-effects model. Results: Eight male rats underwent right sciatic nerve repair using 9-0 Nylon suture. There were gross variations in collagen fiber organization in the repaired nerves compared with the controls. Quantitatively, collagen fibers were more aligned in the control nerves (mean alignment 0.754, SE 0.055) than in the repairs (mean alignment 0.413, SE 0.047; PA Histological Comparison of Two Human Acellular Dermal Matrix Products in Prosthetic-Based Breast Reconstruction
Background: Acellular dermal matrices (ADMs) are an integral component of breast reconstruction. The ideal matrix would be relatively immuno-inert, allow rapid vascularization, and be affordable. The purpose of this study was to histologically compare 2 commonly used ADM products. Methods: This is a prospective histological study of 17 patients (20 breasts) following prosthetic-based breast reconstruction with ADM: Alloderm (LifeCell Corp, Branchburg, N.J.) or Cortiva (RTI Surgical, Alachua Fla.). Biopsies were taken from the dermal matrix and natural capsules surrounding the expander/implant during secondary surgery [Range, 72—694 days (mean, 217 days)]. Biopsy specimens were prepared via hematoxylin and eosin, Masson's trichrome, elastin, and transforming growth factor (TGF)-1 stains. Quantitative analysis of staining was performed with ImageJ software. The clinical outcome of each patient is analyzed in relation to capsule architecture and ADM performance. Results: There were 7 breasts in the Alloderm group and 13 in the Cortiva group. Both groups had similar demographic, aesthetic results, and complication profiles. The TGF-1 staining demonstrated significantly lower levels in the Cortiva capsules (P = 0.0139). The percentage of elastin and collagen are similar in the Cortiva, Alloderm, and natural peri-implant capsules. The native capsules show a significantly greater number of blood vessels when compared with Cortiva and Alloderm (P = 0.0371 and P = 0.0347, respectively); however, there is no difference in vascular pattern between the 2 dermal matrices. Discussion: Postoperatively, Cortiva demonstrates equal vascularity with less TGF-1 activation compared with Alloderm. The clinical success and complication profile were similar between the Alloderm and Cortiva patients.Silicone Migration after Buttock Augmentation
Summary: We present the case of a 30-year-old woman who presented with enlarged inguinal lymph nodes and sacral hyperpigmentation 4 months after gluteal augmentation with silicone implants. Inguinal lymph node biopsy revealed granulomatous lymphadenitis due to foreign material. Upon right buttock implant revision, a 1.5-cm-thick capsule was noted with the absence of peri-implant inflammatory fluid and no macroscopic implant defects. Analysis of the implant by the manufacturer revealed a microscopic silicone leak. The patient's recovery was uneventful, and her symptoms resolved shortly after her reoperation.Examining Length of Hospital Stay after Microsurgical Breast Reconstruction: Evaluation in a Case-Control Study
Background: While possessing numerous benefits, microsurgical breast reconstruction is associated with longer operative times and post-operative hospital length of stay compared to implant-based reconstruction. We therefore evaluate factors associated with increased length of stay (LOS) after microsurgical breast reconstruction with a case-control study design. Methods: All patients undergoing immediate or delayed abdominally-based microsurgical breast reconstruction over a two-year time period were identified. Risk factors associated with LOS greater than or equal to 5 days were identified. Results: A total of 116 patients undergoing immediate or delayed abdominally-based microsurgical breast reconstruction were identified. Of these, 86 (74.1%) had a LOS of 4 days or less (mean: 3.70 days) while 30 (25.9%) had a LOS of 5 days or greater (mean: 5.50 days). With regards to patient demographics and intra-operative factors, patients with a LOS of 5 days or greater were significantly more likely to have diabetes mellitus (pVascular Reconstruction in a Neonate after Iatrogenic Injury during Cardiac Catheterization
Summary: As technology and interventional techniques continue to evolve, both the volume and complexity of cardiac catheterizations will increase, leading to a rise in the number of complications. One of the most morbid complications of cardiac catheterization is vascular injury. We report the case of a 31-day-old, 3.0-kg infant with hypoplastic left heart syndrome who experienced a left common iliac artery disruption during cardiac catheterization resulting in a retroperitoneal hemorrhage. The extent of the vascular injury combined with the vessel caliber posed a technically challenging surgical scenario. Ultimately, the vascular supply to the left lower extremity was reconstructed by the plastic surgery team with a reverse autologous vein graft. To our knowledge, this multidisciplinary approach with the involvement of plastic surgery represents a unique case.Internal Mammary Vessels’ Impact on Abdominal Skin Perfusion in Free Abdominal Flap Breast Reconstruction
Background: Wound healing problems at the donor site in free abdominal flap breast reconstruction cause significant morbidity to patients. No studies have investigated what impact the use of the internal mammary artery in free abdominal flap breast reconstruction has on abdominal skin perfusion. We hypothesized that harvesting the internal mammary vessels (IMV) has a negative effect on abdominal skin perfusion. Methods: The abdomen and anterior thoracic wall of 17 patients scheduled for secondary free abdominal flap breast reconstruction using IMV was pre-, intra-, and postoperatively examined with dynamic infrared thermography. Qualitative and quantitative analyses of the rate and pattern of recovery in Huger's vascular zones were made with each patient being its own control. Zone III on the side where IMV were used was numbered zone IV. The contralateral zone III was used as reference. Results: Postoperative abdominal skin perfusion in zone IV was always significantly reduced compared with zone III (1-tailed t test, PDPF soot as an adsorbent for Cu(II), Cd(II), and Cr(VI) compared with commercial activated carbon
Abstract
The use of carbon soot recovered from diesel particulate filters (DPF) has been investigated as a potential adsorbent for heavy metals including cadmium, chromium, and copper from wastewater. Results were compared with the adsorption performance of powder activated carbon (PAC). The uptake capacity of heavy metals for soot was found to be higher than PAC. And the thermodynamic study result for both soot and PAC indicated the adsorption procedures are exothermic. The adsorption studies were carried out for both single and binary systems. The data are best modeled by the monolayer model and Langmuir isotherm model for single systems. The adsorption mechanisms are more complex for binary systems. The kinetic studies indicated the adsorption happens rapidly within the first 1 h, and the results can be best modeled by pseudo-second-order model. The SEM-EDS analysis revealed the soot possesses higher porosity and surface area. Carboxylic and hydroxyl functional groups are the predominant surface functional group on both soot and PAC as revealed by FTIR and IEP values. The adsorption can be explained by both Van Der Waals force and electrostatic force.
Graphical abstract
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Chaperone Mediated Autophagy (CMA) does it all!
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By Christina Towers, PhD.
The degradation of cellular proteins is a critical step of both regulation and quality control and results in the turn over and recycling of critical amino acids. The two main mechanisms of protein degradation converge on either the proteasome or the lysosome, the latter of which can be further subdivided into macroautophagy, microautophagy, and chaperone mediated autophagy.
Macroautophagy is the process by which double membrane vesicles called autophagosomes deliver damaged proteins and organelles to the lysosome for degradation. Microautophagy also delivers material to the lysosome via vesicles, but in a slightly more direct manner, using vesicles formed from invagination of the lysosomal membrane itself. Distinct from the first two forms of autophagy, chaperone mediated autophagy (CMA) does not use vesicles, but instead uses chaperone proteins to directly target specific proteins to the lumen of the lysosome. One of the most important distinctions is that CMA targets very specific proteins for degradation, only those with a conserved penta-peptide motif in their amino acid sequence.
The process of CMA begins with the heat shock-cognate protein of 70 kDa (Hsc70) binding to the consensus motif to act as a chaperone that guides the targeted proteins to the lysosome-associated membrane protein type 2A (LAMP-2A). Once docked on the outside of the lysosomal membrane, the targeted protein begins to unfold before it is internalized into the lysosomal lumen with the help of other chaperon and co-chaperone proteins, including Hsc90. Proteases and hydrolases that function at low pH in the lysosome then degrade these proteins, recycling critical amino acids1.
While all the forms of protein degradation and autophagy are important in disease, CMA in particular plays a diverse role in both normal biology, as well as cancer and neurodegenerative pathologies. Aberrant activation of CMA has been linked to the survival and proliferation of cancer cells. The mechanism of this regulation is tightly linked to cell metabolism, and studies have shown that inhibition of CMA restricts many rate limiting glycolytic enzymes resulting in reduced cell glycolysis and ATP production2. Additionally, it is thought that upregulated CMA may help to clear the toxic buildup of misfolded proteins during the oncogenic process allowing the cells to survive and continue to proliferate.
Alternatively, in neurodegenerative diseases, CMA plays a protective role, where it helps to facilitate the removal of deleterious proteins that are the staple pathology in many of these diseases3. CMA also plays an interesting role in ageing, one that is somewhat unique compared to other protein degradation mechanisms. A decrease in optimal CMA is associated with ageing, and has been observed in aged cells and tissues of rodents and patients4. This phenotype is directly linked to the decreased stability of LAMP-2A on the lysosomal membrane in aged cells and the subsequent retardation of protein translocation into the lysosomal lumen.
Thus far, many studies across tissue type, process, and disease state have implicated CMA in a pathology, but there is still much to be learned about the mechanisms and implications of this process across biology.
Explore New Autophagy Research Area
Christina Towers, PhD
References
- Cuervo, A. M. & Wong, E. Chaperone-mediated autophagy: roles in disease and aging. Cell Res 24, 92-104, doi:10.1038/cr.2013.153 (2014).
- Kon, M. et al. Chaperone-mediated autophagy is required for tumor growth. Sci Transl Med 3, 109ra117, doi:10.1126/scitranslmed.3003182 (2011).
- Towers, C. G. & Thorburn, A. Therapeutic Targeting of Autophagy. EBioMedicine 14, 15-23, doi:10.1016/j.ebiom.2016.10.034 (2016).
- Cuervo, A. M. & Dice, J. F. Age-related decline in chaperone-mediated autophagy. J Biol Chem 275, 31505-31513, doi:10.1074/jbc.M002102200 (2000).
Category:
Effects of an additive (hydroxyapatite–biochar–zeolite) on the chemical speciation of Cd and As in paddy soils and their accumulation and translocation in rice plants
Abstract
A pot experiment was carried out to investigate the remediation of paddy soils contaminated with both Cd and As. The effects of a soil additive (HZB: hydroxyapatite + zeolite + biochar) on the chemical speciation of Cd and As in the soil and on the accumulation and translocation of these two elements in rice plants were studied. The application of HZB decreased the concentration of acid-extractable Cd in the soil by 7.3–32.6% by promoting the transformation of soil Cd from soluble to insoluble species; as a result, the concentration of organically bound Cd in the soil increased by 6.8–49.5%. The application of HZB also promoted the transformation of soil As from soluble to insoluble species, thus increasing the concentration of Ca-bound As by 34.1–93.4% and reducing the concentration of soil-exchangeable As by 12.2–55.1%. However, when the application rate of HZB was greater than 4.0 g kg−1, the concentration of soil-exchangeable As increased again. It was found that the application of HZB decreased the Cd and As bioaccumulation capacity of rice root, and among various rice organs, rice husk was the highest in Cd transferring capacity, whereas rice root was the highest in As transferring capacity. When the amount of HZB applied was 0.05–0.2%, the Cd and As concentrations in the various parts of the rice plants decreased significantly.
Removal of imidazolium- and pyridinium-based ionic liquids by Fenton oxidation
Abstract
The oxidation of imidazolium (1-hexyl-3-methylimidazolium chloride, HmimCl) and pyridinium (1-butyl-4-methylpyridinium chloride, BmpyrCl) ionic liquids (ILs) by Fenton's reagent has been studied. Complete conversion was achieved for both ILs using the stoichiometric H2O2 dose at 70 °C, reaching final TOC conversion values around 45 and 55% for HmimCl and BmpyrCl, respectively. The decrease in hydrogen peroxide dose to substoichiometric concentrations (20–80% stoichiometric dose) caused a decrease in TOC conversion and COD removal and the appearance of hydroxylated oxidation by-products. Working at these substoichiometric H2O2 doses allowed the depiction of a possible degradation pathway for the oxidation of both imidazolium and pyridinium ILs. The first step of the oxidation process consisted in the hydroxylation of the ionic liquid by the attack of the ·OH radicals, followed by the ring-opening and the formation of short-chain organic acids, which could be partially oxidized up to CO2 and H2O. At H2O2 doses near stoichiometric values (80%), the resulting effluents showed non-ecotoxic behaviour and more biodegradable character (BOD5/COD ratio around 0.38 and 0.58 for HmimCl and BmpyrCl, respectively) due to the formation of short-chain organic acids.
Graphical abstract
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AAV-mediated gene delivery of the calreticulin anti-angiogenic domain inhibits ocular neovascularization
Abstract
Ocular neovascularization is a common pathological feature in diabetic retinopathy and neovascular age-related macular degeneration that can lead to severe vision loss. We evaluated the therapeutic efficacy of a novel endogenous inhibitor of angiogenesis, the calreticulin anti-angiogenic domain (CAD180), and its functional 112-residue fragment, CAD-like peptide 112 (CAD112), delivered using a self-complementary adeno-associated virus serotype 2 (scAAV2) in rodent models of oxygen-induced retinopathy and laser-induced choroidal neovascularization. The expression of CAD180 and CAD112 was elevated in human umbilical vein endothelial cells transduced with scAAV2-CAD180 or scAAV2-CAD112, respectively, and both inhibited angiogenic activity in vitro. Intravitreal gene delivery of scAAV2-CAD180 or scAAV2-CAD112 significantly inhibited ischemia-induced retinal neovascularization in rat eyes (CAD180: 52.7% reduction; CAD112: 49.2% reduction) compared to scAAV2-mCherry, as measured in retinal flatmounts stained with isolectin B4. Moreover, the retinal structure and function were unaffected by scAAV2-CAD180 or scAAV2-CAD112, as measured by optical coherence tomography and electroretinography. Moreover, subretinal delivery of scAAV2-CAD180 or scAAV2-CAD112 significantly attenuated laser-induced choroidal neovascularization in mouse eyes compared to scAAV2-mCherry, as measured by fundus fluorescein angiography (CAD180: 62.4% reduction; CAD112: 57.5% reduction) and choroidal flatmounts (CAD180: 40.21% reduction; CAD112: 43.03% reduction). Gene delivery using scAAV2-CAD180 or scAAV2-CAD112 has significant potential as a therapeutic option for the management of ocular neovascularization.
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Prolapsed bladder following rupture of patent urachal cyst, mimicking bladder exstrophy: a case report and literature review
Abstract
A 26-year-old pregnant woman was diagnosed with fetal bladder prolapse following rupture of a patent urachus/urachal cyst, based on the finding of cyst disappearance with replacement with an infra-umbilical, extra-abdominal solid soft-tissue mass, mimicking bladder exstrophy. The neonatal findings confirmed the prenatal diagnosis. The baby was healthy and had a successful surgical correction. This report provides clues to differentiating ruptured bladder prolapse from bladder exstrophy as follows: (1) well-documented urachal cyst with urine-filled mass in the early gestation, (2) development of solid soft-tissue mass shortly after disappearance of the urachal cyst, and (3) no other structural abnormalities (bladder exstrophy is usually associated with abnormal genitalia, epispadias, or pubic diastasis). This study underlines the differentiation between the two entities because of the vast difference in prognosis, management, and proper counseling.
Minimally invasive esophagectomy in the prone position improves postoperative outcomes: role of C-reactive protein as an indicator of surgical invasiveness
Abstract
Background
The aim of the study was to assess serum C-reactive protein (CRP) level immediately after minimally invasive esophagectomy (MIE) as a surrogate of surgical invasiveness in patients who underwent esophagectomy.
Methods
In total, 104 patients were enrolled in the study: 37 patients underwent MIE in the left lateral decubitus position (MIE-LP) and 67 patients underwent MIE in the prone position (MIE-PP). Serum CRP levels were assessed on POD 1, 3, 5, and 7 after MIE, and were compared with surgical outcomes and duration of systemic inflammatory response syndrome (SIRS) to investigate less invasiveness of the MIE.
Results
Reduced serum CRP level on POD 1 was associated with PP during MIE (P < 0.001) and decreased blood loss (P = 0.03). MIE-PP was identified as a significant independent predictor of reduced CRP level on POD 1 (odds ratio 3.65, P = 0.042). CRP level on POD 7 was associated with gender (P = 0.02), position of MIE (P = 0.011), blood loss (P = 0.02), and respiratory complications and/or anastomotic leakage (P < 0.001). Postoperative respiratory and/or anastomotic complication was identified as a significant predictor of elevated serum CRP level on POD 7 (odds ratio 3.44, P = 0.048). Shorter duration of SIRS was shown in the patients with reduced serum CRP level on POD 1 and 7 (P = 0.03 and P < 0.001, respectively).
Conclusion
Serial assessments of serum CRP level immediately after MIE may be a possible indicator that can reflect surgical invasiveness and postoperative complications.
The exposure to water with cigarette residue changes the anti-predator response in female Swiss albino mice
Abstract
Recent studies have shown that cigarette consumption affects much more than human health. Smoked cigarette butt (SCB) disposal into the environment can bring little-known negative biological consequences to mammals, since it contains many organic and inorganic toxic chemical constituents. Thus, we aim at assessing whether the ingestion of water with leached SCB for 60 days by female Swiss mice changes their defensive behavioral response to potential predators (cats and snakes). We worked with the following groups of animals: control (pollutant-free water), water with environmental concentration of SCB (1.9 μg/L of nicotine), and concentration 1000 times higher (EC1000×). Our data show that the treatments did not cause locomotor, visual, auditory, and olfactory deficit in the animals. However, we observed that the animals exposed to the pollutants did not present behavioral differences in the test session with or without the snake. On the other hand, animals in all groups showed defensive behavior when the test was conducted with the cat in the apparatus. However, female mice presented weaker response than the control. Thus, our data point towards the potential neurotoxic damage caused to mice who have ingested water with SCB residues, even at low concentrations.
Transcriptomic profiling of interacting nasal staphylococci species reveals global changes in gene and non-coding RNA expression
Abstract
Interspecies interactions between bacterial pathogens and the commensal microbiota can influence disease outcome. In the nasal cavities, Staphylococcus epidermidis has been shown to be a determining factor for Staphylococcus aureus colonization and biofilm formation. However, the interaction between S. epidermidis and S. aureus has mainly been described by phenotypic analysis, and little is known about how this interaction modulates gene expression.This study aimed to determine the interactome of nasal S. aureus and S. epidermidis isolates to understand the molecular effect of interaction. After whole-genome sequencing of two nasal staphylococcal isolates, an agar-based RNA sequencing setup was utilized to identify interaction-induced transcriptional alterations in surface-associated populations. Our results revealed differential expression of several virulence genes in both species. We also identified putative non-coding RNAs (ncRNAs) and, interestingly, detected a putative ncRNA transcribed antisense to esp, the serine protease of S. epidermidis, that has previously been shown to inhibit nasal colonization of S. aureus. In our study, the gene encoding Esp and the antisense ncRNA are both downregulated during interaction with S. aureus. Our findings contribute to a better understanding of pathogen physiology in the context of interactions with the commensal microbiota, and may provide targets for future therapeutics.Amplicon-based next-generation sequencing of plasma cell-free DNA for detection of driver and resistance mutations in advanced non-small cell lung cancer
Abstract
Background
Genomic analysis of plasma cell-free DNA is transforming lung cancer care, however available assays are limited by cost, turnaround time, and imperfect accuracy. Here we study amplicon-based plasma next-generation sequencing (NGS), rather than hybrid-capture-based plasma NGS, hypothesizing this would allow sensitive detection and monitoring of driver and resistance mutations in advanced non-small cell lung cancer (NSCLC). Methods
Plasma samples from patients with NSCLC and a known targetable genotype (EGFR, ALK/ROS1 and other rare genotypes) were collected while on therapy and analyzed, blinded to tumor genotype. Plasma NGS was performed using enhanced tagged amplicon sequencing of hotspots and coding regions from 36 genes, as well as intronic coverage for detection of ALK/ROS1 fusions. Diagnostic accuracy was compared to plasma ddPCR and tumor genotype. Results
A total of 168 specimens from 46 patients were studied. Matched plasma NGS and ddPCR across 120 variants from 80 samples revealed high concordance of allelic fraction (R2=0.95). Pretreatment, sensitivity of plasma NGS for the detection of EGFR driver mutations was 100% (30/30), compared to 87% for ddPCR (26/30). A full spectrum of rare driver oncogenic mutations could be detected including sensitive detection of ALK/ROS1 fusions (8/9 detected, 89%). Studying 25 patients positive for EGFR T790M that developed resistance to osimertinib, 15 resistance mechanisms could be detected including tertiary EGFR mutations (C797S, Q791P) and mutations or amplifications of non-EGFR genes, some of which could be detected pre-treatment or months before progression. Conclusions
This blinded analysis demonstrates the ability of amplicon-based plasma NGS to detect a full range of targetable genotypes in NSCLC, including fusion genes, with high accuracy. The ability of plasma NGS to detect a range of pre-existing and acquired resistance mechanisms highlights its potential value as an alternative to single mutation digital PCR-based plasma assays for personalizing treatment of TKI resistance in lung cancer.Prognostic and predictive role of neutrophil/lymphocytes ratio in metastatic colorectal cancer: a retrospective analysis of the TRIBE study by GONO.
Abstract
Background
Neutrophil/Lymphocyte ratio (NLR), defined as absolute neutrophils count divided by absolute lymphocytes count, has been reported as poor prognostic factor in several neoplastic diseases but only a few data are available about unresectable metastatic colorectal cancer (mCRC) patients (pts). The aim of our study was to evaluate the prognostic and predictive role of NLR in the TRIBE trial. Patients and Methods
Pts enrolled in TRIBE trial were included. TRIBE is a multicentre phase III trial randomizing unresectable and previously untreated mCRC pts to receive FOLFOXIRI or FOLFIRI plus bevacizumab. A cut-off value of 3 was adopted to discriminate pts with low (NLR < 3) vs high (NLR ≥ 3) NLR, as primary analysis. As secondary analysis, NLR was treated as an ordinal variable with three levels based on terciles distribution. Results
NLR at baseline was available for 413 patients. After multiple imputation at univariate analysis, patients with high NLR had significantly shorter PFS (HR: 1.27 [95%CI:1.05-1.55], p=0.017) and OS (HR: 1.56 [95%CI: 1.25-1.95], p<0.001) than patients with low NLR. In the multivariable model, NLR retained a significant association with OS (HR: 1.44 (95%CI: 1.14-1.82), p=0.014) but not with PFS (HR: 1.18 [95%CI: 0.95-1.46], p=0.375). No interaction effect between treatment arm and NLR was evident in terms of PFS (p for interaction=0.536) or OS (p for interaction=0.831). Patients with low (HR: 0.84 [95%CI: 0.64-1.08]) and high (HR: 0.73 [0.54-0.97]) NLR achieved similar PFS benefit from the triplet and consistent results were obtained in terms of OS (HR: 0.83 [95%CI: 0.62-1.12] for low NLR; HR: 0.82 [95%CI: 0.59-1.12] for high NLR). Conclusion
This study confirmed the prognostic role of NLR in mCRC pts treated with bevacizumab plus chemotherapy in first line, showing the worse prognosis of pts with high NLR. The advantage of the triplet is independent of NLR at baseline.Investigation of the effectiveness of therapeutic ultrasound with high-resolution ultrasonographic cross-sectional area measurement of cervical nerve roots in patients with chronic cervical radiculopathy: a prospective, controlled, single-blind study
Abstract
Purpose
The purpose of our study was to evaluate the effects of therapeutic ultrasound (US) on chronic cervical radiculopathy (CR) patients using both the clinical parameters and the cross-sectional area (CSA) values of the cervical nerve roots (NR) measured by high-resolution ultrasonography (HRUS).
Methods
Thirty-two patients with chronic CR were included in this prospective, controlled, and single-blind study. All of the patients received therapeutic US at continuous mode, 1-MHz frequency, and 1.5-W/cm2 intensity for 10 sessions. The patients were assessed using VAS for pain, Modified Neck Disability Index, and Short-form 12, and cervical NR were examined with HRUS. The data were obtained before treatment (W0), the second week immediately after treatment (W2), and at the sixth week (W6).
Results
Twenty-nine patients and a total of 42 affected cervical NR and 42 unaffected cervical NR (control group) were evaluated. A significant improvement was observed for all clinical parameters and CSA values of affected cervical NR both at W2 and W6 compared to pre-treatment values (p < 0.05).
Conclusions
We found therapeutic US to be beneficial in improvement of pain, disability, and quality of life of patients with chronic CR. We suggest that CSA measurements may also contribute to both diagnosis and post-treatment evaluation in chronic CR.
Neuroendokrine Tumoren aus psychoonkologischer Sicht – ein Überblick
Zusammenfassung
In aller Regel besteht bei Patienten mit neuroendokrinen Tumoren (NET) ein langwieriger Verlauf, der bereits lange vor Diagnosestellung beginnt. Sie müssen mit viel Ungewissheit umgehen. Dennoch lassen sich allgemeine Aussagen zur Lebensqualität (LQ) und psychischen Verfassung von Patienten mit NET schwer treffen. Zum einen ist NET ein Oberbegriff für eine heterogene Gruppe von Tumoren, die sich in ihrem klinischen Erscheinungsbild stark unterscheiden. Somit gibt es zwangsläufig innerhalb der Gruppe von Patienten mit NET erhebliche Unterschiede in den Belastungen und der LQ. Zum anderen gibt es bislang in der Literatur nur wenige hochwertige Studien, die mittels validierter und NET-spezifischer Messverfahren die LQ bzw. Belastungen von Patienten mit NET analysieren. Um besonders belastete Patienten zu identifizieren, ist eine differenzierte Betrachtung der LQ von Patienten mit NET erforderlich. Nur dann lassen sich auch klinisch relevante Schlüsse ableiten. Für Patienten mit psychischen Belastungen gibt es verschiedene evidenzbasierte Behandlungsmöglichkeiten.
Psychosoziale Aspekte von Harnblasenkarzinompatienten
Zusammenfassung
Tumorpatienten müssen sich mit dem Gefühl der Unsicherheit hinsichtlich des weiteren Lebens und Krankheitsverlaufs sowie mit unerwünschten Nebenwirkungen der Therapie auseinandersetzen. Niedrige Lebensqualität ist bei krebskranken Patienten ein unabhängiger prognostischer Faktor für geringere Überlebensraten. Psychosozialer Stress beeinflusst negativ das Immunsystem (Reduktion der NK-Zellen, Anstieg des Cortisolspiegels). Trotz verbesserter Diagnostik und Therapie bleibt das Blasenkarzinom durch hohe Rezidiv- und Progressionshäufigkeit gekennzeichnet. Für die Behandlung eines Harnblasentumors werden, je nach Tumorstadium, verschiedene therapeutische Maßnahmen empfohlen, die sich auf die Lebensqualität auswirken können. Studien über die psychosozialen Bedürfnisse von Patienten mit Harnblasenkarzinom sind vergleichsweise selten.
Physics’ silence on time
Abstract
In this paper I argue that physics is, always was, and probably always will be voiceless with respect to tense and passage, and that, therefore, if, as I believe, tense and passage are the essence of time, physics' contribution to our understanding of time can only be limited. The argument, in a nutshell, is that if "physics has no possibility of expression for the Now", to quote Einstein, then it cannot add anything to the study of tense and passage, and specifically, cannot add anything to the debate between deniers and affirmers of the existence or reality of tense and passage. Since relativity theory did not equip physics with a new language with which to speak of tense and passage, I draw the further conclusion that relativity theory has not generated the revolution to our conception of time that is attributed to it. In the last section I discuss the motivations behind the continued but misguided attempts to integrate tense into a relativistic setting, and assess the manners in which relativity theory has nevertheless enhanced, albeit indirectly, our understanding of tense and passage.
Etoposide as a single agent in the treatment of mycosis fungoides: A retrospective analysis
Abstract
Several chemotherapy agents have shown efficacy in the treatment of mycosis fungoides (MF). In the literature, there is limited data on the use of single agent etoposide for MF. We aimed to retrospectively review our experience with single agent etoposide in the treatment of advanced-stage or refractory early-stage MF with focus on analyzing its efficacy and safety. We included 13 MF patients who were treated with single agent etoposide. Patients were identified through the Cutaneous T Cell Lymphoma Database of Indiana University that involves patients treated from 2006 to 2016. Overall nine patients (69%) responded to treatment. No complete response was identified. Median time to response was 12.5 weeks (range: 6–25.4). Median duration of response was 43 weeks (range: 5–60) and median time to treatment failure was 31.3 weeks (range: 12.4–230). Hematological toxicity was observed in eight patients including two patients with grade 4 neutropenia and/or lymphopenia leading to sepsis. Higher doses of etoposide were significantly correlated with higher grades of anemia, neutropenia or lymphopenia (p < .05). Our study demonstrates that etoposide is an effective treatment for MF and may be considered in selected patients with progressive MF who have failed other treatments.
Correction to: Possessing epistemic reasons: the role of rational capacities
Abstract
In the original publication of the article, the last sentence in footnote 16 was incorrectly published as "Thanks to—for raising this issue." The corrected sentence should read as "Thanks to Daniel Star for raising this issue."
Speckled lentiginous nevus: understanding the process of development and regression
Speckled lentiginous nevus (SLN) is characterized by a brownish macule studded with blackish, multiple melanocytic nevi, although the cutaneous manifestations may vary by cases, and change by age. Therefore, there has been disagreement as to whether SLN is a congenital or acquired disease 1, 2). In rare cases of SLN, halo phenomenon may occur around the pre-existing lesion, associated with the coexistence of distant vitiligo 3). Here, we report a patient whose café-au-lait spot at birth changed to SLN, followed by the occurrence of vitiligo and poliosis through the process of spontaneous regression phenomenon against the SLN. We examined T-cell clones infiltrating around the melanocytic nevi and in the patient's peripheral blood.
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Publication date: Available online 25 July 2018 Source: Journal of Photochemistry and Photobiology B: Biology Author(s): Marco Ballestr...
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Editorial AJR Reviewers: Heartfelt Thanks From the Editors and Staff Thomas H. Berquist 1 Share + Affiliation: Citation: American Journal...
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Publication date: Available online 28 September 2017 Source: Actas Dermo-Sifiliográficas Author(s): F.J. Navarro-Triviño
