Excellent color-matched repigmentation of human vitiligo can be obtained by mini-punch grafting using a machine in combination with ultraviolet therapy

A new method is reported here for treatment of vitiligo by using mini-punch grafting using a machine (mMG) in combination with ultraviolet light B (UVB) therapy. After UVB had been repeatedly irradiated to the lesional facial skin of a patient for 1 month, many mini-punch grafts were removed from the lesional skin and the same numbers of punch biopsies taken from normal scalp skin were placed into the holes of the recipient skin. Repigmentation started soon, and excellent color-matched repigmentation was observed after 12 months. Our easy and speedy mMG seems to be useful for treatment of vitiligo.     

Impact of a Resident Strike on Emergency Department Quality Indicators at an Urban Teaching Hospital

OBJECTIVE: To evaluate the indicators of activity and quality within the emergency department (ED) during a resident physicians' strike. METHODS: This was an observational study comparing a strike period (SP) and a non-strike period (NSP) in the ED of a 1,000-bed tertiary care teaching hospital in Barcelona, Spain, with an annual census of 100,000 emergency visits. During a period of nine nonconsecutive days, the resident physicians were on strike. Emergency visits were handled by staff members. Data were compared between all patients treated in the ED during the SP and those treated during the NSP, matched by the weekday. The authors compared lengths of stay (LOSs), rates of use of laboratory tests and radiology procedures, numbers of patient walkouts, patient/physician ratios, emergency hospital admission rates, home discharge rates, unscheduled return rates, and mortality rates. RESULTS: The two groups (SP 2,610 patients and NSP 3,634 patients) were comparable in terms of average daily attendance rate (SP: 290 +/- 12 vs NSP: 302 +/- 21; p = 0.13), elective hospital admission rate, and severity of illness. Statistically significant differences were found in terms of mean total patients' LOS (SP: 206.75 +/- 12.27 vs NSP: 235.10 +/- 27.08 minutes; p < 0.001), number of laboratory tests per patient (SP: 0.30 +/- 0.05 vs NSP: 0.38 +/- 0.04; p < 0.001), and radiographs per patient (SP: 0.78 +/- 0.06 vs NSP: 0.88 +/- 0.09; p = 0.021). CONCLUSIONS: This study demonstrated that replacing residents with staff physicians resulted in fewer laboratory tests ordered, fewer radiographs ordered, and shorter lengths of stays in the ED.     

Clinical characteristics and intravascular ultrasound findings of culprit lesions in elderly patients with acute coronary syndrome

Acute coronary syndrome (ACS) is one of the main causes of cardiovascular death. According to rapid aging of society, the peak age of ACS onset has grown older globally. Despite growing recognition of the necessity to build the ACS prevention strategy in the elderly, patients background and culprit lesion morphology of these elderly ACS patients have not been well studied. We sought to assess the clinical characteristics and intravascular ultrasound (IVUS) findings of the culprit lesions in elderly ACS patients. One-hundred and fifty-eight consecutive ACS patients whose culprit lesions imaged by pre-intervention IVUS were divided into two groups based on the age of onset: elderly [E] group (≥75 years, n = 65) and non-elderly [NE] group (<75 years, n = 93). As compared with NE group, hemoglobin (12.7 ± 2.0 g/dL vs. 13.7 ± 1.6 g/dL, p = 0.001), estimated glomerular filtration rate (62.5 ± 22.5 mL/min/1.73 m² vs. 75.5 ± 20.5 mL/min/1.73 m², p = 0.0001), and body mass index (22.9 ± 3.4 kg/m² vs. 24.5 ± 3.4 kg/m², p = 0.003) were significantly lower, and comorbid malignancy was more common (20.0 vs 6.5 %, p = 0.01) in E group. Although whole culprit segment was not positively remodeled (mean vessel area was 15.2 ± 5.6 mm³/mm vs. 16.2 ± 5.1 mm³/mm, p = 0.16) in E group, at maximum external elastic membrane site of the culprit lesion, lumen area was smaller (5.5 ± 3.2 mm² vs. 6.7 ± 3.5 mm², p = 0.04), and plaque burden tended to be more abundant (70 ± 13 vs. 66 ± 13 %, p = 0.08). Interestingly, echo attenuation arc of culprit attenuated plaque was significantly greater in E group than in NE group (157 ± 83° vs. 118 ± 60°, p = 0.01). In conclusion, extracardiac comorbidity was more common in elderly ACS patients, and their culprit coronary lesions were still rupture prone, and “vulnerable.”     

Tricuspid regurgitation occurring in the early‐diastolic phase in a case of heart failure: Insights from echocardiographic and invasive hemodynamic findings

Although the presence and physiological significance of late‐diastolic tricuspid regurgitation (TR) have been reported, those in TR occurring in early diastole have not been well known. We herein first presented a case of heart failure due to dilated cardiomyopathy showing functional TR occurring in the early‐diastolic phase in whom the mechanism for its genesis could be precisely assessed from echocardiographic findings and intra‐cardiac pressure recordings.     

Infiltration of tumor‐associated macrophages is involved in tumor programmed death‐ligand 1 expression in early lung adenocarcinoma

Programmed death‐ligand 1 (PD‐L1) is an immune modulator that promotes immunosuppression by binding to programmed death‐1 of T‐lymphocytes. Although tumor cell PD‐L1 expression has been shown to be associated with the clinical response to anti–PD‐L1 antibodies, its concise regulatory mechanisms remain elusive. In this study, we evaluated the associations of tumor PD‐L1 expression and immune cell infiltrating patterns in 146 cases of early lung adenocarcinoma (AC) to investigate the possible extrinsic regulation of tumor PD‐L1 by immune cells. Using immunohistochemistry, cell surface PD‐L1 expression in tumor cells was observed in 18.5% of stage 0‐IA lung AC patients. Tumor PD‐L1 positivity was significantly associated with stromal invasion, which was accompanied by increased tumor‐associated macrophages (TAM), CD8⁺ cytotoxic T cells and FoxP3⁺ regulatory T cells. Among these immune cells, TAM and CD8⁺ T cells significantly accumulated in PD‐L1‐positive carcinoma cell areas, which showed a tumor cell nest‐infiltrating pattern. Although CD8⁺ T cells are known to induce tumor PD‐L1 expression via interferon‐? production, the increased TAM within tumors were also associated with tumor cell PD‐L1 positivity, independently of CD8⁺ T cell infiltration. Our in vitro experiments revealed that PD‐L1 expression in lung cancer cell lines was significantly upregulated by co–culture with M2‐differentiated macrophages; expression of PD‐L1 was reduced to baseline levels following treatment with a transforming growth factor‐β inhibitor. These results demonstrated that tumor‐infiltrating TAM are extrinsic regulators of tumor PD‐L1 expression, indicating that combination therapy targeting both tumor PD‐L1 and stromal TAM might be a possible strategy for effective treatment of lung cancer.     

Postoperative Radiation Therapy for Pituitary Adenoma

Background: We evaluated the efficacy of postoperative radiation therapy (RT), prognostic factors for local control probability, dose response relationship and treatment sequelae in 75 patients with pituitary adenoma. Materials and methods: A total dose of 48–60Gy (median: 50Gy) was delivered with a conventional fractionation schedule after surgery. Of 75 patients, 55 (73%) were followed for more than 5 years and 27 (36%) were followed for more than 10 years with a median of 95 months. Results: Five- and 10-year local control probabilities were 87.1% and 85.0%, respectively. Univariate analysis revealed that age (p=0.007), tumor volume smaller than 30cm³ (p=0.018) and the absence of prolactin secretion (p=0.003) were significantly favorable prognostic factors for local control probability. After multivariate analysis combining these 3 factors, tumor volume smaller than 30cm³ (p=0.017) and age (p=0.039) were statistically significant. Patients with prolactinoma greater than 30cm³ showed particularly poor local control rates. No significant improvement of the local control rate was detected with increasing total irradiation doses between 48 and 60Gy (p=0.29). The most common side effect was hypopituitarism, and there were no severe sequelae such as optic neuropathy or brain necrosis. Conclusion: Except with prolactinoma, the dose of postoperative RT for pituitary adenoma should not exceed 50Gy. Large prolactinoma, however, was very difficult to control with the irradiation doses between 50 and 60Gy, and would be good candidates for stereotactic radiosurgery or stereotactic radiation therapy.     

Value of whole-body FDG PET in management of lung cancer

18F-fluorodeoxyglucose (FDG) PET imaging provides physiologic and metabolic information that characterizes lesions that are indeterminate by CT. FDG PET imaging is sensitive to the detection of lung cancer in patients who have indeterminate lesions on CT, whereas low grade malignancy such as bronchioloalveolar carcinoma and carcinoid may be negative on FDG PET. The specificity of PET imaging is less than its sensitivity because some inflammatory processes, such as active granulomatous infections, avidly accumulate FDG. This possibility should be kept in mind in the analysis of PET studies of glucose metabolism aimed at differentiating malignant from benign solitary pulmonary nodules. FDG uptake is considered to be a good marker of cell differentiation, proliferative potential, aggressiveness, and the grade of malignancy in patients with lung cancer. FDG PET accurately stages the distribution of lung cancer. Several studies have documented the increased accuracy of PET compared with CT in the evaluation of the hilar and mediastinal lymphnode status in patients with lung cancer. Whole-body PET studies detect metastatic disease that is unsuspected by conventional imaging. Management changes have been reported in up to 41% of patients on the basis of the results of whole-body studies. Whole-body FDG PET is also useful for the detection of recurrence. Several studies have indicated that the degree of FDG uptake in primary lung cancer can be used as an independent prognostic factor. Thus, whole-body FDG PET is clinically very useful in the management of lung cancer.