Necrobiosis lipoidica diabeticorum: a clinicopathologic study

Necrobiosis lipoidica diabeticorum is an unusual dermatologic condition with a characteristic clinical appearance and a clear association with diabetes mellitus. There is currently no treatment that reverses the atrophic changes associated with this lesion. We have carried out a clinicopathologic study on 15 subjects and, in addition, have reviewed 10 further biopsy specimens of necrobiosis lipoidica diabeticorum. We found a frequent association of necrobiosis lipoidica diabeticorum with other chronic complications of diabetes mellitus, including limited joint mobility. It is possible that nonenzymatic glucosylation or other changes in collagen may be important in the etiology of necrobiosis lipoidica diabeticorum and the limited joint mobility. We confirmed that cutaneous anesthesia is usually present in the necrobiosis lipoidica diabeticorum lesions. With the use of an antibody to S100 protein and an immunohistochemical method, there was an apparent decreased number of nerves in the skin lesions. We suggest that sensory loss results from local destruction of cutaneous nerves by the inflammatory process. Finally, in six elliptical biopsies extending into clinically normal skin, we demonstrated that the inflammatory infiltrate of necrobiosis lipoidica diabeticorum extended from the lesion into apparently normal skin surrounding clinically active lesions. Thus, intradermal steroids might be administered to perilesional areas surrounding active lesions in the hope of halting progression.     

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos)

Although the diagnostic and severity grading criteria on the 2013 Tokyo Guidelines (TG13) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice. Here, we conduct a systematic review of the literature to validate the TG13 diagnostic and severity grading criteria for AC and propose TG18 criteria. While there is little evidence evaluating the TG13 criteria, they were validated through a large‐scale case series study in Japan and Taiwan. Analyzing big data from this study confirmed that the diagnostic rate of AC based on the TG13 diagnostic criteria was higher than that based on the TG07 criteria, and that 30‐day mortality in patients with a higher severity based on the TG13 severity grading criteria was significantly higher. Furthermore, a comparison of patients treated with early or urgent biliary drainage versus patients not treated this way showed no difference in 30‐day mortality among patients with Grade I or Grade III AC, but significantly lower 30‐day mortality in patients with Grade II AC who were treated with early or urgent biliary drainage. This suggests that the TG13 severity grading criteria can be used to identify Grade II patients whose prognoses may be improved through biliary drainage. The TG13 severity grading criteria may therefore be useful as an indicator for biliary drainage as well as a predictive factor when assessing the patient's prognosis. The TG13 diagnostic and severity grading criteria for AC can provide results quickly, are minimally invasive for the patients, and are inexpensive. We recommend that the TG13 criteria be adopted in the TG18 guidelines and used as standard practice in the clinical setting. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47 . Related clinical questions and references are also included.     

Assessment of biomarkers associated with rapid renal decline in the detection of retinopathy and its progression in type 2 diabetes: The Fremantle Diabetes Study Phase II

AimsTo determine whether biomarkers for diabetic kidney disease (DKD) can be used to determine the prevalence, progression and/or incidence of diabetic retinopathy (DR) complicating type 2 diabetes.MethodsProteomic biomarkers were measured in baseline fasting plasma from 958 Fremantle Diabetes Study Phase II participants whose baseline and, in those returning for follow-up (n = 764), Year 4 fundus photographs were graded for DR presence/severity. The performance of PromarkerD (three biomarkers and readily available clinical variables which identify prevalent DKD and predict incident DKD and estimated glomerular filtration rate decline ≥30% over four years) for detecting DR prevalence, progression and incidence was assessed using the area under the receiver operating curve (AUC). Logistic regression determined whether individual proteins were associated with DR outcomes after adjusting for the most parsimonious model.ResultsPlasma apolipoprotein A-IV (APOA4) was independently associated with moderate non-proliferative DR at baseline (OR (95% CI): 1.64 (1.01, 2.67), P = 0.047). Model discrimination was poor for all PromarkerD predicted probabilities against all DR outcomes (AUC ≤0.681).ConclusionsPromarkerD and its constituent biomarkers were not consistently associated with DR prevalence or temporal change. APOA4 was associated with prevalent DR, but not DR incidence or progression. Distinct pathophysiological mechanisms may underlie DKD and DR.     

Cryptosporidiosis and AIDS

Cryptosporidiosis in patients with AIDS presents as a chronic enteritis, with biliary complications in about 10% of sufferers. The disease is persistent and progressively fatal. Due to the widespread prevalence of the parasite in the community and amongst domesticated animals, persons with AIDS are constantly at risk. Treatment is extremely difficult in view of the apparent lack of a specific anticryptosporidial drug. Methods of immunomodulation are worth considering, but the main recourse may have to be a prolonged regimen of rehydration and parenteral nutrition. However, if T helper cell function improves, the disease may go into remission or the parasite could be eliminated. Vaccination of those at risk is not feasible at present.     

Assessment of Inter-Laboratory Differences in SARS-CoV-2 Consensus Genome Assemblies between Public Health Laboratories in Australia

Whole-genome sequencing of viral isolates is critical for informing transmission patterns and for the ongoing evolution of pathogens, especially during a pandemic. However, when genomes have low variability in the early stages of a pandemic, the impact of technical and/or sequencing errors increases. We quantitatively assessed inter-laboratory differences in consensus genome assemblies of 72 matched SARS-CoV-2-positive specimens sequenced at different laboratories in Sydney, Australia. Raw sequence data were assembled using two different bioinformatics pipelines in parallel, and resulting consensus genomes were compared to detect laboratory-specific differences. Matched genome sequences were predominantly concordant, with a median pairwise identity of 99.997%. Identified differences were predominantly driven by ambiguous site content. Ignoring these produced differences in only 2.3% (5/216) of pairwise comparisons, each differing by a single nucleotide. Matched samples were assigned the same Pango lineage in 98.2% (212/216) of pairwise comparisons, and were mostly assigned to the same phylogenetic clade. However, epidemiological inference based only on single nucleotide variant distances may lead to significant differences in the number of defined clusters if variant allele frequency thresholds for consensus genome generation differ between laboratories. These results underscore the need for a unified, best-practices approach to bioinformatics between laboratories working on a common outbreak problem.     

A systematic review of the effectiveness of negative pressure wound therapy in the management of diabetes foot ulcers

Foot ulcers are a common complication in patients with diabetes. Negative pressure wound therapy (NPWT) is a wound care therapy that is being increasingly used in the management of foot ulcers. This article presents a systematic review examining the effectiveness of this therapy. The review question is how effective is NPWT in achieving wound healing in diabetes foot ulcers? The primary outcome for this study was the number of patients achieving complete wound healing (secondary outcomes, other markers of wound healing, adverse events and patient satisfaction). A systematic literature review and tabulative synthesis of randomised controlled trials (RCTs). The review identified four RCTs of weak to moderate quality. Only one study examining NPWT in postamputation wound healing reported data on the primary outcome. These data show a 20% improvement in wound healing [odds ratios = 2·0%, confidence interval (CI) ?1·0 to 4·0] and number needed to treat = 6 (CI 4–64). No serious treatment‐related complications were reported by any of the studies. One study suggested a reduction in the risk of secondary amputation (absolute risk reduction = 7·9%, CI 0·5–15·43). Studies also reported an increase in granulation and wound‐healing rates in patients treated with NPWT therapy. No data on patient satisfaction or experience were reported. While all the studies included in the review indicated that the NPWT therapy is more effective than conventional dressings, the quality of the studies were weak and the nature of the inquiries in terms of outcome and patient selection divergent. There is a strong need for larger trials to assess NPWT therapy in diabetes care with different groups of patients and in relation to different clinical objectives and parameters.     

Narrative change in emotion-focused therapy: How is change constructed through the lens of the innovative moments coding system?

Abstract

The aim of this study was to advance understanding of how clients construct their own process of change in effective therapy sessions. Toward this end, the authors applied a narrative methodological tool for the study of the change process in emotion-focused therapy (EFT), replicating a previous study done with narrative therapy (NT). The Innovative Moments Coding System (IMCS) was applied to three good-outcome and three poor-outcome cases in EFT for depression to track the innovative moments (IMs), or exceptions to the problematic self-narrative, in the therapeutic conversation. IMCS allows tracking of five types of IMs events: action, reflection, protest, reconceptualization, and performing change. The analysis revealed significant differences between the good-outcome and poor-outcome groups regarding reconceptualization and performing change IMs, replicating the findings from a previous study. Reconceptualization and performing change IMs seem to be vital in the change process.     

High income improves evaluation of life but not emotional well-being

Recent research has begun to distinguish two aspects of subjective well-being. Emotional well-being refers to the emotional quality of an individual''s everyday experience—the frequency and intensity of experiences of joy, stress, sadness, anger, and affection that make one''s life pleasant or unpleasant. Life evaluation refers to the thoughts that people have about their life when they think about it. We raise the question of whether money buys happiness, separately for these two aspects of well-being. We report an analysis of more than 450,000 responses to the Gallup-Healthways Well-Being Index, a daily survey of 1,000 US residents conducted by the Gallup Organization. We find that emotional well-being (measured by questions about emotional experiences yesterday) and life evaluation (measured by Cantril''s Self-Anchoring Scale) have different correlates. Income and education are more closely related to life evaluation, but health, care giving, loneliness, and smoking are relatively stronger predictors of daily emotions. When plotted against log income, life evaluation rises steadily. Emotional well-being also rises with log income, but there is no further progress beyond an annual income of ~$75,000. Low income exacerbates the emotional pain associated with such misfortunes as divorce, ill health, and being alone. We conclude that high income buys life satisfaction but not happiness, and that low income is associated both with low life evaluation and low emotional well-being.     

Post‐Liver Transplantation Multicentric Castleman Disease Treated with Valganciclovir and Weaning of Immunosuppression

Multicentric Castleman disease is a lymphoproliferative disorder which when seen in the setting of HIV/AIDS is often associated with human herpes virus 8 (HHV‐8) infection. We describe the case of a HIV‐negative man who developed HHV‐8‐associated multicentric Castleman disease 11 years after liver transplantation. The patient presented with fevers and weight loss. Physical examination revealed enlarged cervical, axillary and inguinal lymph nodes. Widespread lymphadenopathy was confirmed on computed tomography (CT) scanning. Histology of an enlarged lymph node showed a polymorphous infiltrate with mature plasma cells, plasmacytoid lymphocytes and occasional blasts within the cortex and paracortex. The diagnosis of Castleman disease was confirmed by the finding of numerous HHV‐8‐immunopositive cells around the regressed lymph node follicles and the detection of HHV‐8 on plasma PCR. Although the conventional treatment for this condition has been combination chemotherapy, in the post‐transplant context it was decided to treat the patient with valganciclovir and cessation of immunosuppression. His symptoms resolved rapidly and repeat plasma PCR done 3 months after starting treatment was negative for HHV‐8. A follow‐up CT scan showed a dramatic reduction in the size and amount of lymphadenopathy. After 15 months of treatment, he remains well with no evidence of graft dysfunction or rejection.     

(v) Meniscal tears,repairs and replacement – a current concepts review

The menisci play a key role in knee function. Maintaining meniscal function should therefore be one of the key goals of any surgeon performing arthroscopic surgery in the knee. This article aims to explore current concepts in meniscal surgery, including a review of the structure and function of the menisci with particular emphasis on the part they play in the biomechanics of load bearing, shock absorption and stability in the knee. The implications of meniscal injury are discussed and current strategies of meniscal resection, repair and replacement are reviewed.