Jessner�CKanof disease induced by leflunomide: a dermal variant of cutaneous lupus?

Leflunomide can have adverse effects, but cases of subacute cutaneous lupus have more rarely been described. This drug, through its immunomodulatory effect, can favor the appearance of a Th2 lymphocyte immune response inducing lupus. A recent study has suggested that Jessner–Kanof disease (JKD) could be a dermal form of lupus. We report a case of subacute cutaneous lupus induced by leflunomide with anti-Ro/SSA Ab and unusual histological presentation, identical to that of JKD. Leflunomide can induce cutaneous lupus characterized by exclusively dermal involvement and histologically comparable to JKD. This observation therefore suggests that JKD could be a dermal variant of lupus. This prompted a revision of the classification of cutaneous lupus, which has until now been divided into acute, subacute and chronic forms but could equally be classed as epidermal, dermal and hypodermal. The last point of interest in our observation is the efficacy of a combination of chloroquine and anakinra, which led to complete remission of the articular and cutaneous symptoms after the failure of corticotherapy.     

Complications of HIV infection in an ageing population: challenges in managing older patients on long-term combination antiretroviral therapy

With the use of combination antiretroviral therapy, the proportion of HIV-infected patients over age 50 has greatly increased. The rate of progression of untreated HIV disease, response to therapy and complicating effects of co-morbidities differ in older versus younger patients. Compared with younger individuals, older untreated HIV patients demonstrate faster rates of CD4+ cell loss and more rapid progression to AIDS and death. With treatment, older patients have a better virological response, but a less robust immunological response. The treatment of older HIV-infected patients is further complicated by pre-existing co-morbid conditions including cardiovascular, hepatic and metabolic complications that may be exacerbated by the effects of HIV infection per se, modest immunodeficiency (i.e. at CD4+ counts >350 cells/mm3), and the metabolic and other adverse effects of combination antiretroviral therapy. Based on these considerations guidelines for the treatment of HIV-infected patients state that increased age is a consideration in initiating antiretroviral therapy in persons with >350-500 CD4+ cells/mm3.     

New imaging techniques and opportunities in endoscopy

Gastrointestinal endoscopy is undergoing major improvements, which are driven by new available technologies and substantial refinements of optical features. In this Review, we summarize available and evolving imaging technologies that could influence the clinical algorithm of endoscopic diagnosis. Detection, characterization and confirmation are essential steps required for proper endoscopic diagnosis. Optical and nonoptical methods can help to improve each step; these improvements are likely to increase the detection rate of neoplasias and reduce unnecessary endoscopic treatments. Furthermore, functional and molecular imaging are emerging as new diagnostic tools that could provide an opportunity for personalized medicine, in which endoscopy will define disease outcome or predict the response to targeted therapy.     

Organ‐level histological and biomechanical responses from localized osteoarticular injury in the rabbit knee

The processes of whole‐joint osteoarthritis development following localized joint injuries are not well understood. To demonstrate this local‐to‐global linkage, we hypothesized that a localized osteoarticular injury in the rabbit knee would not only cause biomechanical and histological abnormalities in the involved compartment but also concurrent histological changes in the noninvolved compartment. Twenty rabbits had an acute osteoarticular injury that involved localized joint incongruity (a 2‐mm osteochondral defect created in the weight‐bearing area of the medial femoral condyle), while another 20 received control sham surgery. At the time of euthanasia at 8 or 16 weeks post‐surgery, the experimental knees were subjected to sagittal‐plane laxity measurement, followed by cartilage histo‐morphological evaluation using the Mankin score. The immediate effects of defect creation on joint stability and contact mechanics were explored in concomitant rabbit cadaver experimentation. The injured animals had cartilage histological scores significantly higher than in the sham surgery group (p < 0.01) on the medial femoral, medial tibial, and lateral femoral surfaces (predominantly on the medial surfaces), accompanied by slight (mean 20%) increase of sagittal‐plane laxity. Immediate injury‐associated alterations in the medial compartment contact mechanics were also demonstrated. Localized osteoarticular injury in this survival animal model resulted in global joint histological changes. © 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 29:340–346, 2011     

Kardiopulmonale Reanimation durch einen professionellen Helfer

Background

The 2005?guidelines for cardiopulmonary resuscitation (CPR) do not define the rescuer’s position while performing basic life support (BLS) by one single rescuer with a bag-valve mask device. Three different methods are possible: chest compressions and ventilations from over the head of the casualty (over-the-head CPR), from the side of the casualty (lateral CPR) and chest compressions from the side and ventilations from over-the-head of the casualty (alternating CPR). The aim of this study was to compare the quality of BLS of these three methods.

Methods

After a standardized theoretical introduction and hands-on training 117?medical students with limited knowledge and training in CPR participated in this study. Students were randomized in a cross-over design and performed a 2?min CPR test for each position on a manikin.

Results

Over-the-head CPR led to significantly more chest compressions (median 139 per 2?min), significantly higher number of inflations (8 per 2?min) and significantly shorter hands-off time (41?s) compared to lateral (136; 8; 42?s) and alternating CPR (125; 7; 46?s). Over-the-head CPR resulted in significantly more correctly performed ventilations (4 per 2?min) and non-significantly fewer correct chest compressions (61 per 2?min) compared to lateral (3; 82) and alternating CPR (3; 80).

Conclusions

Even though the statistical differences between the positions might not be of clinical relevance, according to the data over-the-head CPR is a good option for a single rescuer equipped with a bag-valve mask device and who is familiar with bag-valve-mask ventilation.     

Confocal laser endomicroscopy for the diagnosis of urothelial bladder neoplasia: a technology of the future?

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? Bladder cancer is initially diagnosed by white light cystoscopy followed by histopathological evaluation after transurethral resection of tissue suspicious for cancer. Difficulties may occur especially in the assessment of flat lesions or in discrimination between CIS and inflammatory disease. Confocal endomicroscopy during diagnostic colonoscopy has been a valuable tool for in vivo microscopic visualization and detection of colonic neoplasias and has contributed to optimized detection rates of up to 99%. We evaluated resected bladder urothelium of 18 patients by confocal endomicroscopy and correlated microscopic findings with standard histopathology. Typical tumour growth patterns such as altered nuclear to cytoplasmic ratio, pseudopapillar tissue stratification and neoangiogenesis were readily visible. As nuclear and subnuclear architecture of healthy bladder tissue could be discriminated against neoplastic tissue, confocal endomicroscopy is a promising novel tool for the in vivo microscopic visualization of bladder cancer.

OBJECTIVE

• ? To evaluate bladder urothelium by confocal laser endomicroscopy (CLE) and correlate microscopic findings with standard histopathology.

PATIENTS AND METHODS

• ? Fresh bladder urothelium tissue specimens were topically stained with acriflavine for instantaneous microscopic imaging.
• ? A single‐line laser in a handheld CLE probe delivered an excitation wavelength of 488 nm providing a high resolution of 0.7 µm and an adjustable imaging depth of 0–250 µm.
• ? Resection specimens of 18 patients were investigated with 1000‐fold magnification and ex vivo findings were compared with targeted histopathology (haematoxylin and eosin staining).

RESULTS

• ? Typical tumour growth patterns such as altered nuclear to cytoplasmic ratio, pseudopapillar tissue stratification and neoangiogenesis were readily visible.
• ? Nuclear and subnuclear architecture of healthy bladder tissue could be discriminated against neoplastic tissue.

CONCLUSIONS

• ? In addition to white light cystoscopy, CLE is a promising novel tool for the in vivo microscopic visualization of bladder cancer; first results of the present study show its potential to define microscopic characteristics of bladder cancer tissue.
• ? Further in vivo studies are necessary to determine sensitivity and specificity of the technique.