Refractory pityriasis rubra pilaris treated with etanercept,adalimumab, or ustekinumab: A retrospective investigation

Pityriasis rubra pilaris (PRP) is a rare, difficult to treat papulosquamous disorder that responds variably to retinoids and immunosuppression. Successful use of biologics for treating PRP has been described in the literature by case reports and a limited number of case series. To provide additional data, we retrospectively analyzed cases of PRP treated with biologics at our institution. We identified seven patients with a clear diagnosis of PRP treated with adalimumab, etanercept, and/or ustekinumab at our institution from January 1, 2014 to April 1, 2017. Six of seven patients had type I, adult acquired PRP, and one had type V atypical juvenile PRP. In response to tumor necrosis factor (TNF)‐α inhibition, two patients had marked responses (>75% improvement in involved body surface area), while three patients failed to show any improvement on a TNF‐α inhibitor. In two cases of PRP refractory to TNF‐α inhibition, ustekinumab resulted in a partial response (<75% improvement) in one patient and no response in the other. Compared to other published data, our cohort was substantially more resistant to treatment with biologics, a finding which may provide valuable perspective for dermatologists managing refractory PRP in the future.     

Treatment of acne using a 3-milligram drospirenone/20-microgram ethinyl estradiol oral contraceptive administered in a 24/4 regimen: a randomized controlled trial

OBJECTIVE: To assess the efficacy of the combined oral contraceptive containing 3-mg drospirenone/20-microgram ethinyl estradiol (3-mg drospirenone/20-microgram ethinyl estradiol) administered as 24 consecutive days of active treatment after a 4-day hormone-free interval (24/4 regimen) compared with placebo for the treatment of moderate acne vulgaris. METHODS: Healthy females aged 14-45 years with moderate acne were randomized in this double-blind study to 3-mg drospirenone/20-microgram ethinyl estradiol (n=270) or placebo (n=268) for six cycles of 28 days. The primary outcome measures of acne lesion counts and Investigator Static Global Assessment scale ratings were assessed at baseline and during cycles 1, 3, and 6. RESULTS: The percentage reduction from baseline to endpoint for total lesions is 46.3% for 3-mg drospirenone/20-microgram ethinyl estradiol 24/4 combination oral contraceptive group and 30.6% for placebo group (P<.001). The likelihood of participants in the 3-mg drospirenone/20-microgram ethinyl estradiol 24/4 regimen group having "clear" or "almost clear" skin as rated by the investigators at endpoint was about threefold (odds ratio 3.13, 95% confidence interval 1.69-5.81; P=.001) greater than in the placebo group. The 3-mg drospirenone/20-microgram ethinyl estradiol 24/4 regimen was well tolerated. CONCLUSION: The low-dose combined oral contraceptive containing 3-mg drospirenone/20-microgram ethinyl estradiol administered in a 24/4 regimen significantly reduced acne lesion counts more effectively than placebo and demonstrated greater improvement in the Investigator Static Global Assessment rating of acne. The safety profile was consistent with low-dose combined oral contraceptive use.     

Minimal Incision Surgery as a Risk Factor for Early Failure of Total Knee Arthroplasty

A consecutive series of revision total knee arthroplasty (TKA) performed at 3 centers by 5 surgeons for a 3-year period was reviewed. Revisions performed for infection and rerevisions were excluded. Review of clinical and radiographic data determined incision type, sex, age, time to revision, and primary diagnosis at time of revision. Two-hundred thirty-seven first-time revision TKAs were performed, of which 44 (18.6%) had been a minimal incision surgery (MIS) primary TKA and 193 (81.4%) had been a standard primary TKA. Patients with MIS were younger (62.1 vs 66.2 years, P = .02). Most striking was the difference in time to revision, which was significantly shorter for the MIS group (14.8 vs 80 months, P < .001). Minimal incision surgery TKA accounted for a substantial percentage of revision TKA in recent years at these centers. The high prevalence of MIS failures occurring within 24 months is disturbing and warrants further investigation.     

Ultrasound-guided bilateral rectus sheath block vs. conventional local analgesia in single port laparoscopic appendectomy for children with nonperforated appendicitis

Introduction

Despite its minimally invasive approach, laparoscopic surgery can cause considerable pain. Regional analgesic techniques such as the rectus sheath block (RSB) offer improved pain management following elective umbilical hernia repair in the pediatric population. This effect has not been examined in laparoscopic single-incision surgery in children. We sought to compare the efficacy of bilateral ultrasound-guided RSB versus local anesthetic infiltration (LAI) in providing postoperative pain relief in pediatric single-incision transumbilical laparoscopic assisted appendectomy (TULA) with same-day discharge.

Simultaneous ST-segment elevation in inferior and precordial leads following ingestion of a lethal dose of desipramine: a novel Brugada-like EKG pattern

The typical Brugada electrocardiographic (EKG) pattern includes ST-segment elevation in the right precordial leads (V1–V3) associated with right bundle branch block (rSR′) like morphology. Recently, a Brugada-like EKG pattern with ST-segment elevation in inferior leads called the “Brugada variant” has been reported. We report a case of simultaneous typical and variant Brugada EKG patterns with ST-segment elevation in the inferior as well as the precordial leads following ingestion of a lethal dose of desipramine.     

Antibiotic Use in Thailand: Quantifying Impact on Blood Culture Yield and Estimates of Pneumococcal Bacteremia Incidence

No studies have quantified the impact of pre-culture antibiotic use on the recovery of individual blood-borne pathogens or on population-level incidence estimates for Streptococcus pneumoniae. We conducted bloodstream infection surveillance in Thailand during November 2005–June 2008. Pre-culture antibiotic use was assessed by reported use and by serum antimicrobial activity. Of 35,639 patient blood cultures, 27% had reported pre-culture antibiotic use and 24% (of 24,538 tested) had serum antimicrobial activity. Pathogen isolation was half as common in patients with versus without antibiotic use; S. pneumoniae isolation was 4- to 9-fold less common (0.09% versus 0.37% by reported antibiotic use; 0.05% versus 0.45% by serum antimicrobial activity, P < 0.01). Pre-culture antibiotic use by serum antimicrobial activity reduced pneumococcal bacteremia incidence by 32% overall and 39% in children < 5 years of age. Our findings highlight the limitations of culture-based detection methods to estimate invasive pneumococcal disease incidence in settings where pre-culture antibiotic use is common.     

Analysis of four prevalent filaggrin mutations (R501X, 2282del4, R2447X and S3247X) in Austrian and German patients with atopic dermatitis

Background Recently, mutations in the filaggrin gene (FLG) have been shown to be a major predisposing factor for atopic dermatitis (AD). Objective In this study, we evaluated the influence of four prevalent mutations (R501X, 2282del4, R2447X and S3247X) in a large cohort of 462 Austrian and German AD patients and in 402 control individuals. Results We found a strong association of the FLG mutations with AD. Subgroup analysis revealed a significantly higher proportion of patients with an early age of disease onset and significantly higher median serum IgE levels among mutation carriers. Furthermore, we observed an overrepresentation of null alleles in AD patients with concomitant asthma compared with those without this co‐morbidity. Conclusion Our data confirm and extend the knowledge of the influence of FLG mutations in AD.