Management of recurrent Cushing’s disease

The management of patients with Cushing’s disease remains a major challenge. The remission rate for initial transsphenoidal surgery is reported as 69-94% while the recurrence rate following initially successful transsphenoidal surgery is 2-27%. Treatment options for Cushing’s disease after failed initial therapy or recurrence include repeat transsphenoidal surgery, radiotherapy, medical therapy and bilateral adrenalectomy. Management options following unsuccessful initial surgery or recurrence are presented and discussed.     

Neurotic excoriations: a diagnosis of exclusion

Patients with psychiatric disease may use the skin as a means of communication during times of increased emotional distress. Furthermore, a high incidence of skin disorders among patients with a primary psychiatric condition, including depression, schizophrenia, and anxiety, has been demonstrated, with neurotic excoriation being one of the most commonly diagnosed. Despite the strong association and incidence of psychogenic excoriation in patients with a primary psychiatric disorder, it is important for primary care physicians and dermatologists alike to realize that these patients may have true dermatological disease. The authors present a 53-year-old woman with past medical history significant for schizophrenia, depression, hepatitis C, and diabetes mellitus type II, who was transferred from an outside hospital secondary to anemia in association with diffuse skin lesions. Although she adamantly denied self-inducing the skin lesions, she was diagnosed with neurotic excoriations by primary care and specialty care physicians on three different occasions. After a thorough workup during this admission, the patient was diagnosed with bullous pemphigoid.     

Hair dryer use to optimize pulsed dye laser treatment in rosacea patients

Rosacea is a common chronic inflammatory condition characterized by erythema, telangiectasias, papules, and pustules. While there are many effective treatment options for the papulopustular type, laser therapy remains the most effective modality to treat erythematotelangiectatic rosacea. Erythema and flushing associated with rosacea remains an uncomfortable and socially embarrassing problem for patients. Unfortunately, patients often do not have significant erythema or flushing when they present for laser treatment. With this in mind, we propose a novel technique aimed at enhancing the response of rosacea patients being treated for erythema with pulsed dye laser. Specifically, we present a split-face example of our clinical observation that pre-treatment with forced heated air prior to pulsed-dye laser leads to a greater response in rosacea patients with erythema and flushing.     

Postmortem metabolomics: Correlating time‐dependent concentration changes of xenobiotic and endogenous compounds

Postmortem redistribution (PMR) describes the artificial postmortem concentration changes of xenobiotics that may pose major challenges in forensic toxicology. Only a few studies have systematically investigated time‐dependent postmortem drug concentration changes so far and the a posteriori estimation of the occurrence of PMR is not yet possible. In this context, the general concept that postmortem biochemical changes in blood might parallel drug redistribution mechanisms seems promising. Thus, the current study investigated the possible correlations between time‐dependent postmortem concentration changes of xenobiotic and endogenous compounds; exemplified for authentic morphine (n = 19) and methadone (n = 11) cases. Peripheral blood samples at two time‐points postmortem were analyzed for morphine and methadone concentrations and an (un)targeted postmortem metabolomics approach was utilized to combine targeted quantitative analysis of 56 endogenous analytes and untargeted screening for endogenous compounds (characterizing 1174 features); liquid and gas chromatography–mass spectrometry was used respectively. Individual statistically significant correlations between morphine/methadone and endogenous compounds/features could be determined. Hence, the general applicability of the proposed concept could successfully be confirmed. To verify the reproducibility and robustness of the correlating behavior, a larger dataset must be analyzed next. Once a marker/set of markers is found (e.g. robust correlation with specific xenobiotic or xenobiotic class), these could be used as surrogates to further study the time‐dependent PMR in a broader variety of cases (e.g. independent of a xenobiotic drug present). A crucial next step will also be the attempt to create a statistical model that allows a posteriori estimation of PMR occurrence of xenobiotics to assist forensic toxicologists in postmortem case interpretation.