The Q-switched 1064-nm neodymium-doped yttrium aluminum garnet (QS 1064-nm Nd:YAG) laser is increasingly used for nonablative skin rejuvenation or "laser toning" for melasma. Multiple and frequent low-fluence, large-spot-size treatments are used to achieve laser toning, and these treatments are associated with the development of macular hypopigmentation as a complication. We present a case series of three patients who developed guttate hypomelanotic macules on the face after receiving laser toning treatment with QS 1064-nm Nd:YAG.
Aluminum ; Humans ; Hypopigmentation* ; Melanosis ; Rejuvenation ; Skin ; Yttrium

PURPOSE: Guidelines in western countries recommend retrieving ≥15 lymph nodes (LNs) during gastric cancer resection. This study sought to determine whether the number of examined lymph nodes (eLNs), a proxy for lymphadenectomy, effects survival in node-negative disease. MATERIALS AND METHODS: The US National Cancer Database (2003–2011) was reviewed for node-negative gastric adenocarcinoma. Treatment was categorized by neoadjuvant therapy (NAT) vs. initial resection, and further stratified by eLN. Kaplan-Meier and Weibull models were used to analyze overall survival. RESULTS: Of the 1,036 patients who received NAT, 40.5% had ≤10 eLN, and most underwent proximal gastrectomy (67.8%). In multivariate analysis, greater eLN was associated with improved survival (eLN 16–20: HR, 0.71; P=0.039, eLN 21–30: HR, 0.55; P=0.001). Of the 2,795 patients who underwent initial surgery, 42.5% had ≤10 eLN, and the majority underwent proximal gastrectomy (57.2%). In multivariate analysis, greater eLN was associated with improved survival (eLN 11–15: HR, 0.81; P=0.021, eLN 16–20: HR, 0.73; P=0.004, eLN 21–30: HR, 0.62; P<0.001, and eLN >30: HR, 0.58; P<0.001). CONCLUSIONS: In the United States, the majority of node-negative gastrectomies include suboptimal eLN. In node-negative gastric cancer, greater LN retrieval appears to have therapeutic and prognostic value, irrespective of initial treatment, suggesting a survival benefit to meticulous lymphadenectomy.
Adenocarcinoma ; Gastrectomy ; Humans ; Lymph Node Excision ; Lymph Nodes* ; Multivariate Analysis ; Neoadjuvant Therapy ; Proxy ; Stomach Neoplasms* ; United States*

INTRODUCTIONTreatment of acute lymphoblastic leukaemia (ALL) using intensive chemotherapy has resulted in high cure rates but also substantial morbidity. Infective complications represent a significant proportion of treatment-related toxicity. The objective of this study was to describe the microbiological aetiology and clinical outcome of episodes of chemotherapy-induced febrile neutropaenia in a cohort of children treated for ALL at our institution.

MATERIALS AND METHODSPatients with ALL were treated with either the HKSGALL93 or the Malaysia-Singapore (Ma-Spore) 2003 chemotherapy protocols. The records of 197 patients who completed the intensive phase of treatment, defined as the period of treatment from induction, central nervous system (CNS)-directed therapy to reinduction from June 2000 to January 2010 were retrospectively reviewed.

RESULTSThere were a total of 587 episodes of febrile neutropaenia in 197 patients, translating to an overall rate of 2.98 episodes per patient. A causative pathogen was isolated in 22.7% of episodes. An equal proportion of Gram-positive bacteria (36.4%) and Gram-negative bacteria (36.4%) were most frequently isolated followed by viral pathogens (17.4%), fungal pathogens (8.4%) and other bacteria (1.2%). Fungal organisms accounted for a higher proportion of clinically severe episodes of febrile neutropaenia requiring admission to the high-dependency or intensive care unit (23.1%). The overall mortality rate from all episodes was 1.5%.

CONCLUSIONFebrile neutropaenia continues to be of concern in ALL patients undergoing intensive chemotherapy. The majority of episodes will not have an identifiable causative organism. Gram-positive bacteria and Gram-negative bacteria were the most common causative pathogens identified. With appropriate antimicrobial therapy and supportive management, the overall risk of mortality from febrile neutropaenia is extremely low.

Candidiasis ; epidemiology ; Chemotherapy-Induced Febrile Neutropenia ; epidemiology ; microbiology ; Child ; Cohort Studies ; Escherichia coli Infections ; epidemiology ; Gram-Negative Bacterial Infections ; epidemiology ; Gram-Positive Bacterial Infections ; epidemiology ; Humans ; Influenza, Human ; epidemiology ; Klebsiella Infections ; epidemiology ; Mycoses ; epidemiology ; Precursor Cell Lymphoblastic Leukemia-Lymphoma ; drug therapy ; Pseudomonas Infections ; epidemiology ; Retrospective Studies ; Singapore ; epidemiology ; Staphylococcal Infections ; epidemiology ; Virus Diseases ; epidemiology

Introduction: Bullous pemphigoid (BP) is a chronic, autoimmune blistering disease occurring primarily in the elderly population. The pathogenesis of this condition has been strongly linked to the presence of circulating and tissue-bound autoantibodies against the basement membrane antigens BP180 and BP230. In most cases, the causative agent remains unidentified, but in a selected few, certain medications have been implicated in the pathogenesis of the disease. Dipeptidyl peptidase-4 inhibitors (-gliptins), in particular, which are used primarily in the treatment of diabetes mellitus, have been increasingly suspected to be a prime aggravating drug in the incidence of BP. Case summary: Bullous pemphigoid (BP) is a chronic autoimmune blistering disease mainly affecting the elderly population. While the pathogenesis has not yet been fully elucidated, it has been suggested that there is a correlation observed with certain groups of medications. Among drugs correlated with bullous pemphigoid, the group of dipeptidyl peptidase-4 inhibitors (-gliptins) used in the treatment of diabetes mellitus has been one of the most strongly associated. This is a case of a 64-year-old female on regular maintenance medications including linagliptin who developed generalized pruritus followed a week after by appearance of localized fluid-filled vesicles and bullae on the right lower leg. BP associated with dipeptidyl peptidase-4 inhibitors is characterized as “non-inflammatory” – lesions are localized and associated with less erythema compared to the classic presentation. Serum eosinophilia was absent, and serum autoantibody against BP180 was positive. Histopathologic and immunohistologic results revealed characteristics similar to classic bullous pemphigoid. The association of dipeptidyl peptidase-4 inhibitors to the development of BP was observed to have a long latency period between initiation of drug to onset of lesions. There was significant improvement after both withdrawal of the drug and standard steroids and doxycycline. Unlike other drug-induced BP, dipeptidyl peptidase-4 inhibitor-associated BP was found to have similar prognosis with the classic manifestation as the patient noted recurrence one month after remission despite withdrawal of inciting drug. Conclusion: There has been increasing incidence in DPP-4 inhibitor-associated BP. Though its clinical course is similar to classic BP, a non-inflammatory and more localized presentation would prompt suspicion of association with drug. The long latency in DPP-4 inhibitor and lesion onset suggests that rather than being simply an adverse reaction to treatment, DPP-4 inhibitor-associated BP should be viewed as a drug-associated or drug-aggravated disease. Determining the association of BP to DPP4-inhibitors is significant as the management for these patients not only entails standard management of BP but also withdrawal of the suspect drug, which in this case was found to significantly improve the patient’s lesions after one month. Unlike other drug-induced BP, however, DPP-4 inhibitor associated BP was found to have the same prognosis with classic BP as the patient noted recurrence one month after remission.
Dipeptidyl-Peptidase IV Inhibitors ; Pemphigoid, Bullous ; Pharmaceutical Preparations ; Dipeptidyl-Peptidase IV Inhibitors ; Hypoglycemic Agents

INTRODUCTIONWe aimed to develop and implement a short tandem repeat (STR) polymerase chain reaction alternative to fluorescence in situ hybridisation (FISH) for the preimplantation genetic diagnosis (PGD) of chromosomal translocations.

METHODSSelected informative STRs located on translocated arms of relevant chromosomes were used to discriminate between normal and unbalanced chromosome states in each embryo.

RESULTSPGD cycles were performed on five couples where one spouse carried a balanced translocation. 27 embryos were analysed, of which 12 were normal/balanced, 12 were abnormal/unbalanced and three were indeterminate. Four PGD cycles proceeded to embryo transfer, of which two led to pregnancy. The first pregnancy showed a normal male karyotype, and a healthy baby was delivered at term. A second pregnancy unexpectedly miscarried in the second trimester from unknown causes.

CONCLUSIONSTR analysis is a simple and suitable alternative to FISH for detecting unbalanced chromosomal states in preimplantation embryos.

Female ; Fertilization in Vitro ; Humans ; Male ; Microsatellite Repeats ; genetics ; Polymerase Chain Reaction ; methods ; Polymorphism, Genetic ; genetics ; Pregnancy ; Pregnancy Outcome ; Preimplantation Diagnosis ; methods ; Translocation, Genetic ; genetics

OBJECTIVEHawai'i is an ethnically diverse island state with a high rate of both traditional healing (TH) and complementary and alternative medicine (CAM) use. The aim of this project was to assess TH and CAM use within the pediatric oncology population in Honolulu and improve the delivery of culturally competent care.

METHODSA 9-item survey was distributed to all pediatric oncology patients at Kapi'olani Medical Center for Women and Children for 3 months. The survey inquired about patient ethnicity, TH practices, CAM practices and perception of cultural competence of the care received. Descriptive statistics were calculated for the survey items. Qualitative analysis was done with participant comments to identify themes.

RESULTSSixty-two surveys were completed. TH was used by 39% of the respondents in the home, and 10% in the hospital (top method was traditional foods). CAM was used by 27% of the respondents in the home, and 68% in the hospital (top method was healing touch). Ninety-seven percent of the respondents reported receiving culturally competent care. Areas for improvement included language services and dietary choices.

CONCLUSIONCAM and TH are used frequently by pediatric oncology patients in Hawai'i, and the vast majority of patients and families felt that the care they received was culturally competent.

Background: The PLASMIC score is a convenient tool for predicting ADAMTS13 activity of ＜10%.Lactate dehydrogenase (LDH) is widely used as a marker of haemolysis in thrombotic thrombocytopenic purpura (TTP) monitoring, and could be used as a replacement marker for lysis. We aimed to validate the PLASMIC score in a multi-centre Asia Pacific region, and to explore whether LDH could be used as a replacement marker for lysis. Methods: Records of patients with thrombotic microangiopathy (TMA) were reviewed. Patients’ ADAMTS13 activity levels were obtained, along with clinical/laboratory findings relevant to the PLASMIC score. Both PLASMIC scores and PLASMIC-LDH scores, in which LDH replaced traditional lysis markers, were calculated. We generated a receiver operator characteristics (ROC) curve and compared the area under the curve values (AUC) to determine the predictive ability of each score. Results: 46 patients fulfilled the inclusion criteria, of which 34 had ADAMTS13 activity levels of ＜10%. When the patients were divided into intermediate-to-high risk (scores 5‒7) and low risk (scores 0‒4), the PLASMIC score showed a sensitivity of 97.1% and specificity of 58.3%, with a positive predictive value (PPV) of 86.8% and negative predictive value (NPV) of 87.5%. The PLASMIC-LDH score had a sensitivity of 97.1% and specificity of 33.3%, with a PPV of 80.5% and NPV of 80.0%. Conclusion Our study validated the utility of the PLASMIC score, and demonstrated PLASMIC-LDH as a reasonable alternative in the absence of traditional lysis markers, to help identify high-risk patients for treatment via plasma exchange.

Therapeutic plasma exchange (TPE) has been reported as a possible treatment for osmotic demyelination syndrome – central pontine myelinolysis (ODS-CPM), a degeneration of myelin within the central nervous system related to rapid hyponatremia correction, which though uncommon, has significant morbidity, and has no established specific treatment. We present our experience with a 41-year-old male with chronic kidney disease, maintained on steroids, who presented with lethargy and behavioral changes. Initial metabolic panel showed severe hyponatremia (Na 109 mEq/L). Despite cautious sodium correction, the patient’s sensorium decreased further and was intubated. Involuntary movements of the left face and arm were later seen. T2/FLAIR hyperintensities in the brainstem and thalami affirmed the diagnosis of ODS. A total of nine cycles (one cycle every two to three days) of TPE were completed. The patient was discharged with improved sensorium, from E2VxM4 to E4VxM6, and with no indication for hemodialysis due to improved creatinine. One year later, the patient has no remaining neurologic deficits. Our experience supports other case reports that TPE is a viable therapy for ODS-CPM.
Myelinolysis, Central Pontine ; Renal Insufficiency, Chronic