What Is Endometrial Cancer?

What Is the Main Idea?

The endometrium is the inner lining of the uterus. Endometrial cancer occurs when malignant cells grow in the tissue of the endometrium. This post deals with some of the information you might need to understand this type of cancer.

What Else Can You Learn?

The open access case report “Exceptional Response to Pembrolizumab for Treatment of Metastatic Chemorefractory Endometrial Carcinoma in a Patient with Lynch Syndrome: A Case Report”, published in the journal Case Reports in Oncology, focuses on a patient whose endometrial cancer responded well to treatment with pembrolizumab. This post summarizes the case study.

What Is the Endometrium?

The endometrium is the inner lining of the uterus. It contains epithelial tissue (tightly packed cells that usually have a protective function), connective tissue, and stem cells. The functional layer of the endometrium thickens during the menstrual cycle, readying itself for a fertilized egg. If a fertilized egg doesn’t implant itself in the endometrium, the functional layer is completely shed. This is what causes menstrual bleeding. The basal layer is not shed: Its function is to protect the uterus and regenerate the functional layer.

There are a few endometrial conditions that warrant medical attention. If the endometrium is too thin or too thick, this can affect the chances of a fertilized egg implanting successfully. It can also lead to rejection of the embryo at some point after implantation. If the endometrium grows outside the uterus or grows into the muscular layer of the uterus (the myometrium), this can cause pain and other problems. Polyps growing from the endometrium can also interfere with pregnancy and cause discomfort.

In this post, the focus is endometrial cancer.

What Are the Symptoms of Endometrial Cancer?

Endometrial cancer occurs when malignant cells grow in the tissue of the endometrium. It is crucial to diagnose it early and start treatment. With early treatment, it has a high five-year survival rate (81%) but if it reaches advanced stages, few treatment options exist.

People are advised to consult a doctor if they experience:

  • Bleeding or bloody discharge that is not related to menstruation
  • Bleeding or a white vaginal discharge after the end of menopause
  • Pain or cramping in the pelvic area
  • A lump or mass in the pelvic area
  • Difficulty urinating or pain while urinating
  • Pain during sexual intercourse

A computed tomography (CT) or magnetic resonance imaging (MRI) scan, ultrasound, endometrial biopsy, or certain blood tests (e.g., measuring the CA-125 level in the blood) are used to diagnose endometrial cancer.

Is There a Difference between Endometrial Cancer and Uterine Cancer?

Uterine cancer is often used interchangeably with endometrial cancer. However, technically there is a difference. Uterine cancer can mean endometrial cancer or uterine sarcoma, which is a cancer that forms in the muscles of the uterus, under the endometrium. Uterine sarcoma is very rare, making up less than 5% of uterine cancer diagnoses. The symptoms of uterine sarcoma are very similar to those of endometrial cancer.

What Are the Treatments for Endometrial Cancer?

Surgery is generally the first choice for dealing with endometrial cancer. Chemotherapy is usually chosen for more advanced endometrial cancers (stage III or IV), where metastasis has already occurred. Surgery followed by chemotherapy is common in such cases. Radiation therapy is similarly used when the surgery alone cannot guarantee removal of the cancer tissues.

The surgery is a hysterectomy, which means the removal of the uterus and cervix, although in some cases the ovaries and fallopian tubes must also be removed. If the ovaries are removed, menopause will occur.

What Is the Case Study about?

The case study “Exceptional Response to Pembrolizumab for Treatment of Metastatic Chemorefractory Endometrial Carcinoma in a Patient with Lynch Syndrome: A Case Report” looks at a 46-year old cisgender woman with advanced endometrial cancer. She had gone through chemotherapy with two commonly used drugs: carboplatin and paclitaxel. She was still experiencing progression of the disease. The doctors then treated her with pembrolizumab. The response is described as exceptional, with a decrease in the mass of the tumor and a reduction in the swelling of her lymph nodes.

There are two important pieces of information about this patient. They may contribute to understanding why she had such a strong positive response to the pembrolizumab. One is that she had Lynch syndrome: a genetic predisposition to certain cancer types, including colorectal cancer, stomach cancer, endometrial cancer, and ovarian cancer. The other is that her endometrial cancer was a type with high microsatellite instability (MSI; related to mutations in part of the DNA). Around 30% of endometrial cancers are the high-MSI type, and people with Lynch syndrome often develop this type.

The authors mention the theory that patients with Lynch syndrome and endometrial cancer may respond well to pembrolizumab chemotherapy. Another way of saying this is MSI-high endometrial cancer may be susceptible to pembrolizumab.

This is a case study of a single patient, so it shouldn’t be taken as proof that pembrolizumab alone will treat advanced endometrial cancer. However, adding to the body of evidence for a treatment is important — and it’s important for oncologists to be aware of the possibilities of using a particular drug in difficult cases.

Diagnosing and Treating Gastrointestinal Bleeding

What Is the Main Idea?

Acute and chronic gastrointestinal bleeding are common symptoms of a whole range of diseases of the digestive tract. The acute form can be considered an emergency condition, and current medical advice is to seek medical care if you have any of its symptoms. This post goes into the types, symptoms, and approaches to diagnose and treat gastrointestinal bleeding.

What Else Can You Learn?

The open access case report “Endoscopic Hemostatic Treatment for Acute Gastrointestinal Bleeding by Combined Modality Therapy with PuraStat and Endoscopic Hemoclips”, published in the journal Case Reports in Gastroenterology, focuses on a method for stopping the bleeding that combines a special hydrogel and endoscopic hemoclips. This post has a short summary of the case report as an example of the ways gastrointestinal bleeding can be treated.

What Is Gastrointestinal Bleeding?

Any bleeding that starts within the gastrointestinal tract (also called the digestive tract) is called gastrointestinal bleeding. It can be acute (short-term) or chronic (long-term) and overt (visible to the patient because it comes out in vomit or stool) or occult (internal with no visible component). It can be in the upper tract (mouth, throat, esophagus, stomach) or lower tract (small and large intestines, including the anus).

Generally, chronic gastrointestinal bleeding involves small amounts over a long time and may be caused by a whole range of diseases, including hemorrhoids and anal fissures, ulcers, reflux esophagitis, Crohn’s disease and other conditions that cause gastritis, polyps in the colon, ulcers in the stomach (peptic ulcers) or intestine (colitis), minor injuries, or gastrointestinal tract cancer. Chronic bleeding can lead to anemia.

Acute gastrointestinal bleeding can be considered an emergency condition. It is common and often requires hospitalization to deal with it. If it is severe, it can be rapidly debilitating. All the causes of chronic bleeding can also cause acute bleeding. Major injuries can also be the cause.

Technically, acute gastrointestinal bleeding can also describe situations with a small amount of blood from a source that quickly heals and doesn’t bleed again. However, people probably wouldn’t even notice this happening unless the bleeding was from the mouth or anus (e.g., spotting from a small tear that heals quickly). Therefore, when I write about acute gastrointestinal bleeding here, I’ll be referring to the emergency condition.

What Are the Symptoms of Gastrointestinal Bleeding?

Symptoms other than overt bleeding include abdominal cramps, fatigue, dizziness, weakness, anemic appearance, and shortness of breath. Stool that is black or has the consistency of tar or vomit that looks like coffee grounds are also usually due to bleeding.

In addition, acute gastrointestinal bleeding is associated with the symptoms of shock: a sudden reduction in blood pressure, a significant rise in pulse rate, and fainting. It can also affect urination, although this can be harder to notice if you’re not conscious of your normal patterns. Infrequent urination or inability to produce urine are both signs that you should seek medical help.

Current medical advice is to seek emergency care if you have symptoms of shock, vomit blood, have dark blood in your stool, or have black and tarry stool. For any other symptoms, talking to your primary care physician is considered sufficient.

Is There a Link between COVID-19 and Acute Gastrointestinal Bleeding?

In the first two years of the pandemic, COVID-19 patients receiving treatments in hospital were found to be at higher risk of acute gastrointestinal bleeding, although it is unclear whether this bleeding was due to the virus affecting the tissues of the digestive tract, the impact of the infection on pre-existing conditions, or the types of intervention used (e.g., steroids, intubation). COVID-19 patients who developed such bleeding had a poorer prognosis. COVID-19 can cause acute gastrointestinal symptoms, such as diarrhea, vomiting, abdominal pain, and loss of appetite. There are ongoing studies on possible chronic effects.

What Can Doctors Do about Gastrointestinal Bleeding?

The most important thing will be to identify where the blood is coming from. A physical, minimally invasive examination may be sufficient for bleeding coming from the mouth, throat, anus, and rectum. However, anything beyond that could require an endoscopy, gastroscopy, colonoscopy, or sigmoidoscopy. These are all terms for tests where a camera is put into the body at the end of a long tube so that doctors can examine the walls of the gastrointestinal tract for polyps, tears, ulcers, etc. These can be uncomfortable procedures and in some cases, may be done under general anesthetic. A more recent development is the capsule endoscopy: a pill-sized capsule containing a camera that takes thousands of pictures as it passes through your body.

Imaging tests can also be done: X-rays or magnetic resonance imaging (MRI) when a contrast dye has been ingested or injected and computed tomography (CT) scans all have success in finding the sources of bleeding. Blood and stool tests may also be necessary to see the impact of the bleeding on your system.

After the doctors identify the source of the bleeding, they must try to stop it. Ideally, they will want to do this without causing any more damage that also has to heal. Endoscopic surgery is preferred, and it may be done at the same time as the examination if the bleeding is severe. Special thermal devices may be used to “heat seal” the source of the bleeding. There are also special types of glue and surgical staples that can be used.

What Is an Endoscopic Hemoclip?

Introduced in 1975, the endoscopic hemoclip, sometimes called an endoscopic clip, is a very small metal medical device for closing wounds and other sources of bleeding inside the gastrointestinal tract. They can be placed anywhere from the upper part of the esophagus to the end of the large intestine. They do not interfere with the working of the organs. They don’t damage the tissue, unlike some adhesives and thermal devices.

Are Endoscopic Hemoclips a Permanent Implant?

Some hemoclips fall off and are passed from the body relatively soon after the surgery, even after just a week. Some stay in the body for several weeks or even months. In rare cases, they may be retained in the body, but this is not the intention when they are put in.

What Is the Study about?

The open access case report “Endoscopic Hemostatic Treatment for Acute Gastrointestinal Bleeding by Combined Modality Therapy with PuraStat and Endoscopic Hemoclips” focuses on the effectiveness of a method that combines a product called PuraStat with hemoclips. PuraStat reacts with blood to form a hydrogel that coats the source of bleeding. This slows or stops the loss of blood and supports blood clotting. The case report points out that clinical data on PuraStat is limited and provides information from six cases where acute gastrointestinal bleeding was successfully treated using this combination method. All six patients, including two who had gone into shock from blood loss, had the bleeding stopped and had no further bleeding.

NOTE: The paper contains photos from the surgeries described in three of the cases.

Do These Results Mean This Is the Best Method for Treating Acute Gastrointestinal Bleeding?

This case study puts forward evidence supporting the use of PuraStat plus endoscopic hemoclips to treat gastrointestinal bleeding. However, further study would be needed to determine which sources of bleeding should be treated in this way and whether there are more reliable methods.

That said, it is good to be aware of the available methods so that you can discuss them with your healthcare provider, should you ever need to.

Reflux and Reflux Esophagitis

What Is the Main Idea?

Reflux esophagitis is a common condition that is worth taking seriously: Chronic cases are associated with gastrointestinal bleeding, increased cancer risk, breathing problems and more. This post explains reflux, reflux esophagitis, and some associated terms, and summarizes the current medical advice on the topic.

What Else Can You Learn?

The study “Saliva Secretion Is Significantly Lower in Female Patients with Mild Reflux Esophagitis than in Female Healthy Controls”, published in the journal Digestion, looks at saliva secretion, which could be significant in the progression and presentation of reflux esophagitis.

What Is Reflux Esophagitis?

Have you ever exercised directly after eating or gone for a lie down straight after a big meal? If you have, you might have quickly experienced a burning sensation in your chest or throat, or even had a few acidic burps. That’s because some of the contents of your stomach — food, digestive enzymes, and acid — have come back up into your esophagus. When this happens, even if it’s not that much or that far, the lining of the esophagus (the mucosa) can be damaged. The process of coming back up is called reflux and if it happens too often, you can develop a condition called reflux esophagitis.

Is Reflux the Same as Vomiting?

Reflux is more like a leak — the physiological mechanisms that should keep the stomach open to “downwards” traffic and closed to “upwards” traffic have failed in some way and something has come back up. Your body can usually clear the esophagus again by peristalsis (the muscle movements that push food through the digestive system) and, provided it’s not a case of reflux esophagitis, can neutralize the acidity by causing you to swallow alkaline saliva.

Vomiting occurs when a whole set of muscles, including the diaphragm, intercostal, and abdominal muscles, contract simultaneously one or more times, squeezing the stomach and forcing its contents up and out of the body. The body will not attempt to use peristalsis to stop vomiting or clear things “downwards” again.

Does Reflux Happen in Babies?

We all know that most infants can spit up small amounts of milk or food after a feed — the image of a parent with a towel on their shoulder, infant in their arms, “burping” the baby is very familiar! This is actually reflux. It occurs in babies because their esophagus is not fully developed, and it is generally not dangerous.

Current medical advice is to contact a healthcare provider if reflux starts after 6 months or starts earlier but persists to 1 year. A consultation is also recommended if your baby is spitting up large amounts of food, frequently spitting up food, refusing to eat, coughing or gagging while feeding, crying while feeding, getting frequent ear infections, or not gaining weight.

How Common Is Reflux Esophagitis and What Are the Symptoms?

Reflux esophagitis is a very common condition. In fact, it’s so common and often presents with such typical symptoms that primary care providers can usually diagnose it without an endoscopy, barium X-ray, tissue sampling, or other investigations —unless, of course, there are atypical symptoms (see below).

The typical symptom is heartburn: That’s the burning feeling that starts behind the sternum but spreads as high as in the back of the throat. A sense of having a lump in one’s throat, acid in the throat, increased salivation, and dysphagia (difficulty swallowing) are also symptoms that a doctor or nurse would count as typical.

In more unusual cases, symptoms like chronic chest pain, chronic throat ache, asthma, tooth damage, or spasms in the esophagus may occur — and are more likely to prompt an investigation, since they are also symptoms of other conditions.

How Serious Is Reflux Esophagitis?

If you regularly experience any of the typical symptoms, you should talk to a healthcare provider. While reflux isn’t dangerous short-term, a damaged esophagus and difficulty swallowing are only two of the risks of unmanaged reflux. Ulcers with associated bleeding, increased cancer risk, and even breathing problems can occur, among other things.

Current medical advice is to seek an appointment with a healthcare provider if the symptoms last more than a few days, can’t be relieved by a short period of using over-the-counter antacids, make eating uncomfortable, or are accompanied by unexpected weight loss. Emergency care is essential if the pain in your chest lasts more than a few minutes, you have a history of heart disease, or have shortness of breath or chest pain directly after eating. You should also seek emergency care if you vomit large amounts or frequently or have pain in your mouth or throat while eating.

What Is the Study about?

The study described in the paper “Saliva Secretion Is Significantly Lower in Female Patients with Mild Reflux Esophagitis than in Female Healthy Controls” is interesting because it discusses salivation. As mentioned above, secreting and swallowing saliva, which is alkaline, can help with neutralizing the acid that has leaked into the esophagus during reflux. Therefore, it’s important to investigate the patterns of saliva secretion in patients with reflux issues. This study focuses on the differences between male and female patients and healthy subjects.

Why Study the Differences between Male and Female Patients?

Reflux esophagitis is more common in male subjects. Female subjects are more prone to having symptoms without erosion of the esophageal mucosa. Note that these differences do not automatically mean that there’s a physiological difference between male and female bodies — socioeconomic and behavioral factors also play a part in the progression of reflux esophagitis and the likelihood of seeking treatment.

Differences have been shown that the level of saliva secretion is lower in healthy female subjects than in healthy male subjects. This was in an experiment where saliva secretion was stimulated with chewing gum. Such a difference could be significant in examining differences in the progression of reflux esophagitis in male and female patients. Therefore, in this study, the authors looked at stimulated saliva secretion in 25 male patients with mild reflux esophagitis, 25 female patients, 25 healthy male subjects, and 25 healthy female subjects.

What Did the Researchers Find?

They found that the level of stimulated saliva secretion was significantly lower in female patients than in healthy female controls. Such a difference was not found between male patients and male healthy controls. The subject requires further study before anything definitive can be said. It might explain — or at least be part of the explanation — why there is a difference in the presentation and progression of reflux esophagitis in male and female patients.

At present, this information isn’t useful for a patient talking to their physician, but it’s definitely worth keeping an eye on developments in this area. Anything that helps against this common and painful condition will be good news.

Note: This post is based on an article that is not open-access; i.e., only the abstract is freely available.

Understanding Allergic Rhinitis

What Is the Main Idea?

Allergic rhinitis affects a large portion of the population (up to 30% of adults and 40% of children). The symptoms can range from mild to severe congestion, a runny nose, sneezing, and itchiness, and it can be associated with other conditions, such as allergic conjunctivitis and asthma. This post looks at some of the causes of allergic rhinitis, some ways to manage it, and the diagnostic process.

What Else Can You Learn?

Referencing the paper “Local Allergic Rhinitis: Lights and Shadows of a Mysterious Entity”, published in the journal International Archives of Allergy and Immunology, this post delves into the important but unusual case when someone has a nasal reaction to an allergen but tests negative in the skin-prick and blood tests. Why should we care about this form of the condition?

Why Is My House so Clean?

Whenever I start sneezing, my nose gets runny, and my eyes get itchy, I know why (or at least I think I do): It’s because of dust mites and it’s time to clean (or go outside and ignore the dust). These tiny relatives of ticks and spiders can occur in every location where you find mammals. The Latin names for the most common types are Dermatophagoides farinae and Dermatophagoides pteronyssinus. They live off the skin cells and dander (flakes of hair or fur) shed by mammals, including humans. It may be unpleasant to think of, but dust contains a lot of skin cells and dander — especially in my house, where we have two dogs, two cats, a rabbit, and, if we leave the back door open and unattended, three goats!

The reason for my sneezing is an allergy to the feces and bits of exoskeletons from the dust mites. It’s an uncomfortable and unpleasant reaction and it encourages me to get out the dusters and vacuum cleaner regularly. My diagnoses are allergic rhinitis (an inflammation of the lining of the nose caused by the microscopic particles entering my nose) and allergic conjunctivitis (an inflammation of the clear membrane that protects the eye).

I manage the allergy by minimizing the dust in the house; wearing a mask when I clean dusty areas; keeping the animals we live with groomed; and changing out of dusty clothes outside of our bedroom and sitting room, where I’d be most vulnerable to settled dust. We also have only one carpet in the whole house, and we wash blankets and quilts from sofas regularly. There are plenty of other measures that you can try, including antihistamine pills, anti-inflammatories, and inhalers.

Of course, not everyone has this allergy — some people can be in a dusty house with no reaction at all. And some people have a very different allergic reaction, with exposure resulting in eczema, congestion, or asthmatic attacks, the latter potentially very severe. In this post, I’m focusing on allergic rhinitis as there is an interesting variation of it with an unknown cause.

What Else Causes Allergic Rhinitis?

As we all know, dust mite feces and exoskeletons are not the only allergens that cause allergic rhinitis. Among many other particles, the wind-borne pollen of grasses and trees; cat, dog, rabbit, or horse dander; and mold spores can provoke mild to severe reactions.

Managing a pollen-related allergic rhinitis can involve limiting the time you spend outdoors when pollen levels are high; taking prophylactic antihistamines or using inhalers at those times of year; and changing out of outdoor clothes and washing your face, hands, and even hair immediately after you come in. Managing animal-related allergic rhinitis depends on the severity: It can be anything from avoiding direct contact with the relevant animals to not entering spaces with those animals at all. Mold-related allergic rhinitis is challenging because so many molds are invisible but minimizing mold in the living space and avoiding exposure outdoors, especially in late summer and fall, are important responses.

In all cases, your physicians and other healthcare workers should provide some insight into the management of your form of allergic rhinitis.

Is Allergic Rhinitis Common?

It should be noted that allergic rhinitis is very common, affecting 10–30% of adults and up to 40% of children, as stated in the paper “Local Allergic Rhinitis: Lights and Shadows of a Mysterious Entity” and references therein. Reactions can be mild at first but can worsen over time, and there are potential long-term consequences if the condition is not managed. That’s what makes it a good idea to get tested if you have the symptoms of allergic rhinitis. A specialist should perform certain tests to determine the “guilty” allergens. Commercially available home tests are not recommended as they can produce ambiguous results.

Testing for Allergies

The best-known specialist test is a skin-prick test, where they place droplets of multiple allergens in suspension on the inside of your forearm, then gently prick the skin. A welt (an itchy spot) will appear if you’re allergic to that particle. When I did the skin-prick test, the welts for D. arina and D. pteronyssinus feces and exoskeleton bits were large and sore. I had very small, slightly itchy welts for mold spores and one type of tree pollen, but no other reactions. Therefore, the focus of my allergy management has always been dust mites.

It is also possible to do blood tests. The specialist draws blood and tests to see its reaction to allergens. A positive diagnosis is when your blood produces the immunoglobulin E (IgE) antibody in response to an allergen.

Some additional tests may be done to check for: damage to the lining of the nose and throat due to exposure to the allergen; polyps and other growths occurring in response to continuous inflammation or damage; and the level of restriction of the airflow due to the inflammation, damage, or growths.

Of course, rhinitis might not be caused by allergies at all. There’s also infectious rhinitis, caused by viruses and bacteria, and non-allergic rhinitis, which might be caused by exposure to fumes, certain foods, and non-allergenic particles. You’ve certainly had infectious rhinitis at some point, since it’s commonly associated with rhinoviruses (many of which are responsible for “the common cold”), and if you’ve sneezed going through a department store’s perfume department, you’ve had non-allergic rhinitis.

Why Is Local Allergic Rhinitis Interesting?

Local allergic rhinitis is a possible diagnosis when someone has the symptoms of allergic rhinitis in response to environmental exposure to an allergen but negative skin-prick and IgE tests. For example, if someone had consistently sneezed and developed a runny nose in a dusty environment but tested negative for an allergy to D. arina and D. pteronyssinus feces and exoskeleton bits, the diagnosis would be local allergic rhinitis. Some other conditions might need to be ruled out along the way, but this is a possible diagnosis.

That’s what the paper “Local Allergic Rhinitis: Lights and Shadows of a Mysterious Entity” focuses on. As the authors explain, the word “local” in the name refers to the idea that the body might only product IgE locally (e.g., only in the nasal area) rather than systemically (i.e., in the whole body). That would explain why the traditional tests don’t return positive results — they test the response of skin or blood that is distant from that area.

Testing negative for allergic rhinitis in the two traditional tests can result in a patient not getting the medical treatment and advice they need. Not every state healthcare system recognizes local allergic rhinitis, despite the evidence to back its existence. This means a patient may be given the wrong advice or treatment — or no treatment or advice at all. Local allergic rhinitis should be managed similarly to allergic rhinitis: Depending on the severity of the reaction, avoid the allergen, avoid bringing the allergen into the bedroom and other sensitive areas of the house, wear a mask, take antihistamine medication, etc. However, patients may need to push for additional diagnostics, and sharing “Local Allergic Rhinitis: Lights and Shadows of a Mysterious Entity” with your healthcare provider might help.

Note: One of the authors of the paper declared that they have relationships with companies that produce or sell antihistamine treatments relevant for described medical conditions. It is normal for authors to declare this in case it might be perceived as a conflict of interest. More detail can be found in the Conflict of Interest statement by visiting the original article page.

Diabetes or Not? The Case of Diabetes Insipidus

What Is the Main Idea?

Diabetes insipidus is a relatively rare condition but one worthy of awareness. This post describes the condition, how you would know if you might have it, and why it perhaps shouldn’t be called diabetes. The article “Changing the Name of Diabetes Insipidus: A Position Statement of the Working Group to Consider Renaming Diabetes Insipidus”, published in the journal Hormone Research in Paediatrics, may seem like an odd choice but it goes into an essential topic for healthcare workers and patients: The name of a disease carries weight.

What Else Can You Learn?

This post also talks about urination: a topic we might not love to discuss, but should know more about!

How Often Do People Urinate?

Our toilet habits are rarely a topic of casual conversation, which makes it all the more important to know the fundamentals. The average adult urinates (goes for a pee) 5 to 7 times and the average pre-teen 7 to 10 times in a 24-hour period. If an adult needs to urinate more than 7 times a day or a child more than 10 times a day, they should see a doctor. While there are healthy adults who urinate over 7 times per day, it’s still best to check: It might be nothing, but it might be a sign of something serious.

The amount of urine we produce is definitely not something we know off-hand. It’s easy to find the average amount online. You’ll find the values for an adult 0.8 to 2 liters per day, with less than 0.72 liters or more than 2.5 liters being cause for serious concern. This is translated to somewhere between 120 and 400 ml (or up to 2 cups) per restroom visit for an adult. Why is there such a range in the values of urine production? Because it depends on how much you drink, what you drink, and even what you eat.

Regarding drinking liquids: There is plenty of advice online on how much you should drink, but it’s also important to listen to your body. If you’re thirsty, you should drink. You’ll need more liquids in a dry environment, if you’re exercising, if you’re eating a lot of dry foods, if you have bowel problems, and in many other situations, but your body should let you know. That said, if you find yourself thirsty all the time, even directly after drinking, there may be something wrong.

The values of urine production for children change considerably as they grow up. Therefore, it’s best to talk to a pediatrician or to get a chart showing the ranges for various ages if you’re concerned about a child.

When Should I Ask a Doctor about Urination?

Summing up this information, if you are always thirsty, you urinate more than 7 times a day, and you pass small amounts of urine frequently or very large volumes every time, you should see a doctor. Among other possibilities, these could be symptoms of circulation or kidney problems, diabetes type 1 or 2, or a condition currently called diabetes insipidus.

What Is Diabetes Insipidus?

Diabetes insipidus is not actually related to diabetes type 1 or 2: It has nothing to do with glucose or insulin. It is a rare condition (affecting 1 in 25,000 people) that more commonly develops in adults but can also be seen in children and adolescents. Its main symptoms are polyuria (frequent urination) and polydipsia (frequent drinking). There are two known causes of the disorder: deficiency of a hormone called arginine vasopressin (AVP; sometimes called anti-diuretic hormone, ADH); or resistance to AVP’s actions.

What Is Arginine Vasopressin?

AVP is produced in the hypothalamus and stored in the pituitary gland. When the body’s water levels reduce too much, AVP should be released from the pituitary gland to stop water loss by causing the kidneys to produce a less diluted urine. You can see this in the change of color in your urine — when you’re fully hydrated, it can even be clear, but as you become dehydrated, it gets yellower until it is almost orange in hue.

In the first form of diabetes insipidus, the hypothalamus does not produce AVP. Since the hypothalamus is in the brain, this type of diabetes insipidus is sometimes referred to as central or having a central origin. In the second form, the hormone is produced but the kidneys do not respond to it. Thus, this type is sometimes referred to as nephrogenic.

Why Is It Called Diabetes If It Isn’t Related to Diabetes?

As outlined in “Changing the Name of Diabetes Insipidus: A Position Statement of the Working Group to Consider Renaming Diabetes Insipidus”, the three conditions now known as diabetes type 1, diabetes type 2, and diabetes insipidus were not always recognized as separate. The word diabetes comes from Greek and was related to the meanings “passing through” and “siphon”; the sense of the term as a diagnosis was that patients passed urine like water through a siphon. The history of discoveries about the three conditions is well described in the chapter titled “Historical Context”, so I won’t repeat it here. It’s well worth a read!

In the past 70 years, the discoveries were made that clearly differentiated the two forms of diabetes insipidus from types 1 and 2. However, the name remained the same but, as discussed in the chapter titled “Rationale for Changing the Name of Diabetes Insipidus”, the confusion caused by the umbrella term “diabetes” could even lead to mismanagement of the patient’s condition.

What Are the New Names Proposed?

The paper presents the name arginine vasopressin deficiency (AVP-D) for the form where AVP is not produced in the hypothalamus. It gives arginine vasopressin resistance (AVP-R) for the nephrogenic form. These descriptive names have been endorsed by multiple endocrinology experts and organizations, so it is a strong possibility that the name change will happen.

What’s in a Name and Why Should We Care?

The name of a condition or disease carries weight. As mentioned above, the confusion between diabetes insipidus and diabetes type 1 or 2 led to mismanagement of the condition. Focusing on glucose and insulin when they’re not involved is not just pointless, it’s dangerous. When the medical community or the broader populace adopt a name for a condition, it should be clear and relevant. Diabetes is too strongly connected with glucose and insulin, so I would also back this name change — not that anyone is asking me!

If you are diagnosed with diabetes insipidus or undergoing diagnosis for its symptoms, be sure that you, your family, and the healthcare professionals you work with understand this difference. It’s essential for your well-being. Don’t get tripped up on a name.

Fasting, Feeding, and Abdominal Surgery

What Is the Main Idea?

Surgery requires preoperative fasting. But why? And when can you eat again after surgery? This blog post looks at the question of fasting, feeding, and surgery, with a particular focus on the complications of abdominal surgery.

What Else Can You Learn?

Referencing the paper “Postoperative Nutrition Management: Who Needs What?”, published in the journal Visceral Medicine, this post also discusses the roles of enteral (tube) and parenteral (IV) feeding in the recovery from surgery.

Why Do People Fast before Surgery?

If you’re having surgery under general anesthetic, your physician will tell you not to eat for at least 6 hours before the surgery (but possibly a lot longer) and not to drink for at least 2 hours before the surgery. Why is this? When you go under general anesthetic, your body loses tonus (the continuous low-level activity of tissues like muscles) meaning that the contractions that keep food moving through the digestive system stop. You may know of this movement as peristalsis. Without this movement, your body can react to any solids or liquids in your stomach with a vomiting reflex, which could result in food or drink getting into your lungs and even causing damage.

Always check with your physician how long you should avoid solid foods and fluids before an operation. Even if you’re not having general anesthetic, there may be reasons to fast.

What about Eating after Surgery?

Naturally, having fasted before surgery, you’ll start to feel hungry and thirsty some time afterwards, although not immediately! The body takes some time to want to eat again. Within 1 to 3 days after you wake up from surgery, but most often on the same day, you’ll be asked to drink and eat some simple things: for example, water, weak tea, chicken or vegetable broth, or dry toast. Starting simple and small means your stomach and small intestine aren’t immediately overwhelmed!

It can happen that patients vomit after even this first little amount of food: That’s a sign that they haven’t regained enough tonus and peristalsis isn’t happening. Provided you don’t have this reaction, you’ll slowly be put back on a greater variety of foods.

Does Abdominal Surgery Complicate Matters?

Examples of abdominal surgery are exploratory surgeries like laparotomies, to diagnose internal bleeding and other injury; repair of hernias in the abdominal wall; removal of the appendix or gall bladder; and resection of part of the small or large intestine. Cesarean sections are also abdominal surgeries.

Abdominal surgery adds a complication to fasting before and eating after surgery, particularly intestinal surgery. It might require a longer period of fasting. You might have to drink something that helps flush solids out of your intestine. And after the surgery, your digestive system might need slightly longer to recover. It can take up to three days for some patients to be ready to eat solid food again.

There is evidence that it is safe to take food by mouth within 48 hours of even major abdominal surgery. There is proven to be a very low risk of the passage of simple foods bursting the stitching or affecting the surgical site. This is discussed in the paper “Postoperative Nutrition Management: Who Needs What?”, which talks about the Enhanced Recovery after Surgery protocol. Under a medical professional’s supervision, getting back to taking food by mouth within days of surgery is the preferred approach.

Be Aware of the Risk of a Caloric Gap

However, despite being safe, possible, and desirable, taking food by mouth might not be enough for a patient after their abdominal surgery. The paper mentions that oral feeding is often insufficient to meet the protein and energy requirements of the recovering patient. Protein deficiency can be due to the challenges of digesting protein-rich food after the surgery. A caloric gap (a negative difference between the calories that the body gets from food and the amount of energy it is using) is especially bad during recovery: A good prognosis requires a good nutritional status.

A caloric gap is most dangerous if the patient has a nutritional deficit going into the surgery. Preexisting malnutrition can occur in pregnant people who have had insufficient access to food, in cancer patients, and in people with gastric and intestinal disorders, among others. The referenced paper notes that patients are not always assessed for preexisting malnutrition and that this should be a standard part of the preoperative assessment.

The risk of needing follow-up surgery presents another challenge to patients getting enough protein and energy via oral feeding. Complications can occur after any surgery and re-operation will need further fasting and another period of adjustment before the patient can eat again.

What Is the Alternative to Taking Food by Mouth?

  • Enteral feeding is one option. Also called tube feeding, it involves delivering liquid food directly to the stomach or small intestine through a tube that is inserted via the nose or through the skin and muscles of the abdomen.
  • Parenteral feeding is another option. It can also be called intravenous feeding. A nutritional fluid is infused into the body through a vein. Enteral feeding is preferred to parenteral because it keeps the digestive system active. It is easier to transition to oral feeding from enteral feeding than from parenteral feeding.

Can Enteral Feeding Be Combined with Oral Feeding?

As explained in the paper “Postoperative Nutrition Management: Who Needs What?”, it is important for physicians to have a plan for postoperative nutrition in patients with preexisting malnutrition or other complications creating a protein or caloric gap. The recommendation of combining enteral and oral feeding is mentioned as a good way of preventing weight loss and other complications.

Talk to your physician prior to any surgery about any concerns you may have regarding your weight and nutritional status, fasting, and when you might be back on solid food. It’s important to have a full picture of how things might go.

Note: This post is based on an article that is not open-access; i.e., only the abstract is freely available. Furthermore, the authors of this paper make a declaration about lecture fees and research grants received from pharmaceutical companies. It is normal for authors to declare this in case it might be perceived as a conflict of interest.

What Is the Therapeutic Potential of Microneedling?

What Is the Main Idea?

This post looks at microneedling, which is a cosmetic procedure with some applications in dermatology. It has been gaining in popularity because it is cheaper and requires less expertise than laser-based dermatological techniques. Read this blog post to find out how it works and what it can be used for.

What Else Can You Learn?

Inspired by the paper “Efficacy and Safety of Scalp Microneedling in Male Pattern Hair Loss”, published in the journal Skin Appendage Disorders, this post takes a closer look at the recent use of microneedling to address male pattern baldness: Does it work and how?

What Is Microneedling?

Microneedling is a cosmetic procedure that can have some medical applications. The process involves very small needles going into and out of the skin, making tiny wounds, similar in size to those that occur in tattooing. In fact, some practitioners use tattoo cartridges to microneedle the skin. Others use rollers with the needles on the head. There are also devices that are designed specifically for microneedling: They insert and remove various numbers of needles at various speeds.

The concept behind microneedling is that the body reacts to the wounds by producing more collagen (a fiber-like protein that is a major component of connective tissue in the skin, muscles, tendons, and bones) and elastin (a highly elastic protein that is found in connective tissue and helps tissues in the body resume their shape after stretching or contracting). Increasing the levels of these proteins should help skin heal from various issues. Furthermore, maintaining high collagen and elastin levels in the skin means healthier skin: better protection against injury, better moisture levels, less tendency to wrinkle, and greater elasticity.

Because it increases collagen and elastin levels, microneedling is sometimes called collagen or elastin induction therapy.

Does Microneedling Work?

Research has shown that microneedling is safe and can be effective as a therapy for both wrinkles and scars, including acne scars. Papers have also been published on its benefits for other skin conditions and for skin rejuvenation as part of cosmetic surgery. There is evidence that it can help with hyperpigmentation. It takes days to weeks after a session for therapeutic results to be visible. Similarly to laser treatments, it may take multiple sessions to achieve the desired effect. Importantly, most reviews of the literature show that more research is needed to optimize methodologies and/or establish the potential and limits of the microneedling in therapeutic settings.

Note that microneedling is not advised for people who get keloids (large, raised overgrowths of scar tissue) as it can make the formation of this type of scar tissue worse.

Interestingly, some microneedling devices can also deliver therapeutic agents into the skin. This is a relatively new application of the technology, so considerably more research is needed to establish its safety and efficacy.

What Are the Downsides of Microneedling?

Microneedling is not without its disadvantages, although most are minor. It can cause pain, although this is usually minor and manageable. It may also cause flaking, bruising, or minor bleeding. The healing process takes time, during which you should not go swimming, use certain soaps and lotions, and be exposed to dust. There is also a risk of infection in the period after microneedling if proper care is not taken. Home microneedling devices exist, but dermatologists recommend caution.

What Is Male Pattern Baldness?

Male pattern baldness, also called male pattern hair loss, gets its name from the hair loss following a pattern of receding from the hairline, most often starting with an M-shape with the fastest recession above the temples, and thinning at the top of the head. It can continue until the top of the head is fully bald and the remaining hair at the sides and back is thinning. Its onset and pattern are related to genetic and hormonal factors. It does not have any relationship to illness, but it can cause self-esteem issues. Hair loss without this pattern or with other symptoms (e.g., irregular bald patches, hair loss from other parts of the head, sudden or rapid hair loss, or associated with redness or other scalp disorders) should always be investigated medically.

Is Microneedling Effective for Dealing with Male Pattern Baldness?

Microneedling is offered for more than just skin issues. Many practitioners use it along with other therapeutic agents to address male pattern baldness. The theory is that the hair follicles are not dead: They have shrunk and stopped growing new hair, but they are still alive. Could they be stimulated by microneedling into growing new hair?

The paper “Efficacy and Safety of Scalp Microneedling in Male Pattern Hair Loss” is based on one of a few recent studies on microneedling for this cosmetic purpose. The study used a roller on 15 participants with male pattern baldness and a tattoo cartridge on another 15. Microneedling was the only therapeutic intervention used because the study wanted to see if this technique could be used on its own. While new collagen and elastin formed in the treated skin and a very small number of patients showed brief improvement in hair patterns, there was no sustained improvement in hair density or scalp coverage.

The conclusion of this study is that on its own, microneedling is not a suitable technique for restoring hair growth from inert follicles in male pattern baldness. Studies focusing on its efficacy when combined with other therapeutic interventions are needed.

Talk to Your Dermatologist

Is microneedling on its own or in tandem with another technique suitable for your dermatological condition or type of hair loss? That is a question that can only be answered in conversation with your dermatologist. Microneedling can be successful, but requires some study to establish its limits.

Note: This post is based on an article that is not open-access; i.e., only the abstract is freely available.

Diagnosing Food Allergies

What Is the Main Idea?

This blog post is about the reliable diagnosis of food allergies, which is currently mainly done through the use of oral food challenges. In addition, it refers to the paper “Diagnostic Performance of IgE Anti-Der p 10 to Identify Patients with Shrimp Allergy”, published in the journal International Archives of Allergy and Immunology, which describes one of many studies trying to find new and reliable ways of diagnosing food allergies.

What Else Can You Learn?

The blog post also goes into the differences between food allergies and food intolerances: an important distinction that is often misunderstood.

What Is the Difference between a Food Allergy and a Food Intolerance?

Food allergies are extremely dangerous. If someone has one, it means there is a protein in a foodstuff that causes an anaphylactic reaction from their immune system. This reaction can be life-threatening: Although it may be restricted to skin reactions or a sudden drop in blood pressure, it can also cause the airways to constrict, making it difficult or impossible to breathe. Other effects include nausea and dizziness. Anaphylaxis requires rapid medical intervention.

People with food allergies should carry an EpiPen, which allows them to inject epinephrine into a large muscle, usually the thigh. This medication relaxes the muscles in the airways, stomach, intestines, and bladder; and can increase blood pressure to a safer level. After using an EpiPen, people are still advised to seek medical attention as they may need prescription antihistamines or other support.

Food intolerances are unpleasant, but not necessarily dangerous. If someone has one, it means they have difficulty digesting a certain food, a group of foods, or even a range of different foods. They may suffer bloating, indigestion, cramps, diarrhea, and so on. Skin reactions are also possible. The reaction generally occurs within hours of eating the food.

Medical attention might be necessary as there can be significant impact (e.g., malnutrition due to a lack of proper digestion of food, dehydration from longer-lasting or regular diarrhea, poor quality of life). Note that medical intervention is always advised when a child has a food intolerance, as they can interfere with development.

How Are Food Allergies Diagnosed?

Since the allergic reaction to a food protein can be so serious, it is obviously very important to have a reliable method for diagnosing food allergies. Currently, the commonly used method is an oral food challenge, which works by actually causing an allergic reaction.

Oral food challenges involve giving a patient the food (or the protein from that food) that is suspected to cause an allergy, initially in miniscule quantities that may not cause any reaction. The administrating physician observes the patient for a set period to see if there is any reaction, then gives a slightly larger amount of the food (or protein), and so on. Because the amounts are so small, a severe reaction is not expected. Instead, a mild rash, flushed skin, or hives might develop. If this occurs, the test is concluded and ruled positive (i.e., the patient is allergic to a protein in that foodstuff). Naturally, the patient will then receive something to alleviate the reaction — even a mild allergic reaction can be uncomfortable!

National medical authorities require that oral food challenges only be given by trained medical professionals because there is a small risk of a severe anaphylactic reaction. If this happens, treatment must be administered immediately.

Is This the Only Method for Diagnosing Food Allergies?

Oral food challenges are the only method that is 100% reliable, but there are other methods. Blood tests can also work: A blood sample is taken and tested against various proteins to see if there is a measurable change in the level of the allergy-related antibody immunoglobin E (IgE). However, we do not yet know what the most reliable IgE antibodies are for every food allergy.

A skin prick test can also support diagnosis: Similar to a skin prick test for airborne allergens, a solution containing the protein is placed on the skin, which is then pricked with a needle to allow a small amount under the top layer of the skin. However, a positive reaction from the skin does not always indicate an allergy.

Do Oral Food Challenges Work for Diagnosing Food Intolerances?

The described type of oral food challenge does not work for diagnosing food intolerances because these are digestive reactions, not allergic reactions. Giving someone a miniscule amount of the food will not provoke a digestive reaction; and even giving someone a larger amount will not provoke a quick reaction. Similarly, since a food intolerance is not an allergic reaction, testing for antibody responses or skin responses will not show anything. The best way to diagnose a food intolerance is through elimination diets and food records.

What Is the Paper about?

The paper “Diagnostic Performance of IgE Anti-Der p 10 to Identify Patients with Shrimp Allergy” describes a study done to see if the IgE named anti-Der p 10 would be useful for diagnosing shrimp allergies. This type of study is done to try to find reliable replacements for oral food challenges.

In this case, anti-Der p 10 was found to be a reliable biomarker for predicting a shrimp allergy: Every single patient who was positive for a shrimp allergy in an oral food challenge was also positive for anti-Der p 10.

More studies of this type will be important to identify more IgE antibodies that give similarly reliable results.

A Note about Celiac Disease

Although the symptoms of celiac disease are related to the gut, it is not the same as a gluten intolerance. It is also not a food allergy, although the immune system is involved. Celiac disease is an autoimmune disorder where reactions are triggered by gluten, a protein found in wheat. Therefore, the information in this blog post and in the paper are not relevant for the diagnosis of celiac disease.

In some cases, oral food challenges are given to people who already have a known food allergy. For example, an allergist may order the test to find out if a patient has outgrown the allergy. In clinical trials, oral food challenges help researchers learn how well participants are responding to the treatment under study.

Note: This post is based on an article that is not open-access; i.e., only the abstract is freely available.

An Introduction to Cochlear Implants and Auditory Brainstem Implants

What Is the Main Idea?

This post focuses on cochlear implants and auditory brainstem implants, which are two similar medical devices that can make it possible for some people with hearing loss to hear some sounds. The post describes the differences between them, and lists the benefits and risks. It also lays out some advice for people considering such implants, especially parents of children with hearing loss. In addition, it refers to the paper “Children with Auditory Brainstem Implant: How Do They Perform in Motor and Language Skills?”, published in the journal Audiology and Neurotology, which describes a study that would be interesting to parents of children up for such an implant and for physicians working in this area.

What Else Can You Learn?

The blog post also goes into some of the objections to childhood cochlear implants, which could also apply to auditory brainstem implants. These objections are raised by members of the Deaf community, including many who received such implants as children or infants.

Hearing Aids Aren’t Suitable for Every Type of Hearing Loss

Hearing aids can help people who are hard of hearing to hear sounds by amplifying sounds they have difficulty picking up. They essentially consist of a microphone, a processor programmed to amplify specific sounds, and an in-ear speaker. However, not everyone with hearing loss can benefit from hearing aids: If the hearing loss is due to damage to the ear structure, an implant may be an option.

What Is the Difference between a Cochlear Implant and an Auditory Brainstem Implant?

A cochlear implant is an electronic medical device that can make it possible for some people with hearing loss to hear some sounds. It consists of an external microphone and processor that pick up sounds and transmit them to an implanted wire ending in small electrodes in the cochlea, which is part of the inner ear. The signals transmitted to these electrodes can then be transmitted via the cochlear nerve to the brain.

An auditory brainstem implant can provide some level of hearing to some people who would not be helped by a cochlear implant. For example, if the auditory nerve is missing, the inner ear is scarred after an infection or injury, or the inner ear has an atypical structure, a cochlear implant may not work. Auditory brainstem implants bypass any damage to the inner ear or auditory nerve because the internal wire and electrode array are implanted directly in the brainstem. The external part is similar to a cochlear implant: a microphone and processor.

Cochlear implant surgery is more common and less invasive than auditory brainstem implant surgery, because the latter requires an expertise in complex brainstem work.

After either surgery, the recipient of the implant must work with a specialist to learn how to interpret the signals, as they are not the same as the signals that the ear would generate on its own. It is possible that the recipient of either type will not benefit from the implant at all.

Currently available cochlear implants are more likely than auditory brainstem implants to provide word recognition. Both can require lip reading to gain much benefit in conversation.

Why Are These Implants Seen as Controversial?

Activists in the Deaf community have raised objections to the way these implants are seen as a way to “fix” infants and children who have limited or no ability to hear sounds. They point out that neither surgery is guaranteed to work; that neither provides the ability to hear sounds in the way people commonly understand hearing; and that the aural rehabilitation after surgery can be arduous and upsetting for infants and younger children.

What Do Deaf Adults with Childhood Cochlear Implants Say?

I’ll focus here on cochlear implants because there is more written about them and they are more spoken about within the Deaf community.1

Not all adults who received cochlear implants as infants are happy with the decision having been taken for them. This attitude is especially common if the aim was to “fix” them and put them into mainstream education, with no attempt on the part of the family to learn the national sign language, engage with the Deaf community, and look at broader education possibilities. Even with a cochlear implant, there can be issues with engaging with mainstream education, particularly if the implant is not fully successful and there is no attempt to compensate for any failings with other support (e.g., in-class assistance). Such a child can feel cut off from the Deaf community, which could otherwise provide valuable support.

Other adults who received cochlear implants as infants are happy with them because they had positive experiences. This can include feeling comfortable operating in speech- and sound-centric environments, and finding their way in mainstream education without further support. Some feel the lack of other Deaf people in their lives; some have connected with the Deaf community.

What Does This Mean for Parents?

It’s important for parents considering cochlear or auditory brainstem implants for an infant or child to engage with such information. These personal experiences of Deaf and hard-of-hearing adults can help them make a fully informed decision as well as prompting questions for the surgeons and other physicians.

Ultimately, any implant has more complicated considerations than hearing aids, glasses, mobility aids, and other external devices. It may not be possible to remove implants later and they cannot be “swapped for a better model”. Ensuring that one understands the lifelong implications of an implant is critical.

What about the Videos of Babies Who’ve Received Implants?

Beyond these experiences, objections are raised over the commonly shared videos with titles like “Baby hears for the first time”. The videos rarely show the full truth of the experience, which can involve a whole range of reactions, including infants’ fear and confusion at suddenly receiving signals that their brains don’t know how to interpret. The videos focus instead on the “inspirational” quality of the moment(s).

Within the Deaf community and the broader disabled community, there is a general skepticism about the motivation of non-Deaf and non-disabled people’s attempts to create inspirational content from our1 experiences, challenges, medical procedures, and successes.

Does This Mean That the Implants Are not Appropriate for Teenagers and Adults with Hearing Loss?

Teenagers and adults can advocate for themselves and give informed consent. As such, they can discuss the potential risks and benefits of the implants with their physicians and gain a better understanding of the post-surgical rehabilitation. This is a very different situation. It is especially important for a teenager or adult to engage with how rigorous the post-surgical rehabilitation can be.

What Are the Risks of Cochlear and Auditory Brainstem Implants?

Surgery always carries risks such as bleeding, swelling, and infection. Cochlear implants are generally well tolerated, but there are rare cases of post-surgical tinnitus (ringing in the ears), vertigo, nerve injury causing movement problems in the face, and meningitis. The same risks are associated with auditory brainstem implants, but since they are less commonly used, there is less data on their tolerance in the broader population.

What Is the Paper about?

The authors of “Children with Auditory Brainstem Implant: How Do They Perform in Motor and Language Skills?” focus on how congenital hearing loss or loss of the aural vestibule (the part of the ear between the semi-circular canals and the cochlea) can impair not only the acquisition of language, but also the development of motor skills. The described study involved ten children between the ages of 4 and 17 who had been fitted with an auditory brainstem implant on one side. The children were evaluated on their fine motor control, balance, manual dexterity, language, and sound perception using standardized tests.

The results showed a strong correlation between poor manual and balance skills and poor speech perception and language skills in the children. The group is too small to draw a broad conclusion, but it indicates the need to assess children before and after the implant surgery to establish the baseline manual, balance, and speech perception skills; and to give greater support to children after the implant surgery to ensure the best outcome.

What Does the Paper’s Conclusion Mean for the Parent(s) of a Potential Recipient of an Auditory Brainstem Implant?

The paper focuses on support. It states that an infant or child patient’s parent(s) and physician(s) should ensure the child is going to get the best support and post-surgical rehabilitation, to ensure that the benefits are the best possible. It also shows how important it is to ask for pre- and post-surgical evaluations.

Note: This post is based on an article that is not open-access; i.e., only the abstract is freely available.

1Victor Kelly has adult-onset hearing loss and uses hearing aids, lip reading, Irish sign language, and Danish sign language to communicate. They are also a wheelchair user. Victor considers themself an activist and engages regularly with various disabled communities, including the Deaf community.

How Do Patient Expectations Impact Dermatological Treatments?

What Is the Main Idea?

Patient expectations can affect their treatment experiences, even having an impact on efficacy and tolerability. The open access review paper “Effects of Patients’ Expectation in Dermatology: Evidence from Experimental and Clinical Placebo Studies and Implications for Dermatologic Practice and Research”, published in the journal Dermatology, discusses some of these effects as they relate to dermatological treatments. This post summarizes the main points from that article.

What Else Can You Learn?

The post also gives fundamental information about placebo and nocebo effects and the importance of countering them with information.

The Placebo Effect

I’m sure you’re familiar with the term “placebo effect”. It’s mainly assumed to describe the situation when someone feels better after a drug or treatment that is fake (not designed to have a pharmacological or physiological effect, pharmacologically or medically inactive). Impacts can be apparent improvements in physical or mental health, actual alleviation of some symptoms (e.g., pain relief), or an upswing in energy.

Do Placebos Affect the Body?

Research has shown that placebos do have an effect on the brain: For example, there can be a reduction in activity in the parts of the brain related to pain experiences when a patient receives a placebo and is told it will reduce pain. This reduction in activity can even be mapped in neuroimaging studies. There is also evidence that the body’s own pain management systems (e.g., endogenous opioids like enkephalins and endorphins) can be involved in placebo-related pain management.

Studies into the impact of placebos on other physiological systems and organs are still ongoing, but participants in placebo groups have displayed or reported improvements in their heart rates and blood pressure as well as reduction in anxiety and other psychiatric symptoms.

What Is the Nocebo Effect?

The placebo effect can also be used to describe the negative impact of a treatment: Placebo group participants have reported increased pain, heart murmurs, increased blood pressure, rise in anxiety, and other undesirable effects when given a placebo and told it might have certain side effects. However, this is more accurately referred to as a nocebo effect.

Can Placebo and Nocebo Effects Occur with “Real Medicine”?

It’s important to realise that the placebo effect doesn’t only apply to “fake medicine” or happen in control groups in clinical trials. Medical treatments that are designed to have pharmacological and physiological impacts can also have placebo and nocebo effects. Placebo effects of “real medicine” can include a perceived improvement of symptoms prior to the drug having taken effect and a reduction in illness-related anxiety in the early stages of taking the drug. Nocebo effects of pharmaceutical and medical treatments include patients reporting very rare side effects that they have read or heard about but that cannot be substantiated by a medical examination; perceived negative side effects before it is pharmacologically possible for the drug to have caused them; and patients showing physical symptoms of anxiety around a treatment that should not have such an effect.

What Is the Paper About?

As reported in “Effects of Patients’ Expectation in Dermatology: Evidence from Experimental and Clinical Placebo Studies and Implications for Dermatologic Practice and Research”, there is a large body of evidence that patients’ expectations from an active or “real” treatment can influence the perception of symptoms as well as the efficacy and tolerability of the treatment. The purpose of the paper is to collect the evidence related to patient expectations and medical impacts from dermatological placebo and actual treatments; and to propose some takeaway messages for clinical dermatological practice.

The paper reviews some of the neurobiological mechanisms related to placebo and nocebo effects to “fake” and “real” medical treatments. It also goes into some of the person-to-person differences in responses. An interesting point is that there is no reliable profile of a “responder”: a person who will respond well to placebo treatments or have an additional positive response to actual medical treatments based on good expectations. This means that medical practitioners cannot currently identify whether a patient will gain more from a treatment if they’re told what to expect or indeed experience additional perceived or real side effects if they hear a lot of negative things about treatments.

What Are the Implications for Dermatological Practice?

The article points out that every communication with a patient has the potential to induce positive or negative expectations that can have a knock-on effect on treatment efficacy. The first recommendation is to establish a sense of the patient’s expectations so that they can be discussed in a scientifically grounded way. Positive communication on the treatment’s potential benefits are important, with clear indications of the expectable level of improvement (e.g., “an improvement of 90%”). Patients can also benefit from hearing other people’s successful experiences.

At the same time, the physician is obliged to talk about possible side effects. This is essential in terms of informed consent, but is also critical because a patient must be able to identify whether a side effect requires medical attention. However, these can be framed in terms of how rare or mild they are, how the potential benefits outweigh the side effects, how side effects can be a sign that the drug is working, and so on. The article does state that further study is needed in this area.

An important observation relates to a strategy called partial reinforcement. This is described in the paper in relation to the chronic inflammatory skin disorder called psoriasis. Research has found that mild and moderate psoriasis can be treated with a full-dose of topical corticosteroids for a period of time, followed by using a topical placebo used some of the time and a topical corticosteroid some of the time. The patients were aware that they were using a placebo, but the treatment was still effective. This minimized any side effects from corticosteroids and reduced treatment costs. A placebo that the patient knows about is called an open-label placebo.

What Does This Mean for Me as a Patient?

Consider talking to your dermatologist about this study, especially in terms of how the discussion of drug benefits and side effects can go. Positive framing still works, even when people know that communication techniques are being employed to try to induce a placebo effect. Improving the quality of communication about expectations, effects, and so on is valuable, and worth trying.

Note: Some of the authors of the paper declared that they have relationships with companies that produce or sell dermatological treatments relevant for described medical conditions. It is normal for authors to declare this in case it might be perceived as a conflict of interest. More detail can be found in the Conflict of Interest statement by visiting the original article page.

What’s the Best Method of Monitoring Hair Loss and Related Treatments?

What Is the Main Idea?

Hair loss can be hereditary or a normal symptom of aging, but it can also be a sign of illness. The recent paper “Efficiency of Hair Detection in Hair-to-Hair Matched Trichoscopy”, published in the journal Skin Appendage Disorders, describes the trichoscopic techniques used to monitor the progression of hair loss and support treatment efforts. This post summarizes the authors’ findings.

What Else Can You Learn?

What is the impact of hair loss? And what are some of the causes, besides hereditary and aging? This post summarizes the answers.

What Is the Impact of Hair Loss?

Hair loss may seem trivial at first: It’s commonly associated with male aging and as yet, there are no non-invasive interventions that reliably slow or prevent so-called male pattern baldness. However, hair loss shouldn’t be seen as trivial. Hair has considerable personal and social importance in many cultures and its loss can be very troubling.

Anyone, regardless of gender, can experience hair loss, but it is most common in cisgender men. Male hair loss is associated with aging, lack of virility, loss of attraction, and other markers of social status. In cisgender and transgender men, its impact includes lowered self-esteem, decreased confidence, and depression.

Female hair loss is associated with illness, depression, and lack of self-care. In cisgender women, its impact includes depression, lowered self-esteem, avoidance of social situations, and altered self-image. Transgender women experience hair loss similarly, but it is also linked with increased gender dysphoria. There have been no studies focused on hair loss in non-binary presenting individuals.

What Causes Hair Loss?

Hair loss has multiple potential causes, including genetic predisposition, hormone levels, aging, autoimmune diseases, skin conditions (including psoriasis and certain types of dermatitis), thyroid disorders, anemia, and extreme weight loss (including eating disorder-related weight loss). Hair loss can occur during pregnancy and due to polycystic ovary syndrome. It can also occur during chemotherapy and radiation therapy.

Because of this range of possible causes, some of which have treatment options, some of which do not, it is important for dermatologists to have accurate diagnostic methods. That’s where trichoscopy comes in.

What Is Trichoscopy?

Trichoscopy is another name for scalp dermoscopy: a non-invasive technique for examining the hair and skin of the scalp. It uses magnifications from 10× (usually done with a manual dermoscope) to 1,000× (requiring a videodermoscope). It is generally used for diagnosing hair and scalp diseases. As you may know, dermatological diagnoses are complicated by the superficial similarities in presentation between various dermatological conditions. The close magnification of dermoscopy reveals differentiating details.

Trichoscopy has another use beyond the diagnosis of diseases of the hair and scalp: monitoring how hair loss is progressing and the effects of any treatment. The authors of “Efficiency of Hair Detection in Hair-to-Hair Matched Trichoscopy” compared the various examination and assessment techniques.

Microscopic hair images can be processed statistically using a few different methods. In the referenced study, these were compared. The average errors in determining the change in the hair count were calculated and the authors concluded that the best approach is to combine manually corrected image processing with follicular mapping and hair-to-hair matching. Manual correction of auto-processed results is almost twice as accurate as auto-processing on its own. However, adding follicular mapping and hair-to-hair matching overcomes limitations that manual correction alone cannot — for example, when hair shafts are sticking together in tight follicular units.

Is This Applied Commonly?

Unfortunately, the described combination procedure remains time-consuming, so it’s not possible for every dermatologist to apply it. However, there is ongoing development, and it may become available for regular use in the future. For now, it’s important to know that in challenging diagnostic cases where treatment may be possible, there are advanced techniques that could provide answers.

Note: Some of the authors of the paper declared that they have relationships with companies that may provide treatment or diagnostic equipment relevant for described medical conditions. It is normal for authors to declare this in case it might be perceived as a conflict of interest. More detail can be found in the Conflict of Interest Statement by visiting the original article page.

Does Platelet-Rich Plasma Improve the Outcome of Plastic Surgery?

What Is the Main Idea?

“Platelet-Rich Plasma in Plastic Surgery: A Systematic Review” is a systematic literature review published in the journal Transfusion Medicine and Hemotherapy. The authors (S.K. Hasiba-Pappas and co-workers) reviewed 50 studies that looked at the use of platelet-rich plasma as an aid to healing in various types of plastic surgery and summarized their findings. This post looks at those findings along with other information about platelet-rich plasma.

What Else Can You Learn?

This blog post describes what platelet-rich plasma is, how it is used, and what it can be used for, along with some of the side effects and controversies around its use.

What Is Platelet-Rich Plasma?

Platelet-rich plasma (PRP) is blood taken from a patient and centrifuged (spun very rapidly), which separates the components of the blood and concentrates the platelets within the plasma. This plasma is then re-injected into the patient. This concentrated sample is intended to accelerate healing, particularly of muscles, tendons, ligaments, and joints. The theory is that the higher concentrations of growth factors, cytokines, etc. will stimulate tissue regeneration. There is also some evidence that it could be used in osteoarthritis as a means to reduce inflammation and in bone grafting and lipofilling procedures to increase graft survival. Theoretically, it could be used for treating chronic wounds, burn injuries, and even scars.

Why Is It Important to Have a Literature Review of PRP Use in Plastic Surgery?

The authors of “Platelet-Rich Plasma in Plastic Surgery: A Systematic Review” aimed to collect all the information about PRP use in plastic surgery in one place. This will help advance research into treatments based on this approach. The papers they reviewed included procedures for reconstruction or wound treatment; cosmetic treatment; hand surgery; burn injuries; craniofacial disorders; and fat grafting.

Why Is Platelet-Rich Plasma Use Controversial?

This approach has gained considerable attention in clinical settings because of the potential for accelerating tissue regeneration. However, there is a lack of consistent data on the results of procedures using PRP and the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have not yet approved it fully. For example, the FDA allows it as an “off-label” treatment for certain muscular and skeletal conditions as well as some plastic surgery.

Part of the issue with PRP is the lack of a standardized protocol for its preparation. One of the aims of the authors of “Platelet-Rich Plasma in Plastic Surgery: A Systematic Review” was to look at the differences in preparation methods. They noted that some studies used double-spin centrifugation while others used a single-spin protocol. Some activated the platelets in the PRP, some didn’t. The number of treatments varied as well. This type of variation will always cause controversy when something is considered for medical applications.

Does Platelet-Rich Plasma Treatment Have Side Effects?

The main side effect (or adverse effect) of PRP treatment is pain. Patients report pain at the site of injection and in the joint, muscle, or general area that is injured or damaged. This pain is to be expected though: Platelet-related healing involves an inflammatory response. Platelets release chemicals in the injured area to ensure that other healing factors move to and activate in that area. In addition, as noted in “Platelet-Rich Plasma in Plastic Surgery: A Systematic Review”, hematomas can occur. These are localized bleeding outside of the blood vessels, similar to a bruise. However, hematomas need more careful observation as they can lead to a critical drop in blood pressure. Yet, most patients did not experience any adverse effects and all the authors of the studies reviewed by S.K. Hasiba-Pappas and co-workers concluded that PRP is safe for therapeutic use.

What Were the Results for Plastic Surgery?

Based on the papers reviewed, PRP use showed:

  • Significantly better results in skin grafting, including for skin grafts on burns, and wound treatment
  • Inconclusive results in scar treatment, breast reconstruction, managing hair loss, and face lifts
  • Promising results in hand surgery
  • Varied results in fat grafting

The authors conclude that PRP is becoming increasingly widely used in plastic surgery, with a good number of trials on the benefits in reconstructive and aesthetic surgery. Several beneficial effects have been identified, but the variations in preparation methods, treatment protocols, and outcomes are still holding this method back from widespread use. Unfortunately, further prospective randomized controlled studies are needed, and standardized protocols will be essential.

Should You Ask Your Plastic Surgeon about PRP?

If you are having plastic surgery, particularly skin grafts and wound treatment, but also hand surgery, there’s certainly enough evidence to support talking to your plastic surgeon about the possibility of using PRP to accelerate or improve healing. However, it may be counterindicated by other factors (e.g., the presence of metastatic diseases, active infections, or low platelet counts) or your plastic surgeon may not have the equipment for it. In the future, it’s very likely to become a more common procedure, based on current evidence.

What Are COVID Toes and Can the Vaccines Cause Them?

What Is the Main Idea?

Inspired by the recent report “Vaccine Toes Are the New COVID Toes” published in the journal Skin Appendage Disorders, this post looks at perniosis, more commonly known as chilblains. What causes perniosis? Can COVID-19 cause perniosis and how common are these media-dubbed COVID toes?

What Else Can You Learn?

The post also looks at the case reported in “Vaccine Toes Are the New COVID Toes”. It dealt with a patient who developed pernio-like lesions after vaccination. Importantly, the report and the blog post both discuss why this should not cause concern about the vaccine.

What Is Perniosis?

You might know perniosis by its more common name: chilblains. Although it generally appears as lesions on the skin, it is actually a type of vasculitis (an inflammation of the small blood vessels). It happens when skin is repeatedly exposed to humid air at temperatures between 0 °C and 16 °C, especially when this exposure is followed by rewarming.

This is an abnormal bodily reaction to temperature changes and its underlying cause is unknown. Risk factors include autoimmune disorders, particularly lupus; circulatory disorders, such as Raynaud’s disease; being underweight; and wearing unsuitable clothing for the weather conditions (no gloves, unsuitable shoes, tight clothing).

Perniosis has the appearance of lesions in the form of itchy or burning bluish-red patches and swelling. It is most commonly seen on the hands, toes, ears, nose, and cheeks, but can appear on calves, thighs, buttocks, and other areas. It doesn’t appear immediately after exposure to cold, damp air, but generally hours to a day after the return to warmer temperatures.

Is Perniosis Reversible?

While freezing air can cause permanent damage, perniosis is generally reversible provided there is no blistering or infection. In most people, the lesions will improve after one or two weeks of avoiding exposure to cold-and-rewarming cycles. Some patients benefit from hydrocortisone for the itching or burning sensation, and of course if an infection sets in, that will need to be dealt with.

If there are signs that they’re not healing, seek medical support. Note that diabetes and poor circulation can complicate the healing process. If you know you have either of these conditions, seek medical support after the lesions appear.

What Does Perniosis Have to Do with COVID-19?

Perniosis is not a symptom of COVID-19. However, during the pandemic, some patients have presented with pernio-like lesions on their toes. Deemed COVID toes in the popular press, the lesions are bluish-red and associated with swelling. It has been seen on people of any age but is particularly common in younger patients with no or mild other symptoms.

As with perniosis, COVID toes are generally not dangerous, but they have been seen to last months, worsen with blisters forming, and have the potential for infection. More commonly, they last up to two weeks.

But Are the Lesions Definitely Connected with COVID-19?

A recent study of 21 people with COVID toes suggested that there was no direct relationship between the SARS-CoV-2 virus and these pernio-like lesions, even going as far as to suggest that these were simply perniosis. The cohort wasn’t large enough to say those results are statistically significant, but it is interesting to note that there are divided opinions on COVID toes. Other studies are ongoing, some concluding that there is a direct relationship.

One interesting report is “Vaccine Toes Are the New COVID Toes”. It deals with a case of a person in their 60s who developed pernio-like lesions on their toes around a week after receiving their second dose of the Pfizer-BioNTech COVID-19 mRNA vaccine. The lesions cleared up within 6 weeks. The report also refers to 9 other vaccine-associated pernio-like lesions mentioned in the literature and posits that the lesions have a relationship to the immune system response to the vaccine.

How Common Are “Vaccine Toes”?

As “Vaccine Toes Are the New COVID Toes” points out, there have not been many cases of pernio-like lesions occurring after vaccination. Therefore, it should not be considered a common vaccine response and people should not be reluctant to take the vaccine because of them. Media outlets may be interested in reporting the story, because it relates to COVID-19, and physicians should be aware that patients may express concerns over “vaccine toes” and assuage their fears.

Note: This post is based on an article that is not open access, i.e., only the abstract is freely available.

Understanding and Screening for Prostate Cancer

What Is the Main Idea?

The open access case report “Genetic Analysis of a Family with Multiple Incidences of Prostate Cancer”, published in the journal Case Reports in Oncology, deals with the genomic screening of three brothers, of whom two had prostate cancer. This case includes examples of how genomic screening can be beneficial in making treatment decisions.

What Else Can You Learn?

This post contains information about the prostate and its function, the equivalent organ in cisgender women and trans men, the warning signs of prostate cancer, and the screening and diagnostic process for prostate cancer.

What Is the Prostate and What Is Prostate Cancer?

The prostate is a small gland located just below the bladder and close to the rectum. It has two functions: generating the thick white fluid that mixes with sperm to form semen; and generating the protein (prostate-specific antigen (PSA)) that ensures that semen is liquid. The gland is found in the bodies of cisgender men, trans women, and nonbinary individuals assigned male at birth, as well as in the bodies of some intersex people.

As with any cancer, prostate cancer is due to abnormal cell growth. It can be a slow or rapid growth and metastases (where the cancer spreads to other parts of the body) can occur. It is one of the most common cancers in cisgender men worldwide. Its risk is significantly lower in trans women who use hormone treatments during their transition.

The warning signs of prostate cancer are pain while urinating or difficulty urinating; erectile dysfunction; and blood in the urine. Pain in the bones and a feeling of compression in the lumbar spine are also reported by patients. The issues with urination are caused by the tumor compressing the urethra, which runs through the gland.

Early or localized prostate cancer is diagnosed when the cancer has not spread to other tissues or organs. Locally spread prostate cancer means that the abnormal cell growth has spread to tissues like the seminal vesicles, local lymph nodes, rectum, or the bladder. Metastases mean that the cancer has spread to other parts of the body. Metastatic prostate cancer most commonly affects the lymph nodes, bones, liver, or lungs.

Does Prostate Stimulation Reduce the Risk of Prostate Cancer?

Stimulation of the prostate gland during sexual intercourse can be pleasurable. Although some non-peer-reviewed reports suggest that massaging or stimulating the prostate can reduce the risk of prostate cancer, there is no firm evidence to support this hypothesis. Such massages can be helpful with non-cancerous inflammation of the prostate, which can reduce the risk of cancer. In addition, there is some evidence that massaging the prostate before some screening methods can improve the test sensitivity.

Do Cisgender Women or Trans Men Have Prostate Glands?

There is no prostate gland in the bodies of cisgender women, trans men, or nonbinary individuals assigned female at birth. Rather, they have Skene’s glands, which are sometimes referred to as “the female prostate gland”, despite having a very different structure. Skene’s glands produce the same protein as the prostate gland, PSA, but are otherwise different. Cancer of the Skene’s glands is believed to be extremely rare.

How Can Physicians Screen for Prostate Cancer?

Screening for prostate cancer is common, especially after patients turn 50. A digital rectal exam, where the doctor inserts a finger into the rectum to examine the texture, shape, and size of the prostate, is the most well-known test, mainly due to its use in comedy that plays on outdated and homophobic ideas regarding anal examinations. It is unfortunate that this trope persists as it may prevent some people getting screened regularly or early.

Another regular screening test is the prostate-specific antigen test. A blood sample is analyzed for the protein. Higher than expected levels for a person of that age may indicate prostate inflammation, infection, or cancer.

Diagnostic tests would use an ultrasound, magnetic resonance imaging, or a prostate biopsy (where a sample of cells from the prostate is taken for analysis). If prostate cancer is determined, these are followed by determination of the aggressiveness and potential metastasis of the cancer. Genomic testing may be done at this stage.

Why Is Genomic Testing Helpful?

Genomic testing results support treatment decisions by providing information on the genetic mutations that are present. Some mutations indicate a treatment approach that may be more effective than another. There are several common gene mutations associated with a predisposition to prostate cancer and research is progressing on the implications of the various patterns of mutation.

The case report “Genetic Analysis of a Family with Multiple Incidences of Prostate Cancer” reports on a single-family genomic test performed in China. Such a case does not provide statistically significant information that can be broadly applied, but it does contribute to the store of knowledge on the topic of mutations and prostate cancer. In the case, three brothers in a family were diagnosed with prostate cancer, and BRCA1 G275D appeared to have a high impact on the progress of the cancer. Since prostate cancer with mutations in DNA damage repair genes like BRCA1 and BRCA2 respond favorably to the drugs olaparib and rucaparib, this information would be valuable to the clinical team.

Should I Discuss My Risk of Prostate Cancer with My Primary Care Physician?

It is always advisable to talk about the risk of prostate cancer if you have a prostate and there is any cancer in your family, and especially if there is prostate cancer in your family. Discuss whether early genomic screening, regular physical examination or annual prostate-specific antigen tests might be helpful. Any change in your urination pattern, especially blood in the urine, demands a consultation with a doctor.

Understanding Ectopic Pregnancy

What Is the Main Idea?

This post summarizes the state of knowledge on ectopic pregnancy, a rare but life-threatening complication of pregnancy. Although it only occurs in 1.2 to 1.4% of all reported pregnancies, it is important to have ready access to information on it.

What Else Can You Learn?

The open access case report “Advanced Abdominal Ectopic Pregnancy with Subsequent Fetal and Placental Extraction”, published in the journal Biomedicine Hub, deals with a rare but important case where a fetus from an abdominal ectopic pregnancy was delivered alive. This report shows how a multidisciplinary team performed surgical intervention to save both the fetus and the mother.

What Is Ectopic Pregnancy?

Ectopic pregnancy is the term for any situation when a fertilized egg implants outside of the uterus. It is a complication that occurs in 1.2–1.4% of all reported pregnancies worldwide. While this may not seem like a large number, this can be a life-threatening condition if not identified early. Furthermore, people who experience ectopic pregnancy can go through considerable emotional trauma as the pregnancy must almost always be terminated. Therefore, access to information about this condition is important.

Around 90% of ectopic pregnancies occur when the egg implants in the fallopian tube on its way to the uterus and another 4% in the interstitial region where the fallopian tube enters the uterus. Tubal implantation might be due to inflammation of the tube (for example due to a sexually transmitted infection (STI)), a hormonal imbalance, or an irregularity in the tube shape (either congenital or due to tubal surgery). There is a correlation between smoking and tubal ectopic pregnancies.

Other ectopic pregnancy locations are in scars from previous cesarean sections; in the intramural tissue or myometrium surrounding the uterus; in the cervix; in the ovary; or in the abdominal cavity around the reproductive organs. These implantations are less well understood because they are so rare, but again, inflammation due to STIs or other infections, hormonal imbalance, or irregularities due to scarring are believed to be the cause.

The Medical Response to Ectopic Pregnancies

A tubal or interstitial ectopic pregnancy can cause life-threatening damage to the fallopian tube. Similarly, ectopic pregnancies within cesarean scars, intramural tissue, or the myometrium can cause life-threatening damage to the uterus. Ovarian ectopic pregnancies can self-abort but there may still be damage to the ovary. Cervical ectopic pregnancies can result in significant bleeding and damage to the whole reproductive system. Medical intervention is essential.

Unfortunately, despite efforts from medical teams, it has not been possible to transplant an ectopically implanted egg into the uterus. Damage may already have occurred within the reproductive system. The removal of the egg from the site of implantation is likely to cause further shock. The development of the egg is sometimes abnormal due to the location. Furthermore, these types of ectopic pregnancy must be ended early, long before there is a viable fetus that can survive in an incubator.

Therefore, to prevent life-threatening complications, the pregnancy must be terminated. If it is diagnosed early enough and there is no serious bleeding, this may be done with a medication. However, it may require surgery: either laparoscopic surgery, which involves very small incisions in the abdomen and small surgical tools, or laparotomic surgery, which involves opening the abdomen. The surgery type depends on the degree of damage and bleeding caused by the ectopic pregnancy. Removal of an ovary, fallopian tube, or even a full hysterectomy can be required. It is important to get the clearest possible diagnosis, to know the extent of any bleeding, and to discuss the surgery with full consent to the interventions.

The Aftermath of Ending an Ectopic Pregnancy

All the major medical bodies acknowledge that ending an ectopic pregnancy can emotionally impact the parent(s) in the same way as the loss of a pregnancy at any other stage. Even if the pregnancy is not known about for very long, in many cases, the potential for stress, trauma, depression, and even self-blame is high. The advice is that the parent(s) should seek therapeutic support in the aftermath of the ectopic pregnancy.

Furthermore, there may be an emotional impact from the loss of the ovary, fallopian tube, or whole reproductive system. These are also circumstances where emotional support is highly recommended. There is also considerable anxiety related to future pregnancies. Although many people who have an ectopic pregnancy go on to have a healthy pregnancy later, this fear can remain. It’s always important to acknowledge the emotional impact of such medical interventions and seek support.

What about Abdominal Ectopic Pregnancies?

Abdominal ectopic pregnancies are the only type of ectopic pregnancy that can reach full-term gestation with a viable fetus. This is extremely rare, but it can occur. Between 2008 and 2013, 38 abdominal ectopic pregnancies resulted in a live birth. However, it can result in death of both the fetus and the pregnant person, so medical monitoring and intervention are essential.

The open access case report “Advanced Abdominal Ectopic Pregnancy with Subsequent Fetal and Placental Extraction” deals with a successful live birth. A cisgender woman who was pregnant for the first time aged 38 presented to the hospital, aware that she had been pregnant for at least three months, based on home testing. She was diagnosed with an ectopic pregnancy based on an ultrasound revealing an empty uterus. She refused treatment at that time because she did not want to terminate the pregnancy and feared that the doctors would insist on this. A month later, she returned and was admitted for further evaluation, but refused to remain in the facility for treatment. She did, however, make further visits to the facility and, eventually, in what was believed to be the 35th gestational week, she underwent surgery to deliver the fetus, which had developed normally.

The surgery was performed by a multidisciplinary team and is described in detail in the paper. Not only was the fetus delivered alive and the placenta removed without complications for the mother, but the newborn had no limb defects, facial or cranial asymmetry, joint abnormalities, or central nervous system malformations.

Why Is This Case Report Important?

This is a very unusual case. However, the details of the operation and the experience of the multidisciplinary team that performed it give important insight into how such a case might be handled successfully. Of course, there are many factors that can be different in various abdominal ectopic pregnancies; and it cannot be denied that the woman in this case took a large risk in refusing admission to the hospital.

What Can an Individual Do about Abdominal Ectopic Pregnancy?

The last thing that expectant parents need is more stress. However, it is essential to quickly seek medical help if you suspect or know that you are pregnant (e.g., have missed a period and/or tested positive with a home pregnancy test) and notice:

  • Light, medium or heavy vaginal bleeding.
  • Unexpected urges to have a bowel movement, especially early in pregnancy, or pain when defecating or urinating.
  • Unexpected back, abdominal or pelvic pain, especially early in pregnancy.
  • Extreme light-headedness, with or without fainting.
  • Shoulder pain on one side of the body, particularly if located at the tip of the shoulder where it joins the arm.
  • Feeling very full when lying down despite not having overeaten.

Furthermore, if you are not aware that you are pregnant, but you notice lower stomach pain on one side of the body and/or vaginal bleeding that is different than your normal period (darker, more watery, heavier, more prolonged, or much lighter), then you should seek medical help immediately.

Treating Onychomycosis: A Fungal or Yeast Infection of the Nails

What Is the Main Idea?

Onychomycosis is a relatively common infection of the fingernails and toenails. The currently available oral antifungals are not without risk. In the review article “Complementary and Alternative Therapies for Onychomycosis: A Systematic Review of the Clinical Evidence”, published in the journal Skin Appendage Disorders, alternative treatments were considered.

What Else Can You Learn?

Learn about the causes of onychomycosis and some of the ways you can approach your nail health to prevent it.

What Is Onychomycosis?

Onychomycosis is a fungal infection of the fingernails and toenails. It’s a common infection, occurring in around 10% of the population overall. It’s more common in older people, with around 50% of those over 70 years of age experiencing it. It’s also more common in people with immune disorders, including HIV; auto-immune disorders, including psoriasis; and diabetes. It’s more likely to occur in toenails than fingernails because the damp and dark are more conducive to fungal growth.

There are three main classes of fungus that cause onychomycosis:

  • Dermatophytes are by far the most common. These are fungi that grow on keratin, the protein found in hair, nails, and skin.
  • Non-dermatophyte molds are the least common cause in the general population, but the dominant cause in patients with HIV. They can only infect keratinized tissues if the keratin is damaged by some other infection or physical trauma.
  • Yeasts of the genus Candida are a slightly more common cause than non-dermatophyte molds. Candida is more common in fingernail onychomycosis than in toenail onychomycosis.

How Can Nails Be Protected?

Hand and foot hygiene should go beyond washing the skin and using a nail brush to clean under the nails. It’s also important to consider what environment and condition the nails are in. Continually wearing shoes and socks is not good for the toenails, as it keeps them in the dark and prevents them from drying properly. Wearing nail polish and nail varnish continually means the tissues of the nail bed don’t “breathe” properly. Damaging the nails during gardening exposes them to bacteria and fungus. Leaving dermatophyte infections untreated can allow non-dermatophyte infections to take hold. It’s important to treat your nails as well as you treat your skin, considering them not just as “dead keratin”, but as part of your hands that need good conditions to stay healthy.

How Is Onychomycosis Treated?

As explained in the review article “Complementary and Alternative Therapies for Onychomycosis: A Systematic Review of the Clinical Evidence”, onychomycosis is very difficult to treat. The nails are made of keratin and are not permeable to many topical agents. What’s more, while oral antifungals can be effective against onychomycosis, this type of drug cannot be used in every patient population due to the risk of system-wide effects.

Are Alternative Treatment Strategies Effective?

The authors of the review looked at every paper that mentioned complementary or alternative therapies for the treatment of onychomycosis. They found 17 articles with alternatives, including:

  • Tea tree oil, which seems successful against Candida infections and has shown some potential against dermatophytes.
  • An extract from Ageratina pichinchensis, a plant used in traditional Mexican medicine, which exhibited some therapeutic effectiveness against onychomycosis in pilot clinical trials.
  • An extract from Arthrospira maxima, also called spirulina, which also showed promise in a pilot clinical trial.
  • Vicks VapoRub®, a commercially available topical ointment used to ease breathing, which showed promising results with cure or partial clearance of the fungus in the majority of patients in a non-clinical trial.

Does This Mean These Treatments Can Be Used?

As pointed out in the review article “Complementary and Alternative Therapies for Onychomycosis: A Systematic Review of the Clinical Evidence”, all the results with alternative or complementary therapies for onychomycosis are preliminary. There have not been any large-scale, randomized, placebo-controlled trials. Therefore, while these treatments are promising, they could not be endorsed as official therapies.

However, you could certainly discuss this paper and these treatments with your physician if you had onychomycosis and wanted to try something other than antifungals to deal with it.

Note: This post is based on an article that is not open access, i.e., only the abstract is freely available.

Understanding Penicillin Allergies

What Is the Main Idea?

If a patient has an allergy to penicillin, it can complicate the treatment of common bacterial infections, such as tetanus, meningitis, strep throat, pneumonia, food poisoning, and chlamydia. But are penicillin allergies as common as people believe? And do they cause greater mortality in hospital settings? This post refers to the research article “Impact of Penicillin Allergy Label on Length of Stay and Mortality in Hospitalized Patients through a Clinical Administrative National Dataset” published in the journal International Archives of Allergy and Immunology.

What Else Can You Learn?

This post also briefly explains the common classification of bacteria as Gram-positive or Gram-negative and explains why penicillin cannot be used to treat the latter.

A Very Common Antibiotic

Discovered almost 100 years ago, penicillin has been used to treat infections since 1930. It functions by deactivating the enzymes responsible for forming the cell walls of certain bacteria, called Gram-positive bacteria (see below). Penicillin is not effective against all bacteria, but there are derivatives like amoxicillin and ampicillin, which are commonly prescribed against Gram-negative bacteria (see below).

What Are Gram-Positive and Gram-Negative Bacteria?

The Danish scientist Hans Christian Gram developed a method of staining bacteria to aid in their identification. His method divides them into two large groups: Gram-positive bacteria, which stain violet; or Gram-negative bacteria, which stain pink or red. There are some bacteria that stain with a mixture of pink and violet cells, referred to as Gram-intermediate bacteria.

Gram-Positive Bacteria

Common genera of Gram-positive bacteria include Clostridium, Listeria, Staphylococcus, and Streptococcus, which respectively include species causing botulism and tetanus; listeriosis manifesting as sepsis or meningitis; staph-related food poisoning; and strep throat, meningitis, pneumonia, and pink eye. Gram-positive bacteria have a cytoplasmic cell membrane surrounded by a thick peptidoglycan cell wall. They are susceptible to antibacterial agents that target this cell wall, including penicillin.

Gram-Negative Bacteria

Common genera of Gram-negative bacteria include Chlamydia, Escherichia, Pseudomonas, and Salmonella, which respectively include species causing chlamydia; Escherichia coli food poisoning; ventilator-associated pneumonia and sepsis; and salmonella food poisoning. Gram-negative bacteria have a cytoplasmic cell membrane surrounded by a thin peptidoglycan cell wall surrounded by an outer membrane. This outer membrane protects them from a range of antibacterial agents, including penicillin. They also have other protective measures that are different to those of Gram-positive bacteria.

Allergy to Penicillin

If you are allergic to penicillin, you’ve probably encountered issues with getting treatment for some common bacterial infections. Penicillin allergies can manifest as minor to major skin reactions (hives, rashes, or itching); watery eyes and a runny nose; shortness of breath or wheezing; fever; tissue swelling; or in extreme cases, life-threatening anaphylaxis. There are also delayed reactions that can result from penicillin allergies, although these are rare. These can include inflammation of the kidneys, severe blistering and peeling of the skin, and drug-induced anemia.

Around 10% of the U.S. population report having allergies to penicillin, but several studies have found evidence that this number is too high. Some suggest that just 1 or 2% of the population have allergies. One suggests that as few as 0.03% have serious allergies. Nevertheless, since anaphylaxis is possible and potentially fatal, if a patient reports a penicillin allergy, physicians will avoid prescribing it or any of its derivatives. They may also avoid cephalosporins, a group of antibiotics that have a similar structure to penicillins.

In some cases, this can leave very few options for treatment, as alternative antibiotics may be too expensive for the hospital, clinic, or patient to afford. This could mean a longer hospital stay, which is the topic of the research article “Impact of Penicillin Allergy Label on Length of Stay and Mortality in Hospitalized Patients through a Clinical Administrative National Dataset”.

What Does the Paper Describe?

This study of adult patients in the hospital system in Spain compared the lengths of hospital stay and in-hospital mortalities of patients with and without a penicillin allergy. Note that the patients were not admitted because of the allergy: The study focused on whether having an allergy that might complicate the management of disease had a significant effect on hospitalization.

Over a 10-year period, almost a million patients who were admitted to hospital had a penicillin allergy on record. This was just 2.63% of all hospital admissions. The comparison group was a random sample of equivalent size. The study found:

  • If a patient has a penicillin allergy, they are more likely to have a longer stay in hospital.
  • Penicillin allergies are not associated with higher mortality rates in hospital.

What Does that Mean for You?

If you or a family member have a penicillin allergy, you are probably already familiar with the complications that can arise in the treatment of bacterial infections. It may be important to discuss the results of this study with your physician(s) if a hospital stay is coming up. What will happen if you need an antibiotic while in hospital? And do you need to prepare for a potentially longer stay?

Should Physicians Test for Penicillin Allergies?

A few papers published in recent years have suggested testing for penicillin allergies to see if the patient could in fact tolerate the antibiotic. This approach has not entered common practice, but it might also be worth discussing with your physician if there is a suspected allergy. It would be better to know for sure than to have a more difficult experience because of a false assumption.

Note: This post is based on an article that is not open access, i.e., only the abstract is freely available.

Long-Term Surgical Mask Use and Skin Conditions

What Is the Main Idea?

We’re all accustomed to wearing masks in public now due to the COVID-19 pandemic. However, there are some issues that can occur if masks are worn too much or for too long. The open access report “Demodicosis Associated with Wearing a Face Mask: A Case Report”, published in Case Reports in Dermatology, deals with a case where a naturally occurring ectoparasite became a problem due to a patient’s excessive mask use.

What Else Can You Learn?

Learn more about the life of the common ectoparasite, Demodex, and how infestations can occur.

What Is a Demodex Mite?

Demodex is a genus of common mite that lives on the skin surface, feeding on sebum that is excreted from the hair follicles and sebaceous glands. The two species that are commonly found on humans are Demodex folliculorum and Demodex brevis. Both are referred to as eyelash mites or face mites, but they can be found anywhere on the body. One further species that is found less commonly on humans is Demodex canis, the Demodex mite of the domestic dog. It tends to only be found on humans with immunosuppressive conditions. The feline equivalent, Demodex cati, has not been reported from humans.

Demodex mites are tiny: less than half a millimeter long. They generally don’t cause any problems, but as with a lot of symbiotes and ectoparasites (parasites that live on the outside of the body), if their population builds up, then health issues can occur. Blepharitis (inflammation, scaling and reddening of the eyelids) and demodicosis (a rosacea-like skin condition associated with inflammation of the hair follicles) are two examples of skin conditions directly related to Demodex infestation.

When Do Infestations Occur?

Infestations are most likely to occur if people have suppressed or challenged immune systems, for example due to HIV, cancer, liver disease, or corticosteroid use. However, they can occur in other circumstances, as described in “Demodicosis Associated with Wearing a Face Mask: A Case Report”.

How Can Infestations Be Treated?

Treatment includes topical insecticides or the oral anti-parasitic drug ivermectin. If an infestation is diagnosed early, it may be possible to deal with it using specialized facial wipes for Demodex or even gentle surfactants like baby shampoo. Changes in behavior can also be needed: avoiding oily skin products and cosmetics, for example.

Can Surgical Masks Cause Imbalances in Demodex Populations and Other Skin Problems?

The case described in “Demodicosis Associated with Wearing a Face Mask: A Case Report” deals with a case where behavior rather than immunosuppression led to a Demodex infestation. It’s a behavior that we have all experienced in the past few years: wearing a surgical face mask.

Wearing a face mask for over one hour can cause an increase in skin temperature and sebum excretion in some people. It can also cause the skin to become drier. It would be rare to see any significant issues in an individual with healthy skin after one or two hours. However, wearing a mask for longer continuous periods has been associated with issues in many people, with 5 or 6 hours often cited as the problem point. Skin conditions associated with face mask use include atopic dermatitis, acne, and rosacea.

How Often Should You Change Your Mask?

Public health advice in many countries is that you should change your mask once every four hours, preferably cleaning the face during the change, and not re-use masks over multiple days. It doesn’t matter whether it’s a cloth mask or a surgical mask, the result can be the same from excessive use.

What Is the Report About?

The report is from the first case of demodicosis associated with wearing a face mask. The patient in this case was wearing a surgical mask (at first) and a cloth mask (after suspecting an allergy to something in the surgical mask) for over 8 hours per day for three weeks. The patient was helped by treatment with ivermectin and behavioral changes (avoiding wearing the same mask continuously, using a new mask every day). This quickly cleared up the issue.

The author recommends that demodicosis be included in the differential diagnosis for facial rashes associated with face masks during the COVID-19 pandemic. And we can all take care to change our masks after 4 hours and keep our faces clean using gentle surfactants during the ongoing health measures for COVID-19.

Why Should We Care about Circulating Tumor Cells?

What Is the Main Idea?

Circulating tumor cells (CTCs) are showing promise in cancer diagnostics, with new studies looking at their potential. For example, the study detailed in “Preliminary Clinical Validation of a Filtration-Based CTC Assay for Tumor Burden and HER2 Status Monitoring in Metastatic Breast Cancer”, published in the journal Oncology Research and Treatment, shows how CTCs can be used to determine whether a breast tumor expresses the protein HER2 (human epidermal growth factor receptor 2), which can influence treatment decisions.

What Else Can You Learn?

This post includes fundamental information about CTCs, metastasis, tumor stages and grades, and mutational differences between tumors.

What Is a Circulating Tumor Cell?

Sometimes, a solid primary tumor can shed cells into the blood and lymph vessels. These cells are then carried around the body. They are individually referred to as circulating tumor cells (CTCs) but they can also exist as clusters (CTC clusters).

CTCs can be seeds for additional tumors to grow in other parts of the body. These tumors are called metastases. After metastasis, cancer is much more difficult to treat because all the tumors must be located, and the effect of chemotherapy, radiotherapy, and surgery on multiple organs must be considered.

Note that not every CTC becomes a seed for an additional tumor and the presence of CTCs does not automatically mean that metastasis has occurred. CTCs are not currently considered within definitions of the stages or grades of cancer. In fact, there are indications that CTCs can be shed during all stages of cancer.

What Are the Stages and Grades of Cancer?

As you may know, part of the diagnostic process for cancer involves defining the stage and/or grade. This information helps in informing the treatment regime. Staging defines how advanced the cancer is; grading defines the cell behavior. Information on the size and number of tumors can also be used to determine the tumor load or tumor burden.

One staging system involves defining stages 0 through IV:

  • Stage 0 and stage I cancer, respectively, mean a very small or small tumor located on only one organ. Stage 0 tumors may not require immediate treatment, just monitoring.
  • Stage II and stage III mean that the tumor is growing and may push into or spread to surrounding tissues and lymph nodes. With most cancers, stage II does not involve any actual spread to the surrounding tissues or lymph nodes, but note that the definition of stage II can vary depending on the tumor type, creating some overlap between these categories.
  • Stage IV cancer is when the cancer has spread to other organs. The new tumors (metastases) are distant from the primary tumor and, due to differences in the organ where they arose, can have different characters.

Another staging system is the TNM system:

  • T1–4 to indicate the size of the primary tumor;
  • N0–3 to indicate the number of lymph nodes affected; and
  • M0 or M1 to indicate the absence or presence of metastases.

The grading system in common use defines cancer cells as grade 1, 2, or 3. Those that resemble normal cells and have a normal growth rate are grade 1. When the appearance and growth rate change, the grade increases, with grade 3 indicating abnormal appearance and aggressive spreading due to a high growth rate.

What about Genetic Information?

Other information is of course essential to make informed treatment decisions. We know that there can be significant genetic differences between tumors of the same organs in different people. This relates to the possibility to investigate the tumor mutational burden: the number of non-inherited mutations in the cells of a tumor. It is also important for looking at what receptors the tumor cells are expressing, which influences treatment decisions.

For example, when considering the breast cancer called ductal carcinoma, physicians want to know if the tumor is estrogen receptor-positive (ER+), progesterone receptor-positive (PR+), human epidermal growth factor receptor 2-positive (HER2+), or triple-negative. This information is normally obtained by taking a biopsy directly from the tumor, which can be an invasive and painful process.

What Is the Value of CTCs?

CTCs come from the tumor and therefore carry genetic information about it. They can therefore be used for a process called a liquid biopsy, which is a less invasive way to gather information about a cancer. Rather than taking a solid biopsy directly from the tumor, blood can be drawn and analyzed for CTCs.

However, CTCs are rare. Are there enough to guarantee accurate diagnostic information?

This Study on CTCs Yielded Promising Results

The study detailed in “Preliminary Clinical Validation of a Filtration-Based CTC Assay for Tumor Burden and HER2 Status Monitoring in Metastatic Breast Cancer” is just one of many currently looking at clinically valuable information from CTCs. In this study, blood samples from 47 patients with metastatic breast cancer were analyzed for tumor burden and HER2 status using a new method. The preliminary results indicate that tumor burden and HER2 status can be successfully determined from CTCs. The assay requires further clinical validation, but this is very promising.

Such studies are common, especially since emerging technologies are making it easier to detect and analyze CTCs. If CTC assays can help to determine tumor burden, tumor mutational burden, or even define the grade of a cancer, then liquid biopsies could become a commonplace diagnostic technique.

Crucially, there are studies looking into the possibility of CTCs being used for early diagnosis of cancer, since they can even be shed by stage I solid tumors. Suggestions of using a routine blood test to check for the presence of common cancers have been made. We may be on the verge of an important new phase in cancer diagnosis and treatment.

Note: This post is based on an article that is not open-access; i.e., only the abstract is freely available. Please also note that one of the authors of the paper declared that they are a full-time employee of a biotech company. It is normal for authors to declare this in case it might be perceived as a conflict of interest.

Do Antibiotics Help in Controlling Acute Exacerbation of Asthma?

What Is the Main Idea?

Antibiotics are frequently prescribed to children experiencing acute worsening of their asthma, but are they always needed? Published in the International Archives of Allergy and Immunology, the research article “Antibiotic Treatments Prolong the Wheezing Period in Acute Exacerbation of Childhood Bronchial Asthma” focuses on this question and shows that antibiotics might even make it harder to recover from an asthma attack.

What Else Can You Learn?

The post describes the symptoms of asthma, why attacks occur, and gives some advice on what to do if you’re having an asthma attack.

What Is Bronchial Asthma?

Bronchial asthma is commonly known as asthma. It is an incurable condition that affects the airways (i.e., the trachea, bronchi, and bronchioles). During an episode of asthma, referred to as an asthma attack, the airways swell, narrow, and may produce extra mucus.

Symptoms of an asthma attack include trouble breathing, a tightness across the chest, a cough, and wheezing. The attack can be mild, moderate, or severe, with the differentiation based on the person’s ability to speak, lie down, or sit, and the presence of retractions (where the ribs pull in during a breath). A diagnostic device called a peak flow meter can be used to precisely differentiate the three states. While asthma doesn’t directly cause fevers, there is an association between bronchial asthma and bronchitis that can lead to a fever co-occurring with prolonged or frequent asthma attacks.

Wheezing is a required symptom for a diagnosis of asthma. Described as a high-pitched whistling or purring noise that is particularly noticeable on exhale, wheezing must occur during multiple instances of difficulty breathing.

Asthma can flare up due to allergens in the air (e.g., pollen, dust mite droppings, dander from animals), allergens in the body (e.g., an insect sting, medication, food proteins), irritants in the air (e.g., chemical fumes, sawdust, cigarette smoke), environmental changes (e.g., moving into colder air), or physical exertion.

What Should You Do If You Have an Asthma Attack?

If you have already had a diagnosis of asthma, you probably have an action plan from your physician. You may have an inhaler or other medication. That is certainly enough for a mild asthma attack and may be enough for a moderate attack. Because severe asthma attacks can be life-threatening, there are circumstances when calling an ambulance or seeking emergency care is vital.

For example, if an asthma attack comes on after exposure to allergens, the patient is struggling for every breath, the patient passes out or their lips turn blue, there is a co-occurring fever around 40 °C (104 °F), emergency care is absolutely essential. Attacks lasting longer than 24 hours, milder fevers lasting multiple days, and disruptions to sleep are also given as reasons to seek advice from healthcare professionals.

Antibiotics and Asthma

Managing asthma in children is naturally challenging, particularly when one considers the emotional distress that both child and parent or guardian experience during an asthma attack. This can prompt the desire to go further with attempts to treat the condition than are advisable or necessary.

The research article “Antibiotic Treatments Prolong the Wheezing Period in Acute Exacerbation of Childhood Bronchial Asthma” focuses on an effort to help that may actually do more harm. Medical guidelines in many countries state that antibiotics should not be routinely prescribed to children with worsening asthma symptoms. Nevertheless, children with acute exacerbation of asthma are prescribed antibiotics more frequently, even when they don’t have any signs of a bacterial infection.

The only reason to prescribe antibiotics to someone with asthmatic wheezing is if they have a bacterial infection in their respiratory system or are at a very high risk of developing one (for example, if a family member already has one). Prescribing an antibiotic when there is no presence or risk of bacterial infection is entirely unnecessary.

In the study described in “Antibiotic Treatments Prolong the Wheezing Period in Acute Exacerbation of Childhood Bronchial Asthma”, the researchers examined pharyngeal samples and took clinical information from over 100 children with acute exacerbation of asthma. The period of time when wheezing occurred was of particular interest. They found that over half the children had been given antibiotics and that the period of wheezing was longer in those patients than in the ones who didn’t receive antibiotics. Even in those patients with a bacterial infection (Streptococcus pneumoniae, which can cause pneumonia), the period of wheezing was longer when antibiotics were prescribed.

What Does This Mean for Me?

If you or your child has asthma and a physician suggests an antibiotic during a period when your asthma is worse, ask if it’s absolutely necessary. Although this study needs to be repeated with a larger cohort of patients, it is still a significant indication that antibiotics might hinder the calming of the asthma symptoms. Check if the antibiotic is needed, discuss the pros and cons, share the link to the article with your physician. It’s still possible that the antibiotic is needed: Unchecked pneumonia is dangerous! But this information may be helpful in making a decision that leads to the asthma coming under control sooner.

Note: This post is based on an article that is not open-access; i.e., only the abstract is freely available.

Is COVID-19 Affecting Infants’ Microbiota?

What Is the Main Idea?

COVID-19 is having an impact on infants’ microbiota, and this may affect them in their later lives. Published in the International Archives of Allergy and Immunology, the open access review “The Effect of COVID-19 Pandemic on the Infants’ Microbiota and the Probability of Development of Allergic and Autoimmune Diseases” gives details about the increased risk of allergic and autoimmune diseases in children born during the pandemic.

What Else Can You Learn?

This post includes a reminder of the impact of COVID-19 on the individual as a disease and on our behaviors and lifestyles as a pandemic. This context is important to understand the impact on infant microbiota. The post also gives a brief explanation of the composition and importance of microbiota.

COVID-19 Affects Humans in Various Ways

“How will COVID-19 affect my child?” It’s only natural that a parent would ask this about their child, especially if that child is too young for vaccination. COVID-19 is still a global concern and is likely to remain one for some time, with the potential for more variants, reinfection, and further surges not ruled out.

SARS-CoV-2, the virus that causes COVID-19, is primarily transmitted via respiratory routes. Its highest levels are detected in the lungs and upper respiratory system, but it can spread to other organs, including the heart, kidneys, liver, and brain. Gastrointestinal symptoms are also common and can be persistent.

Although the risk of severe illness from COVID-19 seems to be low in children (unless they have underlying health conditions), given the possibility of SARS-CoV-2 spreading to other organs, it’s important for doctors and parents to have an awareness of how the virus might affect children’s development.

However, it’s also important to consider the effect of the pandemic itself on humans — and again, parents and doctors should be especially concerned when it comes to children. The pandemic has changed the way we live our daily lives, and researchers have studied how this has impacted our psychology, physical health, and development.

The open access review “The Effect of COVID-19 Pandemic on the Infants’ Microbiota and the Probability of Development of Allergic and Autoimmune Diseases” focuses on the impact of the COVID-19 pandemic on the composition of the body’s microbiota.

What Is the Microbiota and How Does COVID-19 Affect It?

The human microbiota consists of trillions of symbiotic microbes (bacteria, fungi, viruses, protists, and archaea) living in and on the human body. The majority are found in the gut, where they play a role in protecting the intestine against colonization by other microorganisms. The gut microbiota is proven to play an essential role in shaping the development of immunity, and it is critical that its development begins in early childhood. Exposure to environmental microbial species and nonharmful symbiotic and commensal organisms should occur during pregnancy, childbirth, and infancy. Factors that are relevant include the levels of social interactions, use of detergents and disinfectants in the child’s environment, exposure to pets, and use of antibiotics.

As the review points out, the lifestyle changes caused by the COVID-19 pandemic have included decreased social interactions; an increased use of detergents, disinfectants, and antibiotics; changes in exposure to pets; and changes in infant feeding patterns. All these behavioral changes have an impact on the infant’s microbiota, and this has a knock-on effect on the immune system.

What Is the Significance of the Impact of COVID-19 on Breastfeeding?

One example of this pertains to breastfeeding patterns. Based on the available evidence, SARS-CoV-2 cannot be transmitted through breast milk. It is recommended that breastfeeding continues, even when the mother has tested positive for COVID-19. Understandably, many choose to be more cautious and stop feeding for the weeks after the positive test. This can affect the microbiota of the child. Even if the COVID-19-positive mother continues breastfeeding, medical advice is that they should use a mask, disinfect their hands, and limit the time holding the baby. This also has an impact, as the child has a change in exposure levels during this critical developmental period.

Breastfeeding and exposure to the mother during breastfeeding reduces the risks of: diseases caused by immune system deficiencies; type 1 diabetes; later-life type 2 diabetes; rheumatoid arthritis; multiple sclerosis; and celiac disease.

What Else Does the Review Cover?

This is just one example of how a change in behaviors during the pandemic can affect the development of a child’s microbiota. The review “The Effect of COVID-19 Pandemic on the Infants’ Microbiota and the Probability of Development of Allergic and Autoimmune Diseases” also gives information on how the mode of delivery of the baby (vaginal birth or cesarean section), use of detergents, antibiotic treatment, and contact with pets have potentially affected the microbiota of infants.

What Is the Conclusion?

It is essential for doctors and parents to be aware of the potential impact of altered microbiota formation. It can provide a greater awareness in the future when children have symptoms of autoimmune diseases and other conditions. This can accelerate diagnostics and ensure that the child gets the support they need sooner. It could also inform current practices regarding exposure to animals, breastfeeding, and exposure to environmental bacterial. Finally, it is a reminder to get older children and family members vaccinated against COVID-19 as soon as possible so that the whole family can return to behaviors that ensure exposure to the necessary environmental microbes.

Atopic Eczema Is Associated with Depression and Anxiety

What Is the Main Idea?

Our mental health can be influenced by long-term conditions, including dermatological ones such as eczema. This post was inspired by the open access research article “Depression, Anxiety, and Suicidal Ideation in Patients with Atopic Eczema in a Prospective Study in Leipzig, Germany”, published in the journal International Archives of Allergy and Immunology. It describes the state of knowledge on the link between atopic eczema, depression, and anxiety, particularly in the light of a recent study.

What Else Can You Learn?

This post also describes some of the ways atopic eczema can be triggered and managed.

Content Warning

This blog post mentions suicidal ideation. There are no descriptions of suicidal ideations or suicide attempts.

What Is Atopic Eczema?

Atopic eczema, which is also called atopic dermatitis, is a chronic skin condition that causes dry, itchy, and cracked skin. It often presents as red, brown, brownish-gray, or purple patches of skin, raised bumps, or scaly patches. It can become swollen or infected if patients scratch it. This type of eczema can be localized or widespread, its manifestation can vary in severity over time, and patients often report considerable associated pain. The symptoms most commonly start in early childhood, but there is also adult-onset eczema.

An association between atopic eczema and allergies has been identified, with some eczema patients showing allergies to certain detergents, foods, or airborne particles like pollen. However, these allergies trigger more severe symptoms rather than being the underlying cause of eczema. Stress and other environmental factors are also known to trigger an increase in symptoms. The actual cause is probably genetic.

Can Atopic Eczema Be Cured?

There is no cure for atopic eczema, but it can be managed. Topical steroids (an artificial version of an adrenal gland hormone) are often prescribed when the symptoms are severe. However, most of the management falls on the patient, with recommendations including:

  • Regular moisturizing of the skin.
  • Identifying and avoiding the triggers of more severe symptoms, which may include soy, wheat, milk, or eggs; soaps, detergents, and other surfactants; or dust and pollen.
  • Reducing the frequency of showers and baths and using only gentle soaps, to prevent drying the skin.
  • Avoiding scratching or rubbing the skin, which includes being gentler when toweling off after a shower or bath.
  • Reducing activities that cause you to sweat or ensuring that sweat does not stay on the body for long.
  • Losing weight if recommended by a dermatologist, as people with eczema and obesity often show more severe symptoms.

What Is the Relationship between Atopic Eczema and Mental Health Conditions?

A significant percentage of patients with atopic eczema present with depression and anxiety. In the study reported in the paper “Depression, Anxiety, and Suicidal Ideation in Patients with Atopic Eczema in a Prospective Study in Leipzig, Germany”, the researchers worked with atopic eczema patients and control subjects to investigate any correlation between the severity of eczema and psychosocial conditions.

Participants in the study had their atopic eczema scored for severity by a trained dermatologist, who used objective indexes. They were also assessed for sleeping problems. They filled out a set of five standardized questionnaires to assess depression, anxiety, social network size, and quality of life. They also did a questionnaire about suicidal ideations, which was designed by the researchers.

The results showed that patients with atopic eczema:

  • Show more signs of anxiety and depression than control subjects.
  • Show more severe anxiety and depression if their eczema is more severe.
  • Are more likely to have suicidal ideation if their eczema is severe.
  • Are not at a higher risk for social isolation.

They also showed that sleep disturbance, which can be associated with atopic eczema, is linked to an increased risk of suicidal ideation.

The findings still require further validation with a larger group of subjects, but considered alongside the results of other studies on eczema and mental health, they show a clear signal about psychological conditions and skin health.

What Do the Results of the Study Mean for Patients?

If you or someone in your life has atopic eczema, it’s important to be aware of the link with anxiety, depression, and suicidal ideation. It’s also important to talk openly with your dermatologist and primary care physician about these findings, and about your own mental well-being. Mental health should never be ignored within the larger treatment plan.

Note: The authors of this paper make a declaration about grants received from pharmaceutical companies and memberships on the boards of such companies. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.

Melanoma Diagnosis: How a New Technology Could Help

What Is the Main Idea?

This post was inspired by the open access research article “The Additive Value of 3D Total Body Imaging for Sequential Monitoring of Skin Lesions: A Case Series” published in the journal Dermatology. The article focuses on the benefits of a recently introduced dermatological technique called 3D total body photography. This blog post describes the conclusions of the article in the context of diagnosing melanoma.

What Else Can You Learn?

This post also gives the risk factors for melanoma and discusses why timely diagnosis is essential but can be challenging. It recommends being actively involved in monitoring your skin health.

What Is Melanoma?

Melanoma is a type of skin cancer that develops in the melanocytes, which are the cells that produce the skin pigment melanin. They are located in the bottom layer of the skin’s epidermis (the outermost layer of the skin). The melanin they produce plays a role in protecting the hypodermis (also known as the subcutaneous tissue) from the damaging effects of ultraviolet radiation. Melanocytes are also part of the immune system.

The risk factors for melanoma are:

  • Excessive exposure to ultraviolet radiation, including from sunlight and tanning beds.
  • A family history of melanoma.
  • Having a large number of moles, unusually shaped moles, fair skin, or a tendency to sunburn.
  • Being immunocompromised.

Although the greatest risk of melanoma is related to the damage from ultraviolet radiation, it can develop on any part of the skin, including those that don’t get much sun. Melanoma has also been found on the eyes, nose, and throat, although these are very rare cases.

The Challenge of Timely Diagnosis of Melanoma

Melanoma is the second most common cancer in adults aged 25 to 49 and its incidence in people under 40 is increasing. It is considered the most serious form of skin cancer. Early treatment is essential to control its spread. If it is detected and treated early, it is usually curable, with a five-year survival rate in the US of 99%. However, if it metastasizes to other parts of the skin or deeper into the body, this survival rate drops significantly.

Regular skin monitoring is the key to detecting any malignancies of the skin, including melanoma. Short-term digital dermoscopy at regular intervals (e.g., once every three months) is the current method applied to moles and other lesions that arouse suspicion. In the longer term, dermoscopy is performed every 6 to 12 months, with the goal of identifying certain changes that might indicate the onset of melanoma. These techniques are successful in detecting melanoma and in avoiding unnecessary surgical intervention (e.g., the removal of benign moles).

However, there is a certain flaw in these approaches. Dermoscopy is time-consuming and is thus generally only applied to known potential issues — moles, lesions and so on. This ignores the rest of the skin, and melanoma can develop from skin with no existing issues. It is essential to have techniques that cover the whole body but are not as time-intensive as traditional dermoscopy or even 2D total body imaging combines with digital dermoscopy.

How 3D Total Body Photography Helps Overcome These Limitations

With 3D total body photography, 92 images of the patient’s body are captured simultaneously and assembled digitally to give a picture of almost the entire surface of the skin. This recently introduced technique is better at imaging curved surfaces. It also makes it much easier to compare images of any part of the body over time, as the images can be compared side-by-side onscreen. Software has been designed to support clinicians working with the images, for example facilitating the linking of an area of the whole-body image to a dermoscopy image of a lesion.

In the research article “The Additive Value of 3D Total Body Imaging for Sequential Monitoring of Skin Lesions: A Case Series”, the authors looked at three case studies to highlight the benefits of using 3D total body photography alongside traditional methods. They identify how helpful it is in the surveillance of skin lesions, particularly when patients have multiple lesions or moles of concern. They also point out the value in identifying issues in areas of skin that were not previously areas of concern.

The cases selected for the paper were chosen by the authors as they have educational value and illustrate the value of longitudinal 3D total body photography alongside other techniques. Based on their experience with the technique, they also suggest that further development of the technology may come in the form of better resolution in the photographs and software-aided analyses of the images.

Should I Ask My Doctor about 3D Total Body Photography?

If you are worried about melanoma, you should regularly see a dermatologist and/or talk to your general practitioner about your concerns. As mentioned, melanoma is dangerous and must be diagnosed and treated early. If you have any of the risk factors listed above, this is all the more reason to have a professional assessment of your skin on a regular basis.

Since it has been shown that 3D total body photography supports the diagnosis of melanoma and other skin malignancies, it’s worth mentioning the technique to your dermatologist and general practitioner. They may be interested in the paper and they may also have experience with the technique or know of a clinic or hospital that practices it. Taking an active role in monitoring your skin health is in your best interest.

Note: One of the authors of the paper declared that they are a shareholder and consultant for two dermatological companies, a consultant for a third, and an advisor for a fourth. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.

The Interesting Case of Raynaud’s Phenomenon Occurring after a COVID-19 Vaccine

What Is the Main Idea?

This post looks at a single case of Raynaud’s phenomenon (a disruption of the blood flow in the fingers and toes) in a patient who had received the AstraZeneca COVID-19 vaccine two weeks prior. It is important to realize that the case does not prove causation, but the correlation is interesting for healthcare professionals and medical researchers. The full details are in the open access case report “Raynaud’s Phenomenon after COVID-19 Vaccination: Causative Association, Temporal Connection, or Mere Bystander?”, published in the journal Case Reports in Dermatology.

What Else Can You Learn?

The post describes Raynaud’s phenomenon: the appearance, risk factors, and treatment. It also describes how to understand case reports like this.

What Is a Raynaud’s Phenomenon?

Raynaud’s phenomenon affects the small muscular arteries of the fingers and toes, and more rarely, the nose, ears, knees, or nipples. When a patient has an episode of Raynaud’s phenomenon, the blood vessels in the affected areas spasm, causing decreased blood flow.

In response to this decrease in blood flow, the pallor of the skin changes, usually becoming much paler. The area becomes numb and cold, often with notable temperature differences between affected digits and unaffected digits. The hands can become swollen and even painful if the patient tries to warm them up. In serious cases, the disruption to the vascular system can lead to sores, pitting, ulceration, or even gangrene. However, for most patients, it is a manageable inconvenience rather than a serious problem.

It affects approximately 5% of the population and is more common in cisgender women than in cisgender men. The cause is unknown, but there are theories that it has something to do with the blood thickness or the blood vessel diameter. Risk factors include smoking, certain medications, exposure to some chemicals, some autoimmune and connective tissue disorders, and injury, including some manual repetitive strain injuries.

Can Raynaud’s Phenomenon Be Treated?

There is no cure. Most of the treatments are behavioral: quitting smoking, avoiding exposure to cold, and avoiding the sources of repetitive strain injuries to the hands. Blood pressure medications can help.

What Happened in the Case?

The case is described in “Raynaud’s Phenomenon after COVID-19 Vaccination: Causative Association, Temporal Connection, or Mere Bystander?”. A 31-year-old white cisgender woman received her first dose of the AstraZeneca COVID-19 vaccine (Vaxzevria). Two weeks later, she developed Raynaud’s phenomenon on three fingers in the form of well-defined, pale, cold, numb areas. She had none of the risk factors associated with Raynaud’s phenomenon and there was no family history of the condition.

After a thorough set of blood tests, the patient was advised to avoid known triggers of Raynaud’s phenomenon, including exposure to cold. The patient showed no symptoms at follow-up appointments (1, 2 and 3 months later). This might be due to the warmer spring weather at the time, so the consulting physician has advised further evaluation in the coming winter.

Is Raynaud’s Phenomenon a Common Response to Vaccination?

It’s rare for people to develop Raynaud’s phenomenon after vaccination. It has been reported to occur after the administration of diphtheria–tetanus, hepatitis B and human papillomavirus vaccines. However, there is no clear association between the vaccines and the condition. More study would be needed to confirm such a relationship.

Why Is This Reported as a Side Effect of the COVID-19 Vaccination?

Healthcare professionals and medical researchers have an obligation to report on all the side effects of drugs that are in circulation, even if the effects only appear in one person. Even if they are not sure that the effect is related to the drug, they must report it. In this case, because the condition appeared in an otherwise healthy person within two weeks of receiving the AstraZeneca COVID-19 vaccine, it is possible that the onset of Raynaud’s phenomenon is related to the vaccine.

The report is important for the medical community. It makes healthcare practitioners aware to ask about the date of COVID-19 vaccination if they have patients presenting with Raynaud’s phenomenon, whether it is a new onset or a recurrence. If more such reports are published, Raynaud’s phenomenon might be added to the list of side effects for the vaccine or a broader study might be undertaken.

The Potential for Adverse Effects from Finasteride

What is the Main Idea?

This post looks at finasteride, explaining what it is, what it is prescribed for, and what adverse effects it can have. It mainly focuses on the psychological adverse effects, including depression and suicidality.

What Else Can You Learn?

The post also looks at the conclusions of the editorial “Suicidality and Psychological Adverse Events in Patients Treated with Finasteride”, published in the journal Skin Appendage Disorders, including a recommendation to physicians considering prescribing the medication.

Content Warning

This blog post discusses suicidality in a clinical manner. There are no descriptions of suicidal ideation or suicide attempts.

What Is Finasteride?

Finasteride is an oral medication used to treat hair loss and noncancerous prostate enlargement in cisgender men and excessive hair growth in cisgender women. It can also be used in hormone therapy for transgender women.

It is an antiandrogen, which means it functions by stopping androgens from having an effect in the body. Finasteride specifically reduces the production of dihydrotestosterone, which is produced in several locations in the body, including in the prostate gland, scalp, and brain.

Does Finasteride Have Adverse Effects?

Although they are rare, adverse effects are known for finasteride. Some of these are reversible, which means they stop after patients stop taking the drug. However, others can persist. In both cases, these effects are rare enough that the medication is still very commonly prescribed.

The adverse effects include disruptions to sex drive and erectile dysfunction; changes in the production of steroids related to the neurological system; loss of muscular strength; breast enlargement in cisgender men; and psychological effects, including depression and increased suicidality (see the next section for a definition of this term).

Post-finasteride syndrome is sometimes used to refer to the collection of serious adverse effects that are seen in patients that take finasteride and persist after they discontinue it. Note that despite there being some literature available on post-finasteride syndrome, it is a contentious term. As pointed out in the editorial “Suicidality and Psychological Adverse Events in Patients Treated with Finasteride”, it is not recognized by the research community as a valid classification. There is even a paper that suggested that post-finasteride syndrome has only been documented in low-quality studies.

What Is Suicidality?

Suicidality is a term that covers all the aspects of suicide: ideation, which means having serious thoughts about suicide; planning; and attempts. In psychological and psychiatric research and practice, suicidality is sometimes discussed in terms of the balance between the will to live and the wish to die, with subjects ranked as nonsuicidal, or having low, moderate or high suicidality.

Note that suicidal ideation does not always imply or lead to planning or attempts. It is a difficult topic to study, because there is no universal definition of suicidal ideation. This makes it difficult to compare results from different research papers. Furthermore, healthcare records often document suicidal ideation as present or absent rather than considering the nuances of it.

Increases in suicidality of any kind in response to medication are considered an adverse effect. If researchers look at a population (a group of people with common demographic characteristics) and see that the suicidality is significantly higher in those taking a medication than in those not taking it, this is called a significant disproportionality signal for increased suicidality.

What Is the Editorial About?

The editorial “Suicidality and Psychological Adverse Events in Patients Treated with Finasteride” looks at the disproportionality signal for suicidality, depression, and other psychological adverse effects related to finasteride. The authors briefly review what is known about this important topic.

The authors have over 20 years’ experience in dermatological practice and prescribe oral finasteride for androgenetic alopecia (male hormone-related baldness). They suggest that prior to prescribing finasteride, it may be important to obtain a personal history or screen for preexisting personality disorders, since there is a significant but rare indication that finasteride could trigger or exacerbate such issues.

What Is the Takeaway Message for Patients?

Finasteride is an important medication with a range of applications, but it shouldn’t be taken lightly. Even if adverse effects are rare, they do occur. Always discuss the adverse effects with your doctor prior to taking a new medication.

How Accurate Is Trichoscopy in Diagnosing Inflammatory Scalp Diseases?

What Is the Main Idea?

This post is based on the free access article “Diagnostic Accuracy of Trichoscopy in Inflammatory Scalp Diseases: A Systematic Review” published in the journal Dermatology, which looks at how a noninvasive diagnostic technique called trichoscopy can be used to differentiate between dermatological conditions with very similar symptoms. If you have a skin condition that’s affecting your scalp and the diagnosis is proving difficult, this article might be of interest to you and your dermatologist.

What Else Can You Learn?

Read this post to gain some insight into the various diseases that can cause inflammatory reactions on the scalp, including the trichoscopic features that differentiate them.

Why Are Inflammatory Scalp Diseases Difficult to Diagnose?

There are multiple diseases that can cause inflammation and lesions on the scalp. Differentiating between them is not simple, as the lesions and other signs can look similar.

For example, psoriasis, seborrheic dermatitis, contact dermatitis, lichen planopilaris, tinea capitis, discoid lupus erythematosus, pemphigus foliaceus, pemphigus vulgaris, dermatomyositis, and syphilis all cause erythematous patches and scaling.

Erythematous patches are red or purple rashes, often raised or circular, sometimes with small blisters in them. They occur due to injured or inflamed blood capillaries. Scaling means that the outer layers of the skin are coming off in large, scale-like flakes. Scaling often has a dry appearance and can be white or red.

Since the macroscopic appearance is so similar between many diseases, differential diagnosis can be very challenging. There are plenty of methods that help, but many involve taking biopsies or performing other tests that may be uncomfortable for the patient.

What Is Trichoscopy?

Trichoscopy is a noninvasive diagnostic method that can be done by a dermatologist in their office. It is based on dermatoscopy, which involves an instrument that shines a special light on the skin and has a magnifying lens. In trichoscopy, hair and scalp structures may be visualized at many-fold magnification. The trichoscopic instruments can give 10- to 70-fold magnification of hair and scalp structures.

It is widely used for diagnosing the reasons for hair loss but recently, there has been a lot of interest in using it to diagnose inflammatory scalp diseases. In particular, medical researchers hope that it can be used to differentiate between conditions with very similar presentations.

How Does Trichoscopy Help?

Because trichoscopy looks at close magnification of the skin, it can reveal subtle features that are not visible to the naked eye. For example, the scaling might appear continuous but on closer examination, it might be patchy. There might be a pattern to the redness on the skin. When these features appear consistently for a particular disease and are different for other diseases, then they can be considered suitable for differential diagnosis.

What Does the Article Say?

As its name suggests, the article “Diagnostic Accuracy of Trichoscopy in Inflammatory Scalp Diseases: A Systematic Review” is based on a systematic review. That means the authors searched for studies describing the frequency of trichoscopic features related to inflammatory scalp conditions and analyzed the accuracy of using these features in differential diagnosis. They found 58 studies that they could include in a qualitative analysis; of those, 57 were suitable for quantitative analysis.

The qualitative analysis involved reading the descriptions of the trichoscopic features in the papers and case reports to find common and differentiating ones across the diseases. The quantitative analysis involved calculating some diagnostic parameters based on the frequency of the feature appearing for that disease.

The authors’ systematic review indicates that trichoscopy can be used as an accessory tool in the differential diagnosis of inflammatory scalp diseases. They list the trichoscopic features that have the highest specificity for each disease. These are described below along with some information about each disease.

What Is Psoriasis?

Psoriasis is an autoimmune disease that causes abnormal, excessive, and rapid growth of the epidermal (outermost) layer of the skin. This usually causes red patches with white scales on top, but there are forms of psoriasis that cause blisters and changes to the nail pits and nail color. There are many treatment options that focus on managing the symptoms, but there is no cure. The most specific trichoscopic features for scalp psoriasis are diffuse and patchy scaling and simple red loops.

What Is Seborrheic Dermatitis?

Seborrheic dermatitis is also a long-term skin condition that causes red, scaly, and inflamed skin. The areas of the skin with a lot of oil-producing glands are most commonly affected, especially the scalp, but it can also occur on the face, chest, and upper back. Its cause is unknown but there are a number of medications that are able to reduce the symptoms. The most specific trichoscopic features for seborrheic dermatitis are comma vessels (slightly curved blood vessels like a comma) and perifollicular pigmentation (skin color changes around the follicles).

What Is Contact Dermatitis?

Contact dermatitis is an inflammation of the skin that is usually due to the skin being exposed to chemical, physical, allergenic, or other irritants. For example, exposure to turpentine, alcohol, kerosine or drain cleaners can cause chemical irritant contact dermatitis. Poison ivy, poison sumac and poison oak cause allergic contact dermatitis. Nickel in jewelry can also cause allergic contact dermatitis. Treatment depends on the cause. Again, the appearance can be dry skin, red rashes, bumps, blisters and swelling, so it is very similar to the other diseases on this list. The most specific trichoscopic features for contact dermatitis are twisted red loops.

What Is Lichen Planopilaris?

Lichen planopilaris, or lichen planus, is a chronic inflammatory disease with a relationship to the immune system. There are many different forms, including ones that affect the mucous membranes, but the types that commonly affect the scalp have similar red or purple patches with a fine, white scaling over the top. Treatments are rarely effective and there is no cure. The most specific trichoscopic features for lichen planopilaris are milky red areas and fibrotic patches (excessive scarring).

What Is Discoid Lupus Erythematosus?

Discoid lupus erythematosus is an autoimmune disorder that presents as scaling or crusty disc-shaped patches of inflamed skin that are often red. They can cause scarring because they can last a long time, especially if they are not treated. If a patient has discoid lupus erythematosus, they should avoid exposure to sunlight as it brings on the lesions. Steroids can be used to treat existing lesions and a special sunscreen can protect against new ones. The most specific trichoscopic features for discoid lupus erythematosus are follicular plugs (oil from the sebaceous glands trapped around the follicles) and erythema (red rashes) encircling follicles.

What Is Pemphigus Foliaceus?

Pemphigus foliaceus is a generally benign autoimmune skin disorder that presents as blisters, particularly ones that appear when the skin is rubbed. It can be managed quite well but there is no cure. The most specific trichoscopic features for pemphigus foliaceus are scaling in the form of white polygonal structures and serpentine vessels (blood vessels that look like snakes).

What Is Pemphigus Vulgaris?

Pemphigus vulgaris is also an autoimmune disorder that presents as blistering of the skin. It differs from pemphigus foliaceus because it also affects the mucous membranes and can erode the skin to a greater degree. It is rare and more serious, potentially life-threatening. As with most of these conditions, there is no cure but steroids and immunosuppressants can keep it under control. The most specific trichoscopic features for pemphigus vulgaris are red dots with whitish haloes and lace-like vessels (blood vessels that look like lace).

What Is Dermatomyositis?

Dermatomyositis causes skin rashes and muscle inflammation. It is considered a muscle disease and it can be life-threatening. It might be an autoimmune disorder, although this has not been established. The skin symptoms are not the most important aspect of the disease. It cannot be cured, but comprehensive treatment involving steroids, immunosuppressants, heat therapy, physiotherapy and rest is essential. The most specific trichoscopic features for dermatomyositis are lake-like vascular structures, which look like dark blue patches on the skin.

What Is Syphilis?

Syphilis is a sexually transmitted bacterial infection, although it can also be spread by contact with an infected sore on the skin or by sharing intimate items like a razor or a toothbrush with an infected person. It is cured with antibiotics. However, if it causes damage to the body during its course, this might be permanent. If it runs past its primary phase, it can cause a patchy or diffuse set of lesions on the scalp. The article doesn’t define a clear differential diagnostic feature for syphilis that can be found with trichoscopy.

Why Would Your Dermatologist Be Interested in This Article?

Naturally, any dermatologist would be interested in techniques that allow them to perform differential diagnoses without invasive biopsies. Even though the article states trichoscopy can be used as an accessory tool rather than a primary tool, it’s still of great importance that such techniques are developed further.

How Does Type 1 Diabetes Affect Brain Development in Young Children?

What Is the Main Idea?

This post looks at the impact of type 1 diabetes on the development of children’s brains. Type 1 diabetes is known to affect multiple organs, but how does it affect the brain’s structure and function? It references the open access review “The Impact of Hypo- and Hyperglycemia on Cognition and Brain Development in Young Children with Type 1 Diabetes” in the journal Hormone Research in Paediatrics, which delves into the details of this important area of impact. If your child has been diagnosed with type 1 diabetes, your physician may be interested in this review, which summarizes everything known about the condition.

What Else Can You Learn?

Read this post to gain a better understanding of type 1 diabetes, the role of insulin, and the role of artificial insulin in treating type 1 diabetes. The post also references the improvements in diabetes management thanks to new technologies. Please also note that World Diabetes Day is on November 14.

What Is Type 1 Diabetes?

Type 1 diabetes is usually a genetic condition, although there are some viruses and environmental factors that may contribute to it. If someone is diagnosed with type 1 diabetes, it means their pancreas is not producing any insulin or only producing very small amounts because their body’s immune system or external factors have destroyed the insulin-producing cells. This means their body cannot work with the glucose from their diet: Glucose doesn’t enter their cells and thus cannot be used to generate energy.

The normal cycle of insulin is straightforward. We eat food. Glucose enters our bloodstream. The increased glucose in the bloodstream causes a signal to be sent to the pancreas, which starts producing and secreting insulin. The insulin facilitates the entry of glucose to the cells. As the level of glucose in the bloodstream (which you may have heard of as the blood sugar level) decreases, insulin secretion stops.

With type 1 diabetes, glucose builds up in the bloodstream. Complications can affect most of the major organs and become life-threatening or cause disabilities.

Does Type 1 Diabetes Only Affect Children?

The condition used to be referred to as juvenile diabetes because its onset is generally during childhood or early adolescence. However, it can also develop in adults. The symptoms of its onset include extreme hunger and unintended weight loss; increased thirst as well as frequent urination, which may include nighttime incontinence; mood changes; fatigue; and blurred vision. Healthcare practitioners urge anyone observing such symptoms in themselves or their child to consult their doctor.

How Is Type 1 Diabetes Treated?

There is no prevention or cure for type 1 diabetes. However, it’s possible for people with the condition to live long and healthy lives. Their health depends on their management of their blood sugar levels, which means being able to manage their food, insulin, and activity levels. This is especially difficult for children, meaning their parents or guardians, other family members, and teachers must support them continuously.

Artificial insulin is a crucial tool in treating type 1 diabetes. It is generally available as an injection although there are also pump-based solutions. The technologies for monitoring blood sugar, warning the patient, and administering the insulin are continuously improving. The best options should be investigated based on the patient and their lifestyle.

What Does the Paper Say about Brain Development?

The open access review “The Impact of Hypo- and Hyperglycemia on Cognition and Brain Development in Young Children with Type 1 Diabetes” focuses on how type 1 diabetes can affect children’s brain structure and function. This is obviously an area of considerable concern to parents or guardians whose children are diagnosed at a young age with the condition. It is a frightening time for everyone concerned with a lot of new information to process.

Two important terms are hypoglycemia (too little sugar in the blood) and hyperglycemia (too much sugar in the blood). The paper refers to the impact of each on the child’s developing brain. Hypoglycemia is well known to have a serious impact on children’s health and development, but an understanding about the impact of hyperglycemia has come more recently. This makes the paper an important one for healthcare practitioners as there may be new information that they are unaware of. Consider sending them the link to the review if you have a child with type 1 diabetes.

It is essential to understand that hypo- and hyperglycemia can both affect the brain structure, causing injury that directly impacts cognitive function (e.g., thinking, listening, learning, reasoning, and focusing); executive function (e.g., adapting, planning, self-monitoring, remembering, and managing time); and even mental health. The focus of the review is mainly the physical changes and cognitive function.

What Does the Future Hold?

As mentioned, new and improved technologies for blood sugar monitoring and insulin delivery are enhancing the flexibility and impact of daily treatment. The aim is to give all type 1 diabetes patients, including children, as “normal” an experience and development as possible. It’s important for parents, teachers and other adults in a child’s life to be as educated as possible about what hypo- and hyperglycemia could mean for the child, and help them to adapt to the challenges and limit any damage caused by type 1 diabetes.

Can Advanced Gastric Cancer Be Treated?

What Is the Main Idea?

This post looks at gastric cancer. What is it, how does it happen, and what are the treatment options? Based on the open access paper “Advanced Gastric Cancer: Current Treatment Landscape and a Future Outlook for Sequential and Personalized Guide” in the journal Oncology Research and Treatment, the post references some of the treatments that are in clinical trials. Your physician may be interested in this new research.

What Else Can You Learn?

Read this post to learn more about the importance of taking gastric symptoms seriously.

What Is Gastric Cancer?

Gastric cancer refers to cancers that arise in the cells of the mucosa, which line the stomach. Risk factors include Helicobacter pylori infections, chronic gastritis, Epstein-Barr virus infections, salty diets, diets that don’t include plant fiber, and smoking cigarettes. The cancer generally begins in the mucosa, but it can spread through the other layers of the stomach lining as well as metastasizing (spreading to other organs).

Early symptoms of gastric cancer are difficult for patients to identify as very serious, as they can have multiple causes and patients often assume they are caused by diet. They include heartburn, loss of appetite and indigestion. That’s why it’s so important to consult your physician if such “mild” symptoms persist. At more advanced stages, gastric cancer causes noticeable issues, including vomiting, jaundice, difficulty swallowing, and sudden weight loss. Advanced stage metastasis causes other symptoms as other organs are affected.

Gastric cancer is the third leading cause of cancer-related death. Unfortunately, partially due to the ambiguous early symptoms, it is often diagnosed when it is at an advanced stage, which precludes surgery as an option. Advanced gastric cancer has a poor prognosis with a very low five-year survival rate.

What Are the Treatment Options?

Most first-line chemotherapy options for gastric cancer combine fluoropyrimidine and platinum, although there are several EMA(European Medicines Agency)- and Swissmedic-approved options. However, newer options are emerging. Adding monoclonal antibodies substantially improves the clinical outcome of treatment. Immuno-oncology is evolving as a strong option, with immunochemotherapy showing significant survival benefits in advanced gastric cancer patients.

The open access paper “Advanced Gastric Cancer: Current Treatment Landscape and a Future Outlook for Sequential and Personalized Guide” states that molecular profiling is recommended for all patients prior to systemic treatment. At a minimum, such profiling should check for the expression of HER-2 (a gene that plays a role in the development of multiple cancers, including breast cancer), Epstein-Barr virus, and programmed death ligand-1 (a molecule with immunoregulatory functions). It’s also recommended to check for predisposition to mutation, which is assessed by looking at the stability of certain short, repeated sequences of DNA called microsatellites. The reason for this recommendation is that the results can influence the treatment regime. If certain targets are identified, immune checkpoint inhibitors can be used. These are drugs that block the protein–protein binding that prevents T cells from killing tumor cells. In other cases, antibodies can be added to the treatment to boost immune responses.

The paper goes on to detail everything that is known about the possible targets for treatment that could improve outcomes in this serious disease. If your physician hasn’t read it, they may be interested in the trials and treatment options mentioned.

What Can I Do?

Gastric health should never be taken lightly. If you have heartburn, nausea, indigestion, or loss of appetite lasting more than a few days, see your doctor. If you have a sudden and unexplained weight loss, see your doctor. If you see blood in your stool or vomit, if you’re vomiting frequently, if you’re bloated or retaining water, see your doctor.

Too often, people accept gastric symptoms as normal or blame them on their last meal. We should all be more conscious of our stomachs: what we put into them and how they feel.


Note: Some of the authors declared that they have scientific consultancy roles with pharmaceutical companies. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.

What Is Personalized Nutrition?

What Is the Main Idea?

Based on the open access paper “Interactions of Carbohydrate Intake and Physical Activity with Regulatory Genes Affecting Glycaemia: A Food4Me Study Analysis” published in the journal Lifestyle Genomics, this post looks at the concept of personalized nutrition. What is it, why should we care about it, and what is the research currently finding?

What Else Can You Learn?

Read this post to learn more about the factors that should be considered when designing a dietary plan. These are things you could discuss with your dietician or healthcare professional to ensure they are getting the full picture.

Food and Exercise Don’t Affect Everyone in the Same Way

We all know that what we eat and how much we exercise can affect our appearance and health. However, obviously not everyone who eats the same food and does the same exercise ends up with the same body type. Other factors, including genetics, have an influence. This makes it difficult for physicians and dieticians to help: There is no universally effective plan for nutrition and exercise. Personalized nutrition might be the answer.

What Is Personalized Nutrition?

Personalized nutrition involves considering a broad range of information about a patient when designing a dietary plan. As with personalized medicine, this approach can integrate data about the patient’s phenotype (their physical and observable body), genotype (their genetic makeup), lifestyle, and clinical history, including biochemical parameters. Personalized nutrition planning may also consider individual food preferences, although this has not always been the case.

The result should be a dietary plan that helps the patient to achieve a goal: for example, reduce their body weight, maintain a lower body weight, manage metabolic conditions like diabetes, or manage food intolerances.

What Is the Food4Me Project?

Food4Me is a special clinical trial focused on the effectiveness of personalized nutrition. There are multiple studies within the project. It describes its mission as understanding the relationship between food and gene expression with the aim of designing a better, healthier, and more individual diet.

The paper “Interactions of Carbohydrate Intake and Physical Activity with Regulatory Genes Affecting Glycaemia: A Food4Me Study Analysis” reports on one Food4Me study that looked at glucose homeostasis: the balance between insulin and glucagon that maintains healthy blood glucose levels. The researchers wanted to know how genetic background, physical activity, and carbohydrate intake interact to influence this important balance.

What Did the Study Involve?

The 1,271 participants in this particular study each completed online questionnaires about their diet, lifestyle, and body type. They also provided blood samples to measure glucose, cholesterol, and other important parameters, and buccal cell samples for genetic analyses. The researchers looked for the expression of 15 genes known to be involved in carbohydrate metabolism or in energy-related processes that affect glucose metabolism. Their expression was used to calculate the participants’ genetic risk scores (GRS), referring to the likelihood of issues with carbohydrate and/or glucose metabolism.

What Is the Significance of the Study?

The expected trends were found. There is a clear impact of carbohydrate intake and physical activity on the concentration of glucose circulating in the blood, and this is influenced by a person’s individual genetic makeup. This means, for example, that while increased physical activity is related to a lower blood glucose concentration, more exercise cannot be the only thing that a healthcare professional or patient considers in glucose level management.

Results like these are the first step towards more effective personalized nutrition. As researchers gain a better understanding of this interplay and other similar food–exercise–genetics relationships, they can start to find the patterns that will support more people in achieving their goals related to the nutrition that’s healthy for them. The Food4Me project has already shown benefits in terms of providing advice to patients and understanding glycemia.

In the meantime, we all need to be aware that the same approach to goals like weight loss and blood glucose management won’t work for everyone. We have to be prepared to try different approaches or even look into what genes our body might be expressing to see if there are any complications.


Note: Two of the authors declared that they have a relationship with Vitas Ltd., which performs the dried blood spot analyses for the study. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.

Tattoos and Delayed Allergic Reactions

What Is the Main Idea?

Delayed allergic reactions, also known as delayed hypersensitive reactions, occur days, weeks or even months after exposure. This post deals with delayed reactions to tattoo ink, based on the case report “Delayed-Type Hypersensitivity Reaction to Red Tattoo Ink Triggered by Ledipasvir/Sofosbuvir for Hepatitis C” and published in the journal Case Reports in Dermatology. Discover why these reactions occur, why they’re difficult to predict and why it’s important to know about them.

What Else Can You Learn?

Learn the difference between an allergy to tattoo ink, keloids and short-term changes in your tattoo. You can also find out what components of different tattoo inks are responsible for allergies.

Tattoos and Allergic Reactions

Did you know that it’s possible to have an allergic reaction to tattoo ink? An allergic reaction is defined as your immune system overreacting to something harmless or relatively harmless. Skin-related allergic reactions can include rashes, itching, flaky or scaly skin, small blisters, and swelling. A common allergic reaction to a tattoo is a red, bumpy, persistent rash that can be very itchy. Interestingly, it can occur in the first days after you get the tattoo or months or years later. To the best of my knowledge, there are no reports of anaphylaxis (the most serious and life-threatening allergic reaction) in response to a permanent tattoo.

There are also times that parts of your tattoo may feel raised for a short time. This can be due to internal and external factors, such as dehydration, tension, or even extreme heat or cold. Remember that a tattoo becomes part of the structure of your skin, which reacts dynamically to your physical state and environment. That means the tattoo will also react.

Are Keloids an Allergic Response?

Note that allergic rashes or slightly raised tattoos are not the same as the formation of keloids. These are enlarged, raised scars that can form anywhere that you have trauma to your skin. They can take months to form and will look like thickened skin. Anyone can get keloids, but not everyone does. If you know that you’re prone to them and you’re getting a tattoo, consider talking to a dermatologist about how you might prevent them occurring.

What Triggers the Allergic Response?

Getting back to allergic reactions: Red tattoo pigments are the most common triggers of this response. This used to be due to the presence of the mercury-derived pigment cinnabar in red inks. Even though this component has been replaced by cadmium red, sienna, sandalwood and other substances, reactions to red ink persist. Because there are multiple ingredients, it is difficult to isolate the component that’s causing the problem.

Other tattoo pigments can also trigger allergic reactions due to metallic components such as nickel, chrome and cobalt, and preservatives like formaldehyde. The carbon-based pigments in black tattoos can cause issues on their own or break down over time to cause issues. Yellow tattoos have particular sensitivity to sunlight, with photoreactive decay potentially leading to allergens being created. The mineral components of blue ink can also be an issue.

What Is a Delayed Hypersensitive Reaction?

The phenomenon of an allergic reaction occurring days, weeks or months after exposure is known as a delayed hypersensitive reaction. Normally, delayed hypersensitive reactions are expected two to three days after exposure, but as mentioned, the time limit is different with tattoos.

This post was inspired by the case of a 51-year old cisgender man, described in the case report “Delayed-Type Hypersensitivity Reaction to Red Tattoo Ink Triggered by Ledipasvir/Sofosbuvir for Hepatitis C”. For four months, the man had had itchy lesions on the red areas of a multi-colored tattoo on his back. They had appeared one week after he started taking ledipasvir/sofosbuvir for a hepatitis C infection. The examination of the lesions showed that he had a delayed hypersensitive reaction to red tattoo ink. Treatment produced a mild improvement.

Can You Test for the Risk of Delayed Hypersensitive Reactions?

Interestingly, when researchers used patch tests on patients with red tattoo reactions, the results were inconsistent, suggesting that this technique is not useful for diagnosing a risk of delayed hypersensitive reactions.

The reason for the reaction — and the reason for the difficulty in diagnosing it — may be a phenomenon related to the metabolism of the tattoo pigments over time. The impact of exposure to the sun, which may cause photochemical breakdown of tattoo pigments, has also been suggested as a cause. The idea is that the pigment might not be an allergen at the time that the tattoo is created, but its breakdown products might cause the reaction.

Immune reconstitution and its related inflammatory syndrome are also mentioned in the paper as reasons for the delayed response. Immune reconstitution is the process of the immune system rebuilding itself after a period of suppression due to disease or medical treatment. Immune reconstitution inflammatory syndrome occurs when the rebuilding immune system overreacts to previously acquired infections or to allergens in the body.

How Common Are Allergic Reactions to Tattoos?

Reports of immune or allergic reactions to tattoos are quite rare. In quite a few cases, the reports of delayed hypersensitive responses involve patients receiving treatments for hepatitis C or HIV and then developing the allergy. These therapies include ledipasvir/sofosbuvir and antiretrovirals, which can lead to immune reconstitution.

Reports of this type will hopefully lead to research into how this occurs as well as increasing the awareness of such phenomena among healthcare workers. It is also worth knowing that drugs and other changes can lead to an immune reaction or tattoo allergy. If it happens, you will know to talk to a specialist right away, rather than waiting to see if it disappears.


Note: Two of the authors of the paper declared that they receive personal fees and/or nonfinancial support from pharmaceutical companies. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.