Machine learning polysomnographically-derived electroencephalography biomarkers predictive of epworth sleepiness scale.

Excessive daytime sleepiness (EDS) causes difficulty in concentrating and continuous fatigue during the day. In the clinical setting, the assessment and diagnosis of EDS rely mostly on subjective questionnaires and verbal reports, which compromises the reliability of clinical diagnosis and the ability to robustly discern candidacy for available therapies and track treatment response. In this study, we used a computational pipeline for the automated, rapid, high-throughput, and objective analysis of previously collected encephalography (EEG) data to identify surrogate biomarkers for EDS, thereby defining the quantitative EEG changes in individuals with high Epworth Sleepiness Scale (ESS) (n = 31), compared to a group of individuals with low ESS (n = 41) at the Cleveland Clinic. The epochs of EEG analyzed were extracted from a large overnight polysomnogram registry during the most proximate period of wakefulness. Signal processing of EEG showed significantly different EEG features in the low ESS group compared to high ESS, including enhanced power in the alpha and beta bands and attenuation in the delta and theta bands. Our machine learning (ML) algorithms trained on the binary classification of high vs. low ESS reached an accuracy of 80.2%, precision of 79.2%, recall of 73.8% and specificity of 85.3%. Moreover, we ruled out the effects of confounding clinical variables by evaluating the statistical contribution of these variables on our ML models. These results indicate that EEG data contain information in the form of rhythmic activity that could be leveraged for the quantitative assessment of EDS using ML.

SARS-CoV-2 alters neural synchronies in the brain with more severe effects in younger individuals.

Coronavirus disease secondary to infection by SARS-CoV-2 (COVID19 or C19) causes respiratory illness, as well as severe neurological symptoms that have not been fully characterized. In a previous study, we developed a computational pipeline for the automated, rapid, high-throughput and objective analysis of electroencephalography (EEG) rhythms. In this retrospective study, we used this pipeline to define the quantitative EEG changes in patients with a PCR-positive diagnosis of C19 (n = 31) in the intensive care unit (ICU) of Cleveland Clinic, compared to a group of age-matched PCR-negative (n = 38) control patients in the same ICU setting. Qualitative assessment of EEG by two independent teams of electroencephalographers confirmed prior reports with regards to the high prevalence of diffuse encephalopathy in C19 patients, although the diagnosis of encephalopathy was inconsistent between teams. Quantitative analysis of EEG showed distinct slowing of brain rhythms in C19 patients compared to control (enhanced delta power and attenuated alpha-beta power). Surprisingly, these C19-related changes in EEG power were more prominent in patients below age 70. Moreover, machine learning algorithms showed consistently higher accuracy in the binary classification of patients as C19 versus control using EEG power for subjects below age 70 compared to older ones, providing further evidence for the more severe impact of SARS-CoV-2 on brain rhythms in younger individuals irrespective of PCR diagnosis or symptomatology, and raising concerns over potential long-term effects of C19 on brain physiology in the adult population and the utility of EEG monitoring in C19 patients.

Experience and challenges for biologic use in the treatment of moderate-to-severe psoriasis in Africa and the Middle East region.

The incidence of psoriasis in Africa and the Middle East (AfME) is high as in other regions and represents a significant problem for both dermatologists and patients. Psoriasis co-morbidities such as obesity, cardiovascular disease and psoriatic arthritis (PsA) are also particularly common in these regions and may be under-recognized and under-treated. Despite this, regional guidelines to aid physicians on the appropriate use of biologic agents in their clinical practice are limited. A group of expert dermatologists from across the AfME region were surveyed to help establish best practice across the region, alongside supporting data from the literature. Although biologics have significantly improved patient outcomes since their introduction, the results of this survey identified several unmet needs, including the lack of consensus regarding their use in clinical practice. Discrepancy also exists among AfME physicians concerning the clinical relevance of immunogenicity to biologics, despite increasing data across inflammatory diseases. Significant treatment and management of challenges for psoriasis patients remain, and a move towards individualized, tailored care may help to address these issues. The development of specific local guidelines for the treatment of both psoriasis and PsA could also be a step towards understanding the distinct patient profiles in these regions.

Confluent and reticulated papillomatosis subsiding spontaneously after delivery: report of one case / Papilomatosis confluente y reticulada que remite espontáneamente después del parto: informe de un caso

Gougerot and Carteaud confluent and reticulated papillomatosis (CARP) is an uncommon dermatosis characterized by hyperpigmented scaly macules or papillomatous papules coalescing into confluent patches or plaques centrally with a reticular pattern peripherally. We report a 28-year-old woman presenting at 16 weeks of gestation with an itchy rash that was biopsied and turned out to be consistent with CARP. Options for treatment were discussed but the woman refused to take any systemic therapy and used only moisturizers throughout her pregnancy. The rash subsided spontaneously after delivery.

[Confluent and reticulated papillomatosis subsiding spontaneously after delivery: Report of one case]. / Papilomatosis confluente y reticulada que remite espontáneamente después del parto: Informe de un caso.

Gougerot and Carteaud confluent and reticulated papillomatosis (CARP) is an uncommon dermatosis characterized by hyperpigmented scaly macules or papillomatous papules coalescing into confluent patches or plaques centrally with a reticular pattern peripherally. We report a 28-year-old woman presenting at 16 weeks of gestation with an itchy rash that was biopsied and turned out to be consistent with CARP. Options for treatment were discussed but the woman refused to take any systemic therapy and used only moisturizers throughout her pregnancy. The rash subsided spontaneously after delivery.

Multiple localized epidermolytic acanthomas of the vulva associated with vulvar pruritus: a case report.

Epidermolytic acanthoma (EA) is a rare benign acquired tumor that most commonly presents as a solitary lesion on the trunk, extremities, male genitalia, and face with a male predominance. Cases occurring on the female genitalia have rarely been reported. We describe the case of multiple localized EAs occurring on the vulva of a 31-year-old woman presenting with the chief complaint of vulvar pruritus. Although rare to occur in the vulvar area, EAs should be included in the differential diagnosis of multiple vulvar papules.

Successful treatment of hydroxyurea-associated chronic leg ulcers associated with squamous cell carcinoma.

Hydroxyurea (HU) is an antineoplastic drug used in the treatment of chronic myeloproliferative neoplasms (MPNs). HU is associated with cutaneous adverse effects, whereas severe complications such as leg ulcers and non-melanoma skin cancers (NMSCs) are rare and only observed after long-term treatment. We herein report a patient with essential thrombocythemia (ET) treated chronically with HU, and who developed refractory bilateral leg ulcers complicated by squamous cell carcinoma (SCC) over both heels. The patient was successfully managed by multiple debridement stages and skin grafting surgeries.

Prurigo pigmentosa: a clinicopathologic study of 4 cases from the middle East.

Prurigo pigmentosa (PP) is a rare inflammatory dermatosis originally reported in Japan. Since then, most reports have originated from Asia, and to a lesser extent from Europe. Although the pathogenesis remains unclear, it is now established that PP is linked to ketoacidotic states. Four patients diagnosed with PP were identified from the dermatopathology database at the American University of Beirut Medical Center between January 2009 and December 2013. Clinicopathologic findings in the 4 patients were similar to those previously reported in the literature. The patients were all female with a mean age of 23.5 years. They all presented with itchy erythematous reticulated papulovesicles/plaques leaving variable reticulated brownish patches. Two patients had, in addition, annular lesions arranged en cocarde and pustules, respectively. In 3 patients, the rash was associated with fasting or dieting. The rash had a predilection to the trunk and proximal part of the upper extremities. One patient had intergluteal area involvement. Two biopsy specimens revealed psoriasiform hyperplasia and neutrophilic exocytosis mimicking psoriasis or an impetiginized spongiotic dermatitis. One biopsy specimen exhibited a mild superficial perivascular lymphocytic infiltrate with ballooning and reticular degeneration, a picture mimicking a viral exanthema. Another biopsy specimen exhibited a picture similar to chronic spongiotic dermatitis. Although mostly described in Japan, PP has been described much less frequently in the Middle East region likely due to mis/underdiagnosis. Therefore, increased awareness is necessary especially because fasting is a common religious practice among Arab countries. Further investigations are necessary to better understand the etiopathogenesis of this rare entity.

Successful treatment of hydroquinone-resistant melasma using topical methimazole.

Melasma is an acquired hyperpigmentation skin disorder in sun-exposed areas. It occurs almost exclusively over the face, and is most commonly seen in women. Several depigmenting agents have been used for the treatment of melasma among which hydroquinone has been the most widely used due to its efficacy and safety in short-term use. However, hydroquinone is recently reported to be a cytotoxic and mutagenic compound in mammalian cells and is thus banned in several countries. Hydroquinone ban has caused investigators to search for alternative depigmenting agents for the treatment of melasma in recent years. Methimazole is an antithyroid agent orally used in humans since several decades and has been shown that when applied topically, it inhibits melanin synthesis and causes skin depigmentation in lab animals as well as human subjects. Herein, we report two hydroquinone-resistant melasma patients who were successfully treated with methimazole cream. Application of 5% methimazole cream once daily resulted in significant improvement of melasma in both patients after 8 weeks. The efficacy of methimazole for melasma treatment as well as its advantages over other known depigmenting compounds (non-mutagenicity, non-cytotoxicity and high tolerability profile) suggests that topical methimazole should be added to the armamentarium of anti-melasma treatment.

Acrodermatitis continua of Hallopeau is a clinical phenotype of DITRA: evidence that it is a variant of pustular psoriasis.

Acrodermatitis continua of Hallopeau (ACH) is a rare, chronic, sterile, pustular eruption that predominantly affects the fingertips with nail involvement. While some consider ACH a distinct entity, many believe it to be a variant of pustular psoriasis, especially as cases of ACH progressing to generalized pustular psoriasis (GPP) have been reported. Recently, recessively inherited mutations in the IL36RN gene, which encodes interleukin-36 receptor antagonist (IL-36Ra), have been demonstrated to be the cause of familial GPP, a condition termed DITRA (deficiency of IL-36Ra). Here, we identified a homozygous missense mutation c.338C>T (p.Ser113Leu) in the IL36RN gene in a male patient with ACH, as well as in his sister who had a history of GPP.

Successful Management of Hydroxyurea-induced Leg Ulcers in Essential Thrombocythemia: Report of 3 Cases.

Essential thrombocythemia is one of the myeloproliferative neoplasms with a plethora of thrombohemorrhagic complications.Hydroxyurea has been proven to be an effective treatment for this condition. However, it is not without side effects. We herein report 3 patients with essential thrombocythemia treated with hydroxyurea who developed refractory leg ulcers, and we outline their successful management. We also review the literature to shed light on the mechanism of this toxicity. Awareness of this important treatment complication is important to avoid the pitfall of futile invasive interventions.

Comparison of bolus only with bolus plus infusion of bivalirudin in patients undergoing elective percutaneous coronary intervention: a retrospective observational study.

BACKGROUND: Anticoagulation therapy during percutaneous coronary intervention (PCI) has been the focus of numerous clinical trials. Low-anticoagulant doses have been successfully used in patients undergoing elective PCI, a situation with low-thrombogenic milieu. OBJECTIVE: The purpose of the study was to evaluate the safety and efficacy of shorter duration of treatment with bivalirudin in patients undergoing elective PCI and receiving optimal antiplatelet therapy. METHODS: We compared patients undergoing PCI who received aspirin and clopidogrel loading dose in addition to either conventional bivalirudin dosing (intravenous [IV] bolus of 0.75 + 1.75 mg/kg per h for the duration of PCI; n = 197) or a reduced bivalirudin dose (IV bolus of 0.75 mg/kg; n = 200). RESULTS: Procedural success was obtained in 100% of cases. The primary end point (in-hospital death, acute myocardial infarction, or need for urgent target vessel revascularization) did not differ between both the groups (6 patients [3%] in the conventional dose group vs 5 patients [2.5%] in the reduced dose group). Major bleeding occurred in 1 patient in the conventional dose group (P = nonsignificant [NS]). Minor bleeding occurred in 4 patients (2%) in the conventional dose group vs 5 patients (2.5%) in the reduced dose group (P = NS) and was mainly due to bleeding at entry site. CONCLUSION: In patients undergoing elective PCI, using bivalirudin as a bolus only dosing may be as effective and less costly when compared with bolus followed by an infusion for the duration of the intervention. A larger study is needed to confirm our findings.