Considerar Ganglio Centinela en pacientes con Carcinoma Epidermoide de alto riesgo.

Sentinel Node Biopsy May Be Underused for High-Risk Squamous Cell Carcinoma

By Marilynn Larkin

November 22, 2017

NEW YORK (Reuters Health) – Sentinel lymph node biopsy (SLNB) is underused and prophylactic lymph node dissection overused in high-risk squamous cell carcinoma (SCC), researchers suggest.

"Cutaneous SCC is the second most common cancer worldwide and has displayed a sharp increase in incidence during the last two decades," Dr. Ashley Wysong of the University of Southern California, Los Angeles told Reuters Health.

Although SCC generally is characterized by low morbidity and mortality, "a subset of cases have elevated local recurrence, metastasis, and death," she said by email. "The single most important predictor of mortality in patients with SCC is the development of lymph node metastasis."

"Updates to SCC staging . . . identify a subset of patients, T2b and T3, with a 30%-50% risk of occult lymph node metastasis found on SLNB," she noted. "Despite this, there remains a lack of standardization in the work-up and management of these patients."

"In melanoma," she noted, "it is standard of care to offer SLNB for patients with T1b melanoma, (which has) an SLNB positivity rate of 7%-10%."

To investigate the use of SLNB in SCC, Dr. Wysong and colleagues created a database of all high-risk patients with the disease treated at UCLA since 2006. Patient and tumor characteristics were documented, as were treatment modality and whether SLNB was performed.

Preliminary data suggest that less than 0.1% of patients with high-risk SCC tumors underwent SLNB, according to the authors' research letter in JAMA Dermatology, online November 15.

By contrast, 14% underwent complete lymph node dissections, of which slightly more than half (56.7%) had microscopic metastasis to local lymph nodes. The rest (43.3%) were free of metastasis.

"Overall, we found prophylactic lymph node dissection to be overused and SLNB underused in high-risk SCC," the authors concluded. "Future prospective studies are needed to further elucidate the use of SLNB in SCC."

Three experts commented on the findings in emails to Reuters Health.

Dr. Richard Keidan, director of the Multidisciplinary Melanoma and Skin Cancer Clinic at Beaumont Hospital in Royal Oak, Michigan, observed, "SLNB should essentially eliminate and replace the use of an elective lymphadenectomy, thereby saving many patients a major operation that offers no benefit when the pathology is negative."

"I strongly agree that lymphadenectomy should not be used in high-risk patients with clinically negative nodes (and agree) that SLNB is significantly underused in patients with SCC," he said.

Dr. Vernon Sondak, Chair, Department of Cutaneous Oncology at Moffitt Cancer Center in Tampa, stated categorically, "I personally don't believe in and do not utilize SLNB for cutaneous SCC."

"The 'high-risk' categories that are currently defined have never been shown to have a suitable yield of positive sentinel lymph nodes – which we would define as a minimum of 5% of cases having a positive sentinel node in a young healthy patient or 10% of cases having a positive sentinel node in an older patient or one with comorbid conditions," he explained.

"So the fact that very few patients in the study underwent SLNB does not bother me in the slightest."

"However, I have never used nor ever even heard of a patient with cutaneous SCC undergoing a prophylactic lymph node dissection," he continued. "We do not do this for any form of cutaneous malignancy, including melanoma, Merkel cell carcinoma and SCC, and we essentially should never be doing a lymph node dissection for any skin cancer without a proven diagnosis of nodal metastases."

Dr. Sondak observed, "We have found that database studies like this one are prone to attribution error, wherein a node dissection is consider to be 'prophylactic' because there is no biopsy report found at that institution - but there is one at another institution, as happens routinely when the biopsy is done at a small hospital or outpatient office prior to referral to a major center for definitive surgery."

"Lymph node dissection is an important part of the treatment of node-positive cutaneous SCC, but in my view it should only be done in the setting of biopsy-proven, clinically detected nodal disease," he emphasized.

"I agree that future prospective studies are needed to determine if there is any role for SLNB in cutaneous SCC. Until those studies are done," he concluded, "patients with clinically negative nodes should be followed without surgery, and ultrasound of the lymph nodes should be used when necessary to augment physical examination."

Dr. Sarah Tuttleton Arron, Associate Director of the Dermatologic Surgery and Laser Center at the University of California, San Francisco, said, "I am not surprised by the low use of SLNB in this study. However, I don't think I would describe it as 'underuse.'"

"While the (new) staging system increases our ability to predict which SCCs are likely to have poor outcomes, there is no data that SLNB improves mortality from SCC," she observed. "Perhaps this is appropriate use - we just don't have the data to support SLNB."

"I would hesitate to draw major conclusions from this study, (which uses) data from a single hospital, which is a major referral center and not generalizable to the entire U.S. population," Dr. Arron concluded.

SOURCE: http://bit.ly/2yVAe6p

JAMA Dermatol 2017.

Reuters Health Information © 2017 

Cite this article: Sentinel Node Biopsy May Be Underused for High-Risk Squamous Cell Carcinoma - Medscape - Nov 20, 2017.

Sal, microbioma, inflamacion e hipertensión!

Salt-responsive gut commensal modulates T_H17 axis and disease
High salt intake changed the gut microbiome and increased T_H17 cell numbers in mice, and reduced intestinal survival of Lactobacillus species, increased the number of T_H17 cells and increased blood pressure in humans.
Nicola Wilck, Mariana G. Matus, Sean M. Kearney et al.

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Cuidado con la Biotina y los examenes de laboratorio.

FDA issues warning on biotin The U.S. Food and Drug Administration (FDA) iswarning that biotin may significantly interfere with laboratory tests. Biotin, also known as vitamin B7, is often found in dietary supplements used for hair, skin, and nail growth. However, the FDA warns that these supplements could contain up to 650 times the recommend daily intake of biotin. According to the FDA, "Biotin in blood or other samples taken from patients who are ingesting high levels of biotin in dietary supplements can cause clinically significant incorrect lab test results. The FDA has seen an increase in the number of reported adverse events, including one death, related to biotin interference with lab tests." The FDA is encouraging providers to talk to patients about the biotin supplements they may be taking. When it comes to avoiding medical snafus, preparation is key. Read more on how to prevent and manage common adverse events in Dermatology World.

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Cromomicosis tratamiento exitoso.

Successful treatment of chromoblastomycosis of 10-year duration due to Fonsecaea nubica

Authors

• Accepted manuscript online: 25 November 2017Full publication history
• DOI: 10.1111/myc.12732  View/save citation
• Cited by (CrossRef): 0 articlesCheck for updates 

• This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/myc.12731

Abstract

We report a case of chromoblastomycosis due to presence of large plaque and verrucous hyperplasia lesions on the left upper limb, with elbow abnormal activities, in a 56-year-old male. The diagnosis of chromoblastomycosis was based on gross and microscopic morphologies, histopathological examination and clinical manifestation. Molecular tools were applied to identifying the causative agent: Fonsecaea nubica, which is rarely reported to be associated with chromoblastomycosis. The patient was initially treated orally with terbinafine (250 mg/day) and itraconazole (200 mg/day), subsequently patient received thermotherapy (45-50 °C, 3 hours/day) for one month. The patient was successfully cured. A literature review was performed to assess general features, treatment and outcome of chromoblastomycosis due to Fonsecaea nubica. All the five reviewed patients were male, over 30-years-old, and their lesions were occurred after traumatic inoculation.

This article is protected by copyright. All rights reserved.

Recomendaciones RCP

November 21, 2017

Updated International Guidelines for Ventilation During CPR

Daniel M. Lindberg, MD reviewing Olasveengen TM et al. Resuscitation 2017 Nov 8.

This update focuses on continuous compressions versus interruptions for ventilation.

Sponsoring Organization: International Liaison Committee on Resuscitation (ILCOR)

Target Audience: Bystanders, emergency medical services (EMS) dispatchers, EMS providers, physicians who care for patients in cardiac arrest.

Background and Objective

Quality cardiopulmonary resuscitation (CPR) has become the central factor in improving outcomes of cardiac arrest. ILCOR has moved from a 5-year cycle for releasing guidelines to a continuous process of conducting systematic reviews and annual publication of recent results. These guidelines focus on the key issue of when to give ventilations during CPR.

Key Recommendations

• Dispatchers should provide instructions for compression-only CPR to bystanders calling about an adult with suspected out-of-hospital cardiac arrest (strong recommendation).

• All bystanders should provide chest compressions. Bystanders who are trained, willing, and able should give rescue breaths (30:2; weak recommendation).

• EMS providers should perform CPR with rescue breaths (30:2) or continuous chest compressions with positive pressure ventilations until a supraglottic device or endotracheal tube is established (strong recommendation).

• When a tracheal tube is in place, give positive pressure ventilations without pausing compressions (weak recommendation).

• For children, ventilation is recommended (weak recommendation), but compressions should not be withheld if bystanders are unable or unwilling to perform rescue breaths.

What's Changed

There are no major changes from the 2015 guidelines, though the strength of some recommendations (such as ventilations for children) have been weakened by recent studies that question prior results.

COMMENT

Although questions remain about the optimal role of ventilations in CPR, several things are clear: (1) Use a 30:2 ratio of compressions:ventilations when possible and appropriate; (2) don't withhold compressions if the rescuer can't or won't give rescue breaths; and (3) once an endotracheal tube is in place, don't pause to give breaths.

EDITOR DISCLOSURES AT TIME OF PUBLICATION

Disclosures for Daniel M. Lindberg, MD at time of publication

Royalties	UpToDate
Grant/Research Support	Colorado Traumatic Brain Injury Trust Fund; Eunice Kennedy Shriver National Institute of Child Health and Human Development
Editorial Boards	The Quarterly Update: Reviews of Current Child Abuse Medical Research; Child Abuse & Neglect: The International Journal

CITATION(S):

Olasveengen TM et al. 2017 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations summary. Resuscitation 2017 Nov 8; [e-pub]. (http://dx.doi.org/10.1016/j.resuscitation.2017.10.021)

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Factores de riesgo para cancer

Nearly Half of All Cancers Tied to Modifiable Risk Factors Like Smoking

By Kelly Young

Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM

Nearly half of all new cancers and cancer-related deaths in the U.S. are due to potentially modifiable risk factors, according to a study in CA: A Cancer Journal for Clinicians.

Using 2014 data from the CDC and the National Cancer Institute, researchers estimated the proportions of cancer cases and deaths among U.S. adults aged 30 and older that were attributable to modifiable risk factors.

Overall, 42% of all incident cancers except nonmelanoma skin cancers and 45% of all cancer deaths were attributable to modifiable risk factors. Here are the proportions of incident cancers and cancer deaths linked to the top risk factors:

• Cigarette smoking: 19% of cancer cases; 29% of deaths
• Excess body weight: 8% and 7%
• Elevated alcohol intake: 6% and 4%
• Exposure to ultraviolet radiation: 5% and 2%

The authors conclude: "Increasing access to preventive health care and awareness about preventive measures should be part of any comprehensive strategy for broad and equitable implementation of interventions to accelerate progress against cancer."

CA: A Cancer Journal for Clinicians article (Free)

Background: Physician's First Watch coverage of rural and urban cancer deaths (Free)

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Recomendaciones hepatitis B

La pifiaron, les faltaron los que van a ser inmunosuprimidos en forma iatrogenica.

CDC, ACP Offer Joint Guidance on Hepatitis B Vaccination and Screening

By Kelly Young

Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD

The CDC and the American College of Physicians have released best practice advice on vaccinating against and screening for hepatitis B virus (HBV).

The document, published in Annals of Internal Medicine, recommends vaccinating the following at-risk adults:

• Patients at risk from sexual exposure — e.g., people whose partners are positive for hepatitis B surface antigen (HBsAg), sexually active people who are not in a monogamous relationship, patients who are being seen for a possible sexually transmitted infection, and men who have sex with men
• Those at risk from mucosal or percutaneous exposure to blood — e.g., injection drug users, healthcare workers
• Patients with chronic liver disease, end-stage renal disease, or HIV
• Pregnant patients who have high-risk sexual activity or drug use
• People who travel to countries where HBV infection is endemic

Clinicians should screen the following at-risk groups for hepatitis B infection:

• People born in countries with an HBV prevalence of 2% or above
• Men who have sex with men
• Injection drug users
• Patients with HIV or end-stage renal disease
• Household and sexual contacts of patients with HBV
• Blood and tissue donors
• Pregnant women
• People with hepatitis C or those who have elevated alanine aminotransferase levels
• Incarcerated people
• Infants born to HBV-infected mothers

Patients who test positive for HBsAg should be provided counseling and HBV-directed care.

Annals of Internal Medicine article (Free abstract)

Background: Physician's First Watch coverage of USPSTF recommendations on screening for hepatitis B (Free)

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Ejercicio en pacientes con úlceras venosas es beneficioso...

Adding Exercise to Compression Therapy Promising for Leg Ulcers

THURSDAY, Nov. 9, 2017 (HealthDay News) -- Supervised exercise training in conjunction with compression may improve outcomes for patients with venous leg ulcers (VLUs), according to a study published online Oct. 27 in the British Journal of Dermatology.

Markos Klonizakis, from Sheffield Hallam University in the United Kingdom, and colleagues assessed the feasibility of a 12-week supervised exercise program combining aerobic, resistance, and flexibility exercises as an adjunct therapy to compression in patients with VLUs. Thirty-nine patients were randomized in a 1-to-1 ratio to the exercise program (three sessions per week) plus compression therapy or compression only.

The researchers found that overall, 72 percent of the exercise group participants attended all scheduled exercise sessions. There were no serious adverse events and only two exercise-related adverse events (e.g., increased ulcer discharge). Median ulcer healing time was lower in the exercise group (13 versus 34.7 weeks) at 12 months. Total health system costs were also lower for the exercise group (£813.27 versus £2,298.57 for the control group).

"Our findings support the feasibility and acceptability of both the supervised exercise program in conjunction with compression therapy and the study procedures," conclude the authors.

Klonizakis, M., Tew, G. A., Gumber, A., Crank, H., King, B., Middleton, G. and Michaels, J. A. (), Supervised exercise training as an adjunct therapy for venous leg ulcers: a randomised controlled feasibility trial. Br J Dermatol. Accepted Author Manuscript. doi:10.1111/bjd.16089

Kratom natural pero adictivo...

FDA Warns Against Use of Kratom

By Amy Orciari Herman

Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM

The FDA is warning patients against using products containing kratom (Mitragyna speciosa), a botanical that some take recreationally or to self-treat opioid addiction. Kratom acts on the same opioid receptors as morphine and "appears to have properties that expose users to the risks of addiction, abuse, and dependence," the agency notes.

Calls to U.S. poison control centers regarding kratom rose tenfold between 2010 and 2015; hundreds of calls are made every year, FDA Commissioner Dr. Scott Gottlieb said in a statement. Side effects of its use include seizures, liver injury, and withdrawal symptoms. The agency knows of 36 kratom-related deaths.

Kratom grows in Thailand, Malaysia, Indonesia, and Papua New Guinea. The FDA banned its importation in 2014, but in the years since, the agency has seized large amounts of kratom-containing dietary supplements.

FDA public health announcement (Free)

FDA commissioner's statement (Free)

Background: Physician's First Watch coverage of 2016 CDC warning on kratom (Free)

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Effect of an Intervention to Promote Breastfeeding on Asthma, Lung Function, and Atopic Eczema at Age 16 Years: Follow-up of the PROBIT Randomized Tr... - PubMed - NCBI

https://www.ncbi.nlm.nih.gov/m/pubmed/29131887/

Effect of an Intervention to Promote Breastfeeding on Asthma, Lung Function, and Atopic Eczema at Age 16 Years: Follow-up of the PROBIT Randomized Trial.

Abstract

Importance: Atopic diseases, including asthma and atopic eczema, are the most common chronic conditions of childhood.

Objective: To investigate whether an intervention to promote prolonged and exclusive breastfeeding protects against asthma, atopic eczema, and low lung function in adolescence.

Design, Setting, and Participants: Follow-up of the Promotion of Breastfeeding Intervention Trial (PROBIT), a cluster randomized trial in 30 Belarusian maternity hospitals and affiliated polyclinics; recruitment of 17 046 healthy term infants took place from June 15, 1996, to December 31, 1997. Data analysis was conducted from May 9, 2016, to April 21, 2017. The primary analytic approach was by modified intention-to-treat analysis.

Interventions: Randomization to receive a breastfeeding promotion intervention vs usual care.

Main Outcomes and Measures: Spirometry and flexural eczema on standardized skin examination by study pediatricians were the primary outcomes; secondary outcomes were self-reported asthma diagnosis ever, and wheezing and flexural eczema symptoms in the previous year.

Results: A total of 13 557 (79.5%) participants were followed up from September 15, 2012 to July 15, 2015. The intervention (7064 [79.7%]) and control (6493 [79.4%]) groups were similar at follow-up (3590 [50.8%] and 3391 [52.2%] male; mean [SD] age, 16.2 [0.6] and 16.1 [0.5] years, respectively). In the intervention group, 0.3% (21 of 7064) had flexural eczema on skin examination and mean (SD) forced expiratory volume in the first second of expiration/forced vital capacity (FEV1/FVC) ratio z score was -0.10 (1.82), compared with 0.7% (43 of 6493) and 0.35 (1.34), respectively, in the control group. In modified intention-to-treat analysis, accounting for clustering by polyclinic, a 54% lower risk of flexural eczema on skin examination was observed in the intervention compared with the control group (odds ratio [OR], 0.46; 95% CI, 0.25 to 0.86). Self-reported flexural eczema symptoms in the past year (OR, 0.57; 95% CI, 0.27 to 1.18), asthma (OR, 0.76; 95% CI, 0.47 to 1.23), and wheezing in the past year (OR, 0.66; 95% CI, 0.37 to 1.18) were less frequently reported in the intervention compared with the control group, but 95% CIs were wide and included the null. There was no significant difference in the FEV1/FVC ratio z score (β -0.15; 95% CI, -0.76 to 0.45). All results were similar with additional adjustment for baseline characteristics, on instrumental variable analysis, and with multiple imputation among all 17 046 randomized participants.

Conclusions and Relevance: A breastfeeding promotion intervention reduced flexural dermatitis risk but had no detectable effect on lung function or questionnaire-derived measures of atopic eczema or asthma in adolescence in a setting where atopic eczema and allergies are rare.

Trial Registration: clinicaltrials.gov Identifier: NCT01561612.

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Coctel de probioticos util en DA

• Original Investigation 

November 8, 2017

Effect of Oral Administration of a Mixture of Probiotic Strains on SCORAD Index and Use of Topical Steroids in Young Patients With Moderate Atopic DermatitisA Randomized Clinical Trial

Vicente Navarro-López, MD^1,2; Ana Ramírez-Boscá, MD^2,3; Daniel Ramón-Vidal, PhD^4,5; et alBeatriz Ruzafa-Costas, PhD²; Salvador Genovés-Martínez, BTech⁵; Empar Chenoll-Cuadros, PhD⁵; Miguel Carrión-Gutiérrez, PhD⁶; José Horga de la Parte, MD⁷; David Prieto-Merino, PhD^8,9; Francisco M. Codoñer-Cortés, PhD⁴

Author Affiliations

JAMA Dermatol. Published online November 8, 2017. doi:10.1001/jamadermatol.2017.3647

Key Points

Question  Can treatment with an oral probiotic reduce the SCORAD index and the use of topical steroids in children with moderate atopic dermatitis?

Findings  This randomized clinical trial of 50 children treated with a mixture of probiotics or placebo for 12 weeks found that SCORAD and topical steroid use decreased significantly in the probiotic group compared with the placebo group.

Meaning  This probiotic is an effective and safe coadjuvant treatment to reduce the SCORAD index and topical steroid use in children with moderate atopic dermatitis.

Abstract

Importance  Oral intake of new probiotic formulations may improve the course of atopic dermatitis (AD) in a young population.

Objective  To determine whether a mixture of oral probiotics is safe and effective in the treatment of AD symptoms and to evaluate its influence on the use of topical steroids in a young population.

Design, Setting, and Participants  A 12-week randomized, double-blind, placebo-controlled intervention trial, from March to June 2016, at the outpatient hospital Centro Dermatológico Estético de Alicante, Alicante, Spain. Observers were blinded to patient groupings. Participants were children aged 4 to 17 years with moderate atopic dermatitis. The groups were stratified and block randomized according to sex, age, and age of onset. Patients were ineligible if they had used systemic immunosuppressive drugs in the previous 3 months or antibiotics in the previous 2 weeks or had a concomitant diagnosis of intestinal bowel disease or signs of bacterial infection.

Interventions  Twelve weeks with a daily capsule containing freeze-dried powder with 10⁹ total colony-forming units of the probiotic strains Bifidobacterium lactis CECT 8145, B longum CECT 7347, and Lactobacillus casei CECT 9104 and maltodextrin as a carrier, or placebo (maltodextrin-only capsules).

Main Outcomes and Measures  SCORAD index score and days of topical steroid use were analyzed.

Results  Fifty children (26 [50%] female; mean [SD] age, 9.2 [3.7] years) participated. After 12 weeks of follow-up, the mean reduction in the SCORAD index in the probiotic group was 19.2 points greater than in the control group (mean difference, −19.2; 95% CI, −15.0 to −23.4). In relative terms, we observed a change of −83% (95% CI, −95% to −70%) in the probiotic group and −24% (95% CI, −36% to −11%) in the placebo group (P < .001). We found a significant reduction in the use of topical steroids to treat flares in the probiotic arm (161 of 2084 patient-days [7.7%]) compared with the control arm (220 of 2032 patient-days [10.8%]; odds ratio, 0.63; 95% CI, 0.51 to 0.78).

Conclusions and Relevance  The mixture of probiotics was effective in reducing SCORAD index and reducing the use of topical steroids in patients with moderate AD.

Trial Registration  clinicaltrials.gov Identifier: NCT02585986

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