Search

We present a case of a 74-year-old man with marked photodamage who was ultimately diagnosed with telangiectasia macularis eruptiva perstans (TMEP) of the scalp. The diagnosis was made more difficult because of the clinical and histological similarity of this case with an early angiosarcoma. TMEP is a benign and indolent rare subtype of cutaneous mastocytosis presenting clinically with red-brown telangiectatic macules, usually symmetrically distributed over the trunk and extremities. Although most cases are limited to the skin, systemic involvement can occur, and this can be a potentially life-threatening disease. Although also rare, in contrast to TMEP, cutaneous angiosarcoma is a highly malignant vascular tumor with a poor prognosis. This case highlights the importance of including TMEP on the differential diagnosis where vascular lesions of the scalp are observed.

Background Vascular trauma data have been submitted to the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Trial (PROOVIT) database since 2013. We present data to describe current use of endovascular surgery in vascular trauma. Methods Registry data from March 2013 to December 2016 were reviewed. All trauma patients who had an injury to a named artery, except the forearm and lower leg, were included. Arteries were grouped into anatomic regions and by compressible and noncompressible region for analysis. This review focused on patients with noncompressible transection, partial transection, or flow-limiting defect injuries. Bivariate and multivariate analyses were used to assess the relationships between study variables. Results One thousand one hundred forty-three patients from 22 institutions were included. Median age was 32 years (interquartile range, 23-48) and 76% (n = 871) were male. Mechanisms of injury were 49% (n = 561) blunt, 41% (n = 464) penetrating, and 1.8% (n = 21) of mixed aetiology. Gunshot wounds accounted for 73% (n = 341) of all penetrating injuries. Endovascular techniques were used least often in limb trauma and most commonly in patients with blunt injuries to more than one region. Penetrating wounds to any region were preferentially treated with open surgery (74%, n = 341/459). The most common indication for endovascular treatment was blunt noncompressible torso injuries. These patients had higher Injury Severity Scores and longer associated hospital stays, but required less packed red blood cells, and had lower in hospital mortality than those treated with open surgery. On multivariate analysis, admission low hemoglobin concentration and abdominal injury were independent predictors of mortality. Conclusion Our review of PROOVIT registry data demonstrates a high utilization of endovascular therapy among severely injured blunt trauma patients primarily with noncompressible torso hemorrhage. This is associated with a decreased need for blood transfusion and improved survival despite longer length of stay. Level of evidence Therapeutic/care management, level III.

An aberrant right subclavian artery is a known arch variant with surgical intervention reserved for those patients presenting symptomatically, those with aneurysmal degeneration particularly of a Kommerell diverticulum, or those with adjacent aortic pathology. Varied surgical approaches have been described, often involving a supraclavicular approach in conjunction with a thoracotomy, or more recently, hybrid endovascular techniques. In the absence of aneurysmal degeneration or associated aortic pathology, surgical repair can be performed safely through a single supraclavicular incision. We present a case of a patient repaired in this fashion.

Objectives To evaluate the efficacy, safety, and tolerability of repeated NGX-4010 treatments in the open-label extension phase of a 52-week study in patients with neuropathic pain due to HIV-associated distal sensory polyneuropathy (HIV-DSP). Methods Patients completing the 12-week, randomized, double-blind phase of the study could enter a 40-week, open-label phase, and receive up to 3, 60-minute NGX-4010 treatments. Patients recorded their "average pain for the past 24 hours" daily using the Numeric Pain Rating Scale (NPRS). Efficacy assessment included the percentage NPRS score reduction from baseline to weeks 2 to 12 after the final treatment, and Patient Global Impression of Change (PGIC) and Clinician Global Impression of Change (CGIC) questionnaires at study termination. Results Of 307 patients randomized, 272 entered the open-label phase; 81, 90, 55, and 46 received 0, 1, 2, and 3 retreatments, respectively. The mean percentage decrease in NPRS score from baseline to weeks 2 to 12 after the final treatment was similar in patients receiving single or multiple NGX-4010 treatments (-25.8%, -27.1%, -24.6%, and -22.7% for 1, 2, 3, and 4 NGX-4010 treatments, respectively). PGIC and CGIC results demonstrated a benefit of NGX-4010 treatment through to the end of the study regardless of the number of treatments received. Transient local application site reactions were the most frequently reported adverse events, and were mainly mild to moderate, nonserious, and did not increase with repeated treatment. Discussion Repeated NGX-4010 treatments were generally well tolerated and resulted in consistent reductions in HIV-DSP-associated pain and improvement in patient-reported outcomes.

Objectives: To review clinical outcomes of endovascular treatment of type B aortic dissection. Methods: All patients treated for type B aortic dissection between 2006-2011 were identified from a prospectively maintained registry. Health systems charts and medical correspondences were reviewed. Measured outcomes included resolution of the indication for intervention, additional procedures, and survival at 30 days and 1 year. Results: 55 patients were treated with TEVAR for type B dissection (mean age, 61 14 years), 39 (71%) for acute dissections and 16 (29%) for chronic dissections. Indications for treatment were pain (21), malperfusion (13), aneurysm (6), uncontrolled hypertension (6), expansion (5), and rupture (4). Success, defined by relief of indication and freedom from death or re-intervention at 30 days, was achieved in 87% of patients. Twenty-six additional procedures were performed in 22 patients prior to, or at the time of TEVAR. These included debranching procedures (8), renal stenting (7), Iliac stenting (5), iliac exposure or conduit creation (2), mesenteric stenting (2), thrombectomy (1), and tube thoracostomy (1). Left subclavian artery coverage was required in 23 patients. Spinal ischemia occurred in 4 patients, and lumbar drainage performed in 2 patients. Three patients required reintervention during the study period. Survival was 93% at thirty-days and 78% at one year. Conclusions: TEVAR is effective in the treatment of the complications of both acute and chronic type B aortic dissection. Additional procedures are frequently necessary, but early results indicate favorable outcomes, while reintervention is rare.

Peripheral neuropathy is the most frequent neurological complication of human immunodeficiency virus (HIV)-1 infection and is commonly associated with the development of chronic pain. This open-label, 12-week pilot study assessed the efficacy, tolerability, and safety of a high-concentration capsaicin dermal patch (NGX-4010; capsaicin, 640μg/cm2, 8% w/w) to treat painful HIV-associated distal sensory polyneuropathy (DSP). Eligible patients had moderate-to-severe pain in both feet due to HIV-associated DSP or antiretroviral toxic neuropathy. Patients received a single 60-minute application of the investigational high-concentration capsaicin patch to the affected areas. The primary outcome measure was the mean percent change in numeric pain rating scale (NPRS) during weeks two to 12 postadministration. After a single 60-minute NGX-4010 application, the mean percent change from baseline in "average pain for past 24 hours" NPRS scores during weeks two to 12 was −40% (95% CI: −61%, −19%; P=0.0020). Similar results were observed for "worst pain for past 24 hours" and "pain now" scores. Eight of 12 patients (67%) were treatment responders (≥30% pain decrease). Four of 12 patients (33%) experienced a ≥50% reduction in pain. Treatment was generally well tolerated. Treatment-associated pain was self-limited and could be managed with short-acting opioids. This study demonstrates that treatment of painful HIV-associated neuropathy with a single application of NGX-4010, a high-concentration capsaicin patch, was feasible, well tolerated, and associated with significant reduction in pain over the 12 weeks studied. No safety concerns were identified. Controlled studies of NGX-4010 for the treatment of painful HIV-associated neuropathy are warranted.

A recently modified commercial enzyme immunoassay (Gonozyme; Abbott Laboratories, North Chicago, IL) for Neisseria gonorrhoeae antigens was compared with bacteriological culture for diagnostic sensitivity, specificity, and predictive value. A total of 480 specimens were tested by both methods; 355 from females attending a sexually transmitted disease clinic ("high-risk") and 125 from female Family Planning clients ("low-risk"). Sensitivity and specificity of enzyme immunoassay for sexually transmitted disease clinic specimens were 79.7 and 97.9%, respectively (55 positive, 280 negative, 6 false positive, 14 false negative). In the low-risk population, sensitivity and specificity were 100 and 97.5%, respectively (3 positive, 119 negative, 3 false positive, 0 false negative). Despite modification, sensitivity of the method remains low for our sexually transmitted disease clinic population, but the test may have applicability for preliminary screening in low-prevalence settings.

Effects of 10, 20, and 30% N2O on decision-making strategy, reaction-times, sustained attention, the Digit Symbol Substitution Test (DSST), short-term memory and the Clyde Mood Scale were assessed in 12 test subjects. Decision-making strategy, as measured by 2-choice probability-learning, was unaffected by 30% N2O once a strategy had been formulated, but reaction-times were increased. Sustained attention was significantly affected in 33% of our subjects, whereas performance on the DSST and on the short-term memory task was impaired in virtually all subjects. Changes were noted in several mood-scale factors with 30% N2O. No residual drug effects were found.