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Neuropathic ulcers or diabetic foot ulcers are preventable ulcers associated with diabetes mellitus. These ulcers occur in the setting of unrecognized trauma, peripheral neuropathy, and foot deformities; however, they are often complicated by peripheral arterial disease and infection. Approximately 15% of individuals with a neuropathic ulcer require limb amputation as a result of infection. Not only are neuropathic ulcers a burden to the patient but also to the economy. The cost of diabetic foot ulcer care is approximately $1.38 billion per year. This makes neuropathic ulcers an important therapeutic target. This review presents the pathophysiology, clinical presentation, evaluation, management, and prevention of neuropathic ulcers.

Introduction: Basal cell carcinoma nevus syndrome (BCCNS) is a rare syndrome characterized by multiple basal cell carcinomas (BCC), odontogenic keratocysts, and other abnormalities. The most common etiology, the loss-of-function PTCH1 mutations and consequent constitutive hedgehog signaling, can be blocked by smoothened inhibitors (SIs). However, other causes and alternative pathways have been identified.Areas covered: Vismodegib and sonidegib are SIs approved for treating advanced BCCs and BCCNS-BCCs, but not without adverse effects. Other SIs include itraconazole, SUBA-itraconazole, and paridegib. Their roles in treating resistance to vismodegib and sonedegib warrant further investigation. Inhibition of downstream hedgehog signaling or PI3K by arsenic trioxide, imiquimod, and busparlisib may control SI resistance. Other potential therapeutic targets to control resistance include TP53, BRCA1, wnt, and SUFU.Expert opinion: BCCNS is more complex than a genetic disease whose consequences result from...

Basal Cell Carcinoma Nevus Syndrome (BCCNS), also known as Gorlin syndrome, is a rare autosomal dominant condition with a substantial disease burden, thought to occur secondary to chromosome 9 mutation evoking a Hedgehog (Hh) signaling aberration that leads to early development of numerous basal cell carcinomas (BCCs). Individuals with BCCNS also present with keratocystic odontogenic tumors, medulloblastomas, and palmar or plantar pits1. This condition demonstrates variable expressivity, leading to differing phenotypes, even within the same family2. BCCNS diagnosis requires meeting two major or one major and two minor criteria (Table 1) or presence of Chromosome 9 and/or PTCH1 mutations1. This article is protected by copyright. All rights reserved.

Chondrodermatits nodularis chronica helicis (CNCH), first described by Max Winkler in 1915, presents as a sore nodule on the helix or antihelix of the external ear. In this paper, we review the etiopathogenesis and management options of CNCH. This condition has a multifactorial etiology; however, sustained pressure from sleeping on one side is the favored theory. Currently, there are many surgical and non-surgical methods of treating CNCH. Most practitioners recommend conservative measures first in their patients, such as pressure-relieving prostheses, prior to surgical treatment. Surgery is the gold standard of therapy with cartilage and wedge excisions yielding recurrence rates of about 10%. Carbon dioxide laser and photodynamic therapy are newer treatment modalities for CNCH, yet they have recurrence rates similar to conservative therapy. In conclusion, due to the high rates of CNCH recurrence, wedge resection is the suggested treatment for CNCH after conservative measures fail.

Systemic lupus erythematosus (SLE) is a multi-organ, autoimmune disease in which patients lose self-tolerance and develop immune complexes which deposit systemically causing multi-organ damage and inflammation. Patients often experience unpredictable flares of symptoms with poorly identified triggers. Literature suggests exogenous exposures may contribute to flares in symptoms. An online pilot survey was marketed globally through social media to self-reported SLE patients with the goal to identify specific subpopulations who are susceptible to disease state changes based on analyzed exogenous factors. The pilot survey was promoted for two weeks, 80 respondents fully completed the survey and were included in statistical analysis. Descriptive statistical analysis was performed on de-identified patient surveys and compared to previous literature studies reporting known or theorized triggers in the SLE disease state. The pilot survey identified similar exogenous triggers compared to previous literature, including antibiotics, increasing beef intake, and metal implants. The goal of the pilot survey is to utilize similar questions to develop a detailed internet-based patient interactive form that can be edited and time stamped as a method to promote continuous quality improvement assessments. The ultimate objective of the platform is to interact with SLE patients from across the globe longitudinally to optimize disease control and improve quality of care by allowing them to avoid harmful triggers.

Colorectal cancer (CRC) is the third leading cause of cancer death in the United States. Recently, more focus has been placed on developing effective screening tools to detect the presence of both precancerous and cancerous lesions present in the colon and rectum. Colonoscopy has been well established as the gold standard of the colon and rectal cancer screening. However, not all patients are willing to undergo a colonoscopy due to the procedure's invasive nature. Non-invasive screening methods have been developed to appeal to patients who refuse colonoscopy. Fecal occult blood tests have long been used by physicians, in addition to colonoscopy, in an effort to screen for CRC. New screening methods, such as fecal immunochemical test (FIT) and stool DNA (sDNA) testing, have been developed as a more sensitive screening measure to attempt to accurately screen patients who have precancerous or cancerous colorectal lesions. This article compares CRC screening techniques through literature review in order to determine which tests offer the most sensitive detection of CRC and precancerous lesions in average-risk adults over the age of 50 years old. Through this review, it can be seen that sDNA is more sensitive than FIT in detecting all stages of CRC, as well as precancerous lesions.

An acute dry cough results commonly from bronchitis or pneumonia. When a patient presents with signs of infection, respiratory crackles, and a positive chest radiograph, the diagnosis of pneumonia is more common. Antibiotic failure in a patient being treated for community-acquired pneumonia requires further investigation through chest computed tomography. If a lung mass is found on chest computed tomography, lung empyema, abscess, and cancer need to be included on the differential and managed aggressively. This report describes a 55-year-old Caucasian male, with a history of obesity, recovered alcoholism, hypercholesterolemia, and hypertension, presenting with an acute dry cough in the primary care setting. The patient developed signs of infection and was found to have a lung mass on chest computed tomography. Treatment with piperacillin-tazobactam and chest tube placement did not resolve the mass, so treatment with thoracotomy and lobectomy was required. It was determined through surgical investigation that the patient, despite having no risk factors, developed a lung abscess. Lung abscesses rarely form in healthy middle-aged individuals making it an unlikely cause of the patient's presenting symptom, dry cough. The patient cleared his infection with proper management and only suffered minor complications of mild pneumoperitoneum and pneumothorax during his hospitalization.

Patients with Basal Cell Carcinoma Nevus syndrome are assumed to have a chromosome 9 mutation, such as a PTCH1 [9q22] mutation, despite the majority of patients with BCCNS being diagnosed through the presence of major and minor diagnostic criterion. The main treatment for BCCNS, Hedgehog inhibitors (HhI), targets these mutations. The results of an internet based survey of self-identified adults with BCCNS which was launched through SurveyMonkey with access provided by the Basal Cell Carcinoma Nevus Syndrome Life Support Network (www.BCCNS.org). Of a total of 395 participants, 282 and 289 individuals responded to questions regarding PTCH1 and chromosome 9 genetic testing, respectively. Those who reported having been genetically tested for either PTCH1 and/or chromosome 9 mutations, were limited to 14-28 % of all BCCNS patient respondents. Of those genetically tested, 12% reported they were negative for PTCH1 and 11% were negative for chromosome 9 mutations. Biogenetic pathway testing needs to be performed on a higher percentage of phenotypical BCCNS patients and the results correlated with HhI treatment responses. These results suggest the need to recognize that phenotypical BCCNS consists of multiple subpopulations of patients with differing biogenetic signaling mutations making current treatment less than adequate for phenotypical BCCNS individuals.

Basal Cell Carcinoma Nevus Syndrome is a rare condition in which patients need to meet certain major or minor diagnostic criteria or test positive for chromosome 9 or PTCH1 mutations to be diagnosed. The results of an internet based survey of self-identified adults with BCCNS which was launched through SurveyMonkey with access provided by the Basal Cell Carcinoma Nevus Syndrome Life Support Network (www.BCCNS.org). Of 45 respondents, 11 individuals reported having locally advanced BCCs and 6 individuals reported having both locally advanced and metastatic BCCs. Of the 11 individuals with locally advanced BCCs, 8 reported having lesions on the scalp. Of the 6 patients with locally advanced BCCs, 3 reported having abnormally thick hair distribution. There were 6 individuals with both locally advanced and metastatic BCCs and 5 reported having BCCs on their scalp. Thick hair distribution was reported by 3 of 4 patients with locally advanced and metastatic BCCs. Overall, it was determined that patients with BCCNS develop aggressive BCCs on their scalp despite thick hair distribution. Patients with BCCNS have an overactive hedgehog signaling pathway. This pathway is also known to play a role in follicle cycling and is believed to lead to increased rates of malignancy.1,2 Despite the presence of thick hair, patients with BCCNS should have their scalp skin closely examined to identify and treat BCCs at early stages of development.