Necrobiosis lipoidica developing within a surgical scar in a non-diabetic patient: Type III Koebner phenomenon (isomorphic response), Wolf's isotopic response or Ruocco's immunocompromised cutaneous district?

Sir, Necrobiosis lipoidica is a chronic granulomatous disease typically associated with diabetes mellitus. We report a case of necrobiosis lipoidica occurring in a surgical scar in a non-diabetic patient. We found only nine previous reports of necrobiosis lipoidica appearing after trauma or in surgical scars, as a manifestation of Type III Koebner phenomenon. Most of these were in diabetic patients..

Designing and implementing a massive open online course: Lessons learnt

•In this paper, we describe the design, implementation, and evaluation of a Massive Open Online Course, or MOOC, on good practice in the application of Intellectual Property. It is aimed primarily at teachers and students, and taught in Spanish. We have used the Spanish legislation on Intellectual Property. This paper outlines the structure and content of a course developed on an ad-hoc basis, and describes its evaluation by participants in questionnaires and a final survey. The results of the initial questionnaire are framed by a) the participant''s profile, and b) by consideration of the MOOC''s implementation, given the results of the satisfaction survey. In this paper we describe the advantages of the MOOC and identify areas for improvement

Liquen aureus zosteriforme. Caso clínico pediátrico

Lichen aureus is a rare pigmented purpuric dermatosis. We present an unusual case because of the pediatric age and the great number of lesions with zosteriform distribution. He is a 10-yearold boy, with a brownish, smaller than 1 cm, sharp edges, lichenified surface, asymptomatic macule, over the inner aspect of the left leg with a zosteriform distribution. The histology showed a band-like inflammatory infiltrate in the superficial dermis, composed of lymphocytes, histiocytes, erythrocytes and haemosiderin. He was diagnosed with zosteriform lichen aureus and was treated with topical mometasone furoate during 3 weeks resulting in partial lightening of the macules. Lesions have remained 2 years later, and new ones have appeared in the ipsilateral ankle. We must consider differential diagnosis with other pigmented purpuric dermatitis and pigmented purpuric mycosis fungoides. There are many therapeutic options and it tends to disappear spontaneously, so new studies are necessary

Mapping the disease-specific LupusQoL to the SF-6D

Purpose To derive a mapping algorithm to predict SF-6D utility scores from the non-preference-based LupusQoL and test the performance of the developed algorithm on a separate independent validation data set. Method LupusQoL and SF-6D data were collected from 320 patients with systemic lupus erythematosus (SLE) attending routine rheumatology outpatient appointments at seven centres in the UK. Ordinary least squares (OLS) regression was used to estimate models of increasing complexity in order to predict individuals’ SF-6D utility scores from their responses to the LupusQoL questionnaire. Model performance was judged on predictive ability through the size and pattern of prediction errors generated. The performance of the selected model was externally validated on an independent data set containing 113 female SLE patients who had again completed both the LupusQoL and SF-36 questionnaires. Results Four of the eight LupusQoL domains (physical health, pain, emotional health, and fatigue) were selected as dependent variables in the final model. Overall model fit was good, with R2 0.7219, MAE 0.0557, and RMSE 0.0706 when applied to the estimation data set, and R2 0.7431, MAE 0.0528, and RMSE 0.0663 when applied to the validation sample. Conclusion This study provides a method by which health state utility values can be estimated from patient responses to the non-preference-based LupusQoL, generalisable beyond the data set upon which it was estimated. Despite concerns over the use of OLS to develop mapping algorithms, we find this method to be suitable in this case due to the normality of the SF-6D data

Long-Term exercise intervention in patients with McArdle disease: clinical and aerobic fitness benefits

Introduction: The long-term effects of exercise in patients with McArdle disease—the paradigm of ‘exercise intolerance’—are unknown. This is an important question as the severity of the disease frequently increases with time. Purpose: To study the effects of a long-term exercise intervention on clinical and fitness-related outcomes in McArdle patients. Methods: Seventeen patients (exercise group: N=10, 6 male, 38±18yrs; control: N=7, 4 male, 38±18yrs) participated in a twoyear unsupervised intervention including moderate-intensity aerobic (cycle-ergometer exercise for 1h) and resistance (high load-low repetition circuit) training on 5 and 2-3 days/week, respectively. Patients were assessed at baseline and postintervention. Besides safety, outcomes included clinical severity (e.g., exercise intolerance features) on a 0-3 scale (primary outcome), and aerobic fitness, gross muscle efficiency, and body composition (total/regional fat, muscle, and bone mass) (secondary outcomes). Results: The exercise program was safe and resulted in a reduction of one point (-1.0, 95% confidence interval -1.6—-0.5, p=0.025) in clinical severity vs. the control group, with 60% of participants in the exercise group becoming virtually asymptomatic and with no functional limitation in daily life activities. Compared with controls, the intervention induced significant and large benefits (all p<0.05) in the workload eliciting the ventilatory threshold (both in absolute (watts, +37%) and relative units (watts·kg-1 of total body mass or of lower-limb muscle mass, +44%)), peak oxygen uptake (ml·kg-1 ·min-1 , +28%) and peak workload (absolute (+27%) and relative units (+33%)). However, no significant changes were found for muscle efficiency nor for any measure of body composition. Conclusions: A two-year unsupervised intervention including aerobic and resistance exercise is safe and induces major benefits in the clinical course and aerobic fitness of patients with McArdle disease

Thymic development beyond β-selection requires phosphatidylinositol 3-kinase activation by CXCR4

T cell development requires phosphatidylinositol 3-kinase (PI3K) signaling with contributions from both the class IA, p110δ, and class IB, p110γ catalytic subunits. However, the receptors on immature T cells by which each of these PI3Ks are activated have not been identified, nor has the mechanism behind their functional redundancy in the thymus. Here, we show that PI3K signaling from the preTCR requires p110δ, but not p110γ. Mice deficient for the class IB regulatory subunit p101 demonstrated the requirement for p101 in T cell development, implicating G protein–coupled receptor signaling in β-selection. We found evidence of a role for CXCR4 using small molecule antagonists in an in vitro model of β-selection and demonstrated a requirement for CXCR4 during thymic development in CXCR4-deficient embryos. Finally, we demonstrate that CXCL12, the ligand for CXCR4, allows for Notch-dependent differentiation of DN3 thymocytes in the absence of supporting stromal cells. These findings establish a role for CXCR4-mediated PI3K signaling that, together with signals from Notch and the preTCR, contributes to continued T cell development beyond β-selection

Is Meta-Analysis for Utility Values Appropriate Given the Potential Impact Different Elicitation Methods Have on Values?

A growing number of published articles report estimates from meta-analysis or meta-regression on health state utility values (HSUVs), with a view to providing input into decision-analytic models. Pooling HSUVs is problematic because of the fact that different valuation methods and different preference-based measures (PBMs) can generate different values on exactly the same clinical health state. Existing meta-analyses of HSUVs are characterised by high levels of heterogeneity, and meta-regressions have identified significant (and substantial) impacts arising from the elicitation method used. The use of meta-regression with few utility values and inclusion criteria that extend beyond the required utility value has not helped. There is the potential to explore greater use of mapping between different PBMs and valuation methods prior to data synthesis, which could support greater use of pooling values. Researchers wishing to populate decision-analytic models have a responsibility to incorporate all high-quality evidence available. In relation to HSUVs, greater understanding of the differences between different methods and greater consistency of methodology is required before this can be achieved

Predicting Productivity Losses from Health-Related Quality of Life Using Patient Data.

OBJECTIVE: This paper estimates productivity loss using the health of the patient in order to allow indirect estimation of these costs for inclusion in economic evaluation. METHODS: Data from two surveys of inpatients [Health outcomes data repository (HODaR) sample (n = 42,442) and health improvement and patient outcomes (HIPO) sample (n = 6046)] were used. The number of days off paid employment or normal activities (excluding paid employment) was modelled using the health of the patients measured by the EQ-5D, international classification of diseases (ICD) chapters, and other health and sociodemographic data. Two-part models (TPMs) and zero-inflated negative binomial (ZINB) models were identified as the most appropriate specifications, given large spikes at the minimum and maximum days for the dependent variable. Analysis was undertaken separately for the two datasets to account for differences in recall period and identification of those who were employed. RESULTS: Models were able to reflect the large spike at the minimum (zero days) but not the maximum, with TPMs doing slightly better than the ZINB model. The EQ-5D was negatively associated with days off employment and normal activities in both datasets, but ICD chapters only had statistically significant coefficients for some chapters in the HODaR. CONCLUSIONS: TPMs can be used to predict productivity loss associated with the health of the patient to inform economic evaluation. Limitations include recall and response bias and identification of who is employed in the HODaR, while the HIPO suffers from a small sample size. Both samples exclude some patient groups

Early life risk factors and their cumulative effects as predictors of overweight in Spanish children

Objectives: To explore early life risk factors of overweight/obesity at age 6 years and their cumulative effects on overweight/obesity at ages 2, 4 and 6 years. Methods: Altogether 1031 Spanish children were evaluated at birth and during a 6-year follow-up. Early life risk factors included: parental overweight/obesity, parental origin/ethnicity, maternal smoking during pregnancy, gestational weight gain, gestational age, birth weight, caesarean section, breastfeeding practices and rapid infant weight gain collected via hospital records. Cumulative effects were assessed by adding up those early risk factors that significantly increased the risk of overweight/obesity. We conducted binary logistic regression models. Results: Rapid infant weight gain (OR 2.29, 99% CI 1.54–3.42), maternal overweight/obesity (OR 1.93, 99% CI 1.27–2.92), paternal overweight/obesity (OR 2.17, 99% CI 1.44–3.28), Latin American/Roma origin (OR 3.20, 99% CI 1.60–6.39) and smoking during pregnancy (OR 1.61, 99% CI 1.01–2.59) remained significant after adjusting for confounders. A higher number of early life risk factors accumulated was associated with overweight/obesity at age 6 years but not at age 2 and 4 years. Conclusions: Rapid infant weight gain, parental overweight/obesity, maternal smoking and origin/ethnicity predict childhood overweight/obesity and present cumulative effects. Monitoring children with rapid weight gain and supporting a healthy parental weight are important for childhood obesity prevention

Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease

Background: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. Methods: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P = 0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P = 0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P = 0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P = 0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P = 0.31). Conclusions: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. (Funded by Novartis; CANTOS ClinicalTrials.gov number, NCT01327846.