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BACKGROUND: Persistent airflow limitation (PAL) occurs in a subset of patients with asthma. Previous studies on PAL in asthma have included relatively small populations, mostly restricted to severe asthma, or have no included longitudinal data. The aim of this post-hoc analysis was to investigate the determinants, clinical implications, and outcome of PAL in patients with asthma who were included in the ATLANTIS study.METHODS: In this post-hoc analysis of the ATLANTIS study, we assessed the prevalence, clinical characteristics, and implications of PAL across the full range of asthma severity. The study population included patients aged 18-65 years who had been diagnosed with asthma at least 6 months before inclusion. We defined PAL as a post-bronchodilator FEV1/forced vital capacity (FVC) of less than the lower limit of normal at recruitment. Asthma severity was defined according to the Global Initiative for Asthma. We used Mann-Whitney U test, t test, or χ2 test to analyse differences in baseline characteristics between patients with and without PAL. Logistic regression was used for multivariable analysis of the associations between PAL and baseline data. Cox regression was used to analyse risk of exacerbation in relation to PAL, and a linear mixed-effects model was used to analyse change in FEV1 over time in patients with versus patients without PAL. Results were validated in the U-BIOPRED cohort.FINDINGS: Between June 30, 2014 and March 3, 2017, 773 patients were enrolled in the ATLANTIS study of whom 760 (98%) had post-bronchodilator FEV1/FVC data available. Of the included patients with available data, mean age was 44 years (SD 13), 441 (58%) of 760 were women, 578 (76%) were never-smokers, and 248 (33%) had PAL. PAL was not only present in patients with severe asthma, but also in 21 (16%) of 133 patients with GINA step 1 and 24 (29%) of 83 patients with GINA step 2. PAL was independently associated with older age at baseline (46 years in PAL group vs 43 years in non-PAL group), longer duration of asthma (24 years vs 12 years), male sex (51% vs 38%), higher blood eosinophil counts (median 0·27 × 109 cells per L vs 0·20 × 109 cells per L), more small airway dysfunction, and more exacerbations during 1 year of follow-up. Associations between PAL, age, and eosinophilic inflammation were validated in the U-BIOPRED cohort, whereas associations with sex, duration of asthma, and risk of exacerbations were not validated.INTERPRETATION: PAL is not only present in severe disease, but also in a considerable proportion of patients with milder disease. In patients with mild asthma, PAL is associated with eosinophilic inflammation and a higher risk of exacerbations. Our findings are important because they suggest that increasing treatment intensity should be considered in patients with milder asthma and PAL.FUNDING: Chiesi Farmaceutici and Dutch Ministry of Economic Affairs and Climate Policy (by means of the public-private partnership programme).

The technique of dermoscopy has come a long way since its inception for characterization of suspicious nevi for early detection of dysplastic changes in predisposed individuals. Not only has its scope expanded to aid in quick diagnosis of a majority of nonmelanocytic disorders of the skin, hair, and nails, but it is being rightfully exploited for a plethora of nondiagnostic uses. Its use in the diagnosis of various pigmentary, papulosquamous, and infectious disorders and disorders of the scalp and hair, nails, and mucosa bears testimony to the ongoing expansion of its protean indications across skin types. Dermoscopy has transformed the conventional approach to dermatological diagnosis from clinicopathological correlation to clinico-dermoscopic-pathological correlation. It aids in convincing an otherwise reluctant patient to agree to biopsy and guides the selection of optimum site for the same. Dermoscopic clues suggestive of stability or activity of the lesion and/or disease in various dermatoses are being accrued. Early assessment of therapeutic response to treatment is helpful for physicians, patients, and researchers conducting clinical studies. Aesthetic uses of dermoscopy are opulent and being explored. Dermoscopy has also provided the much-needed balancing act of interaction between practitioners and the new generation of patients. Last but not the least, dermoscopy has resulted in patients’ better understanding of their disorders and improved compliance with treatment protocols.

The injudicious use of antifungals, indiscriminate use of corticosteroids for instant relief, persistence of predisposing factors like sweat retention and uncontrolled diabetes, and emerging resistance to antifungals across the globe have rendered the management of an erstwhile simple infection, the superficial cutaneous mycoses highly complicated and tricky. Ciclopirox is an old yet efficacious, versatile, and safe topical antifungal of the hydroxypyridone family. Despite its numerous beneficial properties over the majority of other topical antifungals, it remains underutilized.

Spiegler–Fendt sarcoid/lymphocytoma cutis, presenting as an asymptomatic, slowly progressive, erythematous macule of the size of a guinea over the left cheek, is presented in a 7-year-old girl, the diagnosis of which was complimented by lymphocytic exocytosis with spongiosis of the epidermis. Immunohistochemistry revealed wide-ranging T-cell variations, which was more positive for T-cell markers, CD3, of which predominance of CD4 subset was seen, emphasizing its role as a diagnostic tool.

Fructose consumption is responsible for the onset of insulin resistance (IR), and metabolic syndrome. It possesses no functional utility in body and its detrimental effects on hepatic metabolic milieu are beyond those produced by glucose. The need of the hour is to identify fructose-induced IR as an unique pathological state to be managed differentially. The effect of aqueous leaf extract of Aegle marmelos (AM) on hepatic markers of insulin resistance using HepG2 cells cultured in either fructose or glucose-rich environment is investigated. Human hepatocellular carcinoma cells (HepG2) were grown under standard conditions in either-DMEM without glucose (NC), DMEM with high glucose 25 mM (Glu), DMEM-glucose+0.55 mM fructose (FC1), DMEM-glucose+1 mM fructose (FC2) or DMEM-glucose+1 mM fructose+0.1 µM insulin (FC3). The cells were treated with either AM, rutin, quercetin, metformin or pioglitazone and assessed for levels of hexokinase, phosphofructokinase (PFK), aldehyde dehydrogenase, phosphatidylinositol kinase (PI3K), signal transducer and activator of transcription-3 (STAT-3), mitochondrial target of rapamycin (mTOR), hypoxia-induced factor (HIF-1α), vascular endothelial growth factor (VEGF) and tumour necrosis factor (TNF-α). Summarily, when results from fructose- and glucose-rich environment were compared, then (1) IR was more pronounced in former; (2) AM performed better in former; (3) metformin and pioglitazone were equivocal in either; (4) rutin and quercetin showed deviant effects from AM; and lastly (5) effects of rutin were closer to AM than quercetin. We hypothesize that AM ameliorates fructose-induced IR through a mechanism which is distinct from standard drugs and not shared by individual phytoconstituents in toto.

Background: Hair transplantation in the current context has emerged as one of the most sought after treatments for andro-genetic alopecia. In conventional FUE technique of hair transplantation graft damage may occur due to various factors which can be eliminated by Instant Follicular Hair Unit Transplant (IFHUT), an innovative technique which involves extraction of hair follicle one by one from the safe donor area and implanting them immediately after extraction. Methods: 10 patients of andro-genetic alopecia were inducted to the study. One half of the donor area was utilized for IFHUT, while the other for conventional FUE and the implantation results were compared pictographically as well as with trichoscopy and documented at each follow up. Results: Significantly, better growth was seen by the naked eyes, pictographic comparison and hair scope examination in the IFHUT site in 9 patients. Conclusion: Although this technique presents a steeper learning curve for the surgeon, need for clear protocols and proper execution, the efficacy and superiority of results presented by the IFHUT method show the potential of this technique to reshape the future of the hair transplant industry.

Epidermolysis bullosa pruriginosa, a rare variant of dominant inheritance pattern, characterized by itchy, papules and/or nodules coalescing to form plaque(s), studded by blisters, is describe in a young man an index case. In all 12 afflicted individuals of the 27 family members was interesting, the diagnosis of which was made by its morphology and inflammatory changes in the epidermis, comprising hyperkeratosis, moderate acanthosis, presence of inflammatory cells, and above all inflammatory cell containing sub-epidermal cleavage or cleft.

Background/purpose To plan a quality improvement project, we need to understand the practice patterns of physicians. We undertook an online survey of systemic lupus erythematosus (SLE) patients and physicians providing care to SLE patients to determine the patterns of medical care provided to SLE patients. Materials and methods Two self-report surveys were developed. A 12-item survey for the patients and a 13-item survey for physicians enquired about longitudinal care for SLE. Surveys were administered online to physicians providing care to SLE patients, and to patients who self-identified as having SLE, through the Lupus Society of Illinois. Patient and physician data were analyzed for physician practice patterns for SLE care, using chi square tests and t tests. A P value of 0.05 or less was considered significant on two-tailed tests. Results A total of 283 patients completed the survey. Mean (SD) age and disease duration of patients were 45.9 (13.2) and 12.7 (9.7) years. Half of the participants were being seen at 3–4-month intervals. More than 70% of patients reported being tested for antinuclear antibody (ANA), and 20–30% anti-ENA antibody and Sjögren’s (SSA/SSB) antibodies, respectively, at each follow-up visit. Eighty-six rheumatologists completed the surveys. Mean (SD) age was 55 (12) years and 56% were men. More than half (54%) provided care only in a private practice setting. More than 80% of physicians reported seeing their SLE patients at 3–4-month interval. Only 2% reported performing ANA tests at each visit, while 4–5% performed anti-ENA and anti-SSA/SSB antibody tests at each visit for their SLE patients. More than 75% of physicians in private practice also ordered sedimentation rate at each visit for their SLE patients. Conclusions Unnecessary laboratory investigations may be being ordered routinely for patients at every visit. These results indicate a need for physician education on indications and utility of some of the laboratory tests such as ANA.

Erythroderma/generalized exfoliative dermatitis, presenting with intensely itchy, dry, scaly, widespread erythema covering whole of the skin surface is reported, the diagnosis of which was primarily clinical but was supplemented by histopathology. Other investigations such as hemogram, immunoglobulin E (IgE), and serum fluorescent enzyme immunoassay (FEIA) were supportive; while IgE was high, serum FEIA was extraordinary high. Identifying it as a clinical pearl of hyper-IgE syndrome, recovery of heavy coloniz ation of Klebsiella pneumoniae, anaerobic Gram-negative bacteria, was contrastingly unique responding affectively to metronidazole, a drug specific for the purpose.

Erectile dysfunction/impotence, a universal phenomenon, is a type of sexual dysfunction, the incidence of which is unknown. Certainly, its management options has changing scenario, in particular, take cognizance of phosphodiesterase type 5 inhibitors being the pivot, the highlight of which form the main stay of stage first, supplemented by drugs of stage second and technique adoptive for stage third, emphasizing their relative merits.

Glucocorticoids, corticosteroids/steroids sparing (replacement) maintenance immunosuppressive/adjunct drugs delivery has always been a challenging overture. Azathioprine, cyclophosphamide, dapsone, immunoglobulin, and interferon are agents in this category. The pharmacology and pharmacokinetics of the preceding drugs include specific recommendations, generic names, availability, mode of administration, dosage schedule, and the essentials of drug management.

Erythema annulare centrifigum emphasizing the role of beta cell of head of pancreas in its plausible causation is describe, the features of which conformed to non-insulin dependent diabetes mellitus type 2.

A rare association of herpes zoster/shingles concomitantly occurring in a heavy weight elderly man with established non-insulin dependent (Type 2)/ adult onset diabetes mellitus is reported, highlighting the cardinal clinic features apparent has numbness, tingling, painful, group of vesicle / blister over an erythematous background occupying the left cheek ipsilaterally conforming to the distribution of branches of the facial nerve. The relevant citations were taken cognizance of and incorporated in the text. The response to acyclovir 800 mg 5 times in a day for period of 10 ten days was gratifying.

Background The role of IL-17 immunity is well established in patients with inflammatory diseases, such as psoriasis and inflammatory bowel disease, but not in asthmatic patients, in whom further study is required. Objective We sought to undertake a deep phenotyping study of asthmatic patients with upregulated IL-17 immunity. Methods Whole-genome transcriptomic analysis was performed by using epithelial brushings, bronchial biopsy specimens (91 asthmatic patients and 46 healthy control subjects), and whole blood samples (n = 498) from the Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes (U-BIOPRED) cohort. Gene signatures induced in vitro by IL-17 and IL-13 in bronchial epithelial cells were used to identify patients with IL-17–high and IL-13–high asthma phenotypes. Results Twenty-two of 91 patients were identified with IL-17, and 9 patients were identified with IL-13 gene signatures. The patients with IL-17–high asthma were characterized by risk of frequent exacerbations, airway (sputum and mucosal) neutrophilia, decreased lung microbiota diversity, and urinary biomarker evidence of activation of the thromboxane B2 pathway. In pathway analysis the differentially expressed genes in patients with IL-17-high asthma were shared with those reported as altered in psoriasis lesions and included genes regulating epithelial barrier function and defense mechanisms, such as IL1B, IL6, IL8, and β-defensin. Conclusion The IL-17–high asthma phenotype, characterized by bronchial epithelial dysfunction and upregulated antimicrobial and inflammatory response, resembles the immunophenotype of psoriasis, including activation of the thromboxane B2 pathway, which should be considered a biomarker for this phenotype in further studies, including clinical trials targeting IL-17.

Introduction Transition is defined as the purposeful and planned movement of adolescents and young adults with chronic physical and medical conditions from child centred to adult orientated health care services.1 Evidence supports that poorly planned transition in asthma is associated with an increased risk of non-adherence and loss to follow-up during a highly vulnerable period. It is essential that the transition process is co-ordinated and matched to developmental abilities of individuals and care not simply transferred at the age of 16 as has historically been the case. In line with NICE guidance on transition planning, we aimed to set up a regional transition service for severe asthma engaging young adults and their carers in service design and delivery. Methods A questionnaire aimed at exploring concerns and issues surrounding transition planning was developed and sent to asthmatics aged 14–16, on step 4 or 5 treatments under paediatric services across the region. Two focus discussion groups were held inviting families of those due to transition shortly and those who had recently transferred care. Results 17 completed questionnaires were analysed: median age 15 years, 9 male, average number of admissions per year 3.3. 71% expressed worries about their care moving to adult services and 94% felt that it was important that they were prepared for the move. Effective information sharing and communication were considered key, along with the provision of a named transition co-ordinator, meeting the adult team early and a gradual process of transition over 2 years. 8 families participated in the focus groups and similar themes emerged. Those who had recently transferred care felt unsupported and vulnerable, expressing anxiety surrounding emergency admissions. Shared pre-planned care pathways, asthma passports and alerts linked to health records were considered important. Conclusion Based on this feedback, we co-produced a patient-centred transition model with our young adults (figure 1) and at North Manchester have established a young adult severe asthma clinic. To date, 31 young adults are currently transitioning to one of 3 adult centres in the region and evaluation of services and patient experience are under review. Reference Blum RW. Journal Adolescent Health1993;14(7):570–6.

A 56-year-old man presented with multiple, skin-colored, raised eruptions of the scrotum that had been present for 2 years. Their onset had been gradual, and they had been increasing in size, resulting in cosmetic disfigurement. A year previously, he had been operated on for a bilateral vaginal hydrocele with partial excision and eversion of the sac (Jabouley method).

The clinical diagnosis of cutaneous tuberculosis (CT) was based on criteria of reinfection and reactivation. Laboratory tests are mandatory but have limitations, thus demanding continuous innovation. In our study, we took punch biopsies from lesions on 48 patients. Half of these biopsies underwent histopathologic investigation, and the other half were analysed using the BACT Alert 3D system, the Amplified

A 6-month-old, 4-kg, dehydrated girl, an Indian native, was admitted with recurrent episodes of diarrhea that had occurred since age 2 months. She had stopped breastfeeding. She had also had concomitant vomiting and loss of appetite. Later, the mother noticed progressively increasing erythematous eruptions around the anogenital and the oral region. The baby had been born to a short-stature mother and was delivered by lower segment cesarean section. Regular antenatal follow-up was normal.

Footwear contact dermatitis is a common problem with multifactorial exogenous, as well as endogenous, etiologies. Patch testing is the gold standard for detection of the possible contactants. A cross-sectional study was conducted in 108 outpatients over a period of 18 months. Demographic data comprising age, sex, and occupation were collected. Details of clinical and laboratory investigations were used to define the incriminating ingredient(s), subsequently confirmed by patch test using Indian standard and footwear series approved by the Contact and Occupational Dermatitis Forum of India. Reading and interpretation were carried out according to the International Contact Dermatitis Research Group (ICDRG) guidelines. Of the 108 patients, 64 were girls or women and 44 boys or men. Although footwear contact dermatitis affected all age groups, most individuals were 21 to 40 years old. The morphology and distribution of the lesions were very specific. Patch testing was helpful, the primary sensitizing agent being mercapto mix, followed by mercaptobenzothiazole, potassium dichromate, and paraphenylenediamine. Footwear contact dermatitis is an extraordinary entity, requiring a high level of expertise (or knowledge) to determine its etiology through history, clinical examination, and patch testing.

Atopic dermatitis is well-known age-related/oriented caption recognized through well-defined clinical features usually having an onset in infancy invariably marching towards childhood, adolescent adult and elderly (senile) phases. This particular aspect seems unique, and was succinctly explored through literature, the highlights of which form the position paper for vivid comprehension of evolving clinical spectrum, which might add up to elevation of dreaded symtomatology, a part component of the entity. The criteria for intrinsic and extrinsic variant of AD, in particular, are emphasized.

Multiple/overlap autoimmune syndrome, comprising systemic lupus erythematosus, dermato-polymyositis, and non-insulin dependent/adult onset diabetes mellitus is being reported in a 53-year-old woman. The diagnosis of each of them was based on cardinal clinical criteria supplemented by laboratory undertones. The drug delivery (management) and approaches (strategies), in particular takes cognizance of stability and acceptable improvement, but for abrupt multiple group vesicular eruption over the erythomatosus base accompanied by numbness, tingling and pain essentially afflicting the right forehead and the face for which acyclovir was administered in recommended dosages for herpes zoster vericella (shingles).

Oral mucosal lesions (OMLs) present with a variety of manifestations, emanating largely from tobacco chewing, smoking, and consumption of alcohol. Evolution of the lesions may be facilitated by poor oral hygiene and restorative dental materials, as well as by trauma, infections, and immune-mediated diseases. Two hundred consecutive patients seen at a pre-eminent dermatologic clinic formed the study group. They were interviewed about clinical manifestations, duration of the lesion, patient's age and sex, and incriminating factors. After informed consent had been gained, a thorough clinical examination was performed to define the precise morphology, site, and distribution of lesions. Confirmation of the clinical diagnosis by histopathology and other relevant techniques was confirmed.

Lyme disease/borreliosis (LD) is a well-known arthropod-transmitted entity in the northern hemisphere. The incidence of LD is reportedly rising throughout the world, although better diagnostic facilities may be contributory. The disease distribution is expanding in Europe, with its presence being now documented at higher altitudes and latitudes. Borrelia burgdorferi sensu lato is the most important genospecies leading to LD, although newer ones continue to be discovered. The variations in clinical spectrum with genospecies involved are an interesting feature. The alteration in gene expression while the organism cycles between two very different hosts is intriguing and has been described. The disease presents in three stages-namely, the early localized, early disseminated, and late stage. Erythema chronicum migrans is the pathognomic early lesion, and its diagnosis is purely clinical; however, laboratory diagnosis is essential for later manifestations. Two-tier serologic testing using an enzyme-linked immunosorbent assay (ELISA) as the first tier and immunoglobulin M (IgM) and IgG immunoblot as the second, if ELISA is positive or equivocal, is the mainstay of diagnosis. Doxycycline is the cornerstone of treatment, whereas parenteral therapy, mainly with ceftriaxone, is indicated in a few specific scenarios.

Biologics are a group of drugs that precisely affect certain specific steps in the immune response and are an extremely useful group when used in an appropriate setting. However, their use can often be a double-edged sword. Careful patient selection and thorough knowledge of adverse effects is a key to their successful use in various disorders. The initial enthusiasm has gradually given way to a more cautious approach wherein a balance is sought between clinical usefulness and expected side effects. The adverse effects of the biologics most commonly used in dermatology have been carefully listed for ready reference. The plausible causes of the adverse reactions are succinctly outlined along with their incriminating factor(s). Besides, in brief, the attention has been focused on their management. The content should provide an essential didactic content for educating the practitioner.

Atopic dermatitis is a well-recognized clinical entity, several facets of which continue to be mystified. Accordingly, its etio-pathogenesis is largely elusive. It appears to be an outcome of interplay of several undertones, namely: genetics, maternal factor and inheritance, pregnancy/intrauterine, environmental factors, immune dysregulation, immuno-globulins, role of diet, and infection. Besides, recent innovative breakthroughs consisting of nutritional supplementation, the highlights of which were considered worthwhile to take stock of to define its current status. An endeavor to enlighten the audience has been made for their benefit.