A 58-year-old man and his son presented with the clinical and histologic characteristics of porokeratosis plantaris, palmaris, et disseminata. Porokeratosis plantaris, palmaris, et disseminata also occurred in two other family members. Marked improvement was demonstrated with oral aromatic retinoid (Tigason) therapy. The differential diagnosis from the other types of porokeratosis is discussed. It is suggested that punctate porokeratosis is a form fruste of porokeratosis plantaris, palmaris, et disseminata.

Porokeratosis plantaris, palmaris, et disseminata.

Archives of Dermatology

Substantial gaps exist between recommendations for guideline-directed medical therapy (GDMT) for chronic kidney disease (CKD) and its use in real-world clinical practice. This includes suboptimal dosing of renin-angiotensin system inhibitors (RASi), low uptake of sodium-glucose co-transporter&#xa0;2 inhibitors (SGLT2i) for CKD, and low uptake and/or transient use of potassium binders to manage RASi-induced hyperkalemia. Suboptimal RASi therapy deprives patients of the full cardiorenal benefits associated with RASi, and increases the risk of cardiorenal adverse events and mortality. Hyperkalemia can be managed and optimal RASi dosing can be continued by using novel potassium binders, such as sodium zirconium cyclosilicate or patiromer. Similarly, low uptake of SGLT2i might be associated with the concern of an accelerated decline in estimated glomerular filtration rate and, therefore, disease progression when initiating SGLT2i. Numerous clinical trials have demonstrated that adding SGLT2i to RASi therapy can improve clinical outcomes and prolong patient survival in CKD. The recently published Kidney Disease: Improving Global Outcomes (KDIGO) 2024 clinical practice guideline for the evaluation and management of CKD extends the recommendation of SGLT2i to individuals with CKD without diabetes, reinforces the cardiorenal benefits of optimized RASi, recommends the addition of newer drug classes in suitable patients with CKD, and notes the use of novel potassium binders to manage hyperkalemia and enable optimal use of GDMT. In doing so, the guideline targets achievement of the "quadruple aim" of GDMT in CKD, i.e., enabling optimal use of RASi and SGLT2i in most patients, along with nonsteroidal mineralocorticoid receptor antagonists, and glucagon-like peptide-1 receptor agonists in diabetic kidney disease. This manuscript constitutes a call to action to raise awareness of the growing clinical and economic burdens of CKD and to promote a united approach to the early detection and optimal treatment of CKD through stricter adherence to GDMT.

Guideline-Recommended Disease-Modifying Therapies for Patients with Cardiorenal Disease: A Call-to-Action Narrative Review.

Advances in Therapy

Pneumonia is a frequent cause of intensive care unit (ICU) admission and is the most common infection in ICU patients across all geographic regions. It takes 48-72h for most patients to respond to appropriate antibiotic therapy. Non-response is typically defined as the persistence/worsening of clinical signs-such as fever, respiratory distress, impaired oxygenation and/or radiographic abnormalities-with rates ranging 20-30%. Several factors can contribute to non-response. Host factors, including immunosuppression, chronic lung disease, or ongoing aspiration, may impair resolution. Additionally, incorrect antibiotic dosing, atypical or resistant pathogens (such as multidrug-resistant bacteria, Mycobacterium tuberculosis, or fungal infections) may be responsible, requiring alternative antimicrobial strategies. A septic complication related to pneumonia (e.g., empyema) or not (e.g., acalculous cholecystitis) may need to be excluded. Finally, non-infectious conditions (e.g., pulmonary embolism, malignancy, secondary ARDS or vasculitis) that can mimic or potentiate pneumonia must be considered. Although non-responding pneumonia is frequent, its management lacks strong evidence, and its approach is based mostly on the art of medicine and clinical judgement. Clinicians should continuously reassess the medical history and physical exam, review microbiological data, and consider imaging such as chest CT. Bronchoscopy or repeat sputum sampling may aid in identifying alternative pathogens or non-infectious causes. The management of a non-responding pneumonia depends on the findings of a structured reassessment. Herein, we provide guidance on how to identify and manage non-responding pneumonia. Ultimately, addressing pneumonia that does not respond to antibiotics is crucial for preventing complications, optimizing antimicrobial stewardship, and improving patient outcomes.

How to approach a patient hospitalized for pneumonia who is not responding to treatment?

Intensive Care Medicine

The "Fantastic Four," a term coined in 2021 to refer to the four key drug pillars in the treatment of heart failure with reduced ejection fraction (beta-blockers, renin-angiotensin system and neprilysin inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors, or SGLT2 inhibitors), has demonstrated excellent performance in reducing morbidity and mortality in this setting. However, in heart failure with mildly reduced or preserved ejection fraction, the same benefits were not observed with this combined treatment where, for many years, management in this context was limited to diuretics and comorbidity control. Recently, however, new therapeutic options have emerged, demonstrating effectiveness in reducing cardiovascular outcomes in this specific group: the "Dynamic Duo"-comprising SGLT2 inhibitors and Finerenone-has shown promising results, alongside the introduction of semaglutide as a potential "wild card" treatment for patients with obesity. Despite the ongoing need for therapies that significantly reduce overall mortality, these new treatments have effectively lowered hospitalization rates and improved symptoms in such patients. As a result, a new era in heart failure management is beginning.

"The Dynamic Duo": The New Management of Drug Treatment for Heart Failure with Mildly Reduced or Preserved Ejection Fraction.

Arquivos Brasileiros de Cardiologia

Functional neurological symptom disorder, specifically, functional limb weakness, is a commonly seen condition in clinical neurological practice and requires careful examination for diagnosis. Specific and detailed examination techniques have been developed and validated over the past 100&#xa0;years to help clinicians differentiate functional limb weakness from objective neurological weakness. These techniques vary in sensitivity, specificity, clinical application, and limitations. However, over time, the studied and/or validated forms of these exam techniques may have been lost and often not performed or taught in the way it was originally studied, thus decreasing the reliability of the examiner's findings. With many new examination techniques for functional limb weakness having been studied in recent years, it is important to not only review the form of each of these examination techniques, but also discuss the clinical applications, limitations, and utility of each. To date, there has been no comprehensive review demonstrating the exact form of all the studied and/or validated examination techniques for functional limb weakness and their proposed clinical utility. This review analyzes 9 examination techniques for functional limb weakness that have been studied for validity and provides readers with the exact technique of examination used to study each. It also outlines their sensitivity, specificity, clinical applications, and limitations to help clinicians accurately diagnose functional limb weakness.

A practical guide to assessing functional motor weakness: a review of validated techniques.

Journal of Neurology

Heart failure (HF) with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) represents approximately half of all HF cases, yet therapeutic options are limited. Mineralocorticoid receptor (MR) overactivation by aldosterone has long been recognized as a key driver of vascular inflammation, cardiac fibrosis, and cardiac hypertrophy, pathophysiological processes integral to the development and progression of HFmrEF/HFpEF. The non-steroidal MRA finerenone has been developed with a distinct pharmacological profile: potent and selective MR blockade with a reduced risk of off-target hormone-related side effects. Large, multicenter randomized placebo-controlled trials in chronic kidney disease and type 2 diabetes patients (FIDELIO-DKD, FIGARO-DKD) first highlighted finerenone's cardiorenal benefits, including a reduction in death from cardiovascular causes and hospitalization for HF. More recently, the FINEARTS-HF trial extended this evidence base to patients with HFmrEF/HFpEF, demonstrating a significant reduction in the risk of worsening HF events and death from cardiovascular causes. Ongoing studies, such as REDEFINE-HF, CONFIRMATION-HF, and FINALITY-HF, will examine the potential role of finerenone in HF across a broad spectrum of ejection fractions and different clinical settings. This review synthesizes the evolving evidence supporting the role of finerenone as a new option in the management of HF.

The role of finerenone in heart failure.

Trends in Cardiovascular Medicine

Vomiting after oral administration of medication is common in children. Despite this, there is a lack of formal guidelines and recommendations on this topic. This article is intended for doctors and nurses who treat children to support the management of this everyday clinical dilemma. This article describes the development of a decision support tool and provides an overview of factors to consider. The decision support tool provides advice for making informed decisions. It was based on a literature search combined with an informal consensus discussion in a group of paediatricians, clinical pharmacologists, and clinical pharmacists, followed by an internal review. The decision support tool is now in clinical use.

If a Child Vomits After an Oral Medication-Should We Re-Dose or Not?

Acta Paediatrica

Trigeminal neuralgia (TN) is a disorder characterized by recurrent, unilateral brief electric shock-like pains, abrupt in onset and termination, limited to the distribution of one or more branches of the trigeminal nerve, and triggered by innocuous stimuli.

The literature on the diagnosis and treatment of TN was retrieved and summarized.

The diagnosis is made almost entirely based on the patient's history. In classical TN, the neurological examination is typically normal, whereas the exam in secondary TN is focused on surveilling for signs of multiple sclerosis (MS) or a cerebellopontine tumor. The appropriate imaging technique is magnetic resonance imaging (MRI) with contrast of the trigeminal ganglion, which is recommended prior to interventional procedures. The treatment of a patient with TN is a team effort and should always be multidisciplinary, addressing all dimensions of pain. Carbamazepine or oxcarbazepine are first-line medical treatments. Microvascular decompression (MVD) is the technique of choice for patients without or with minor comorbidities. Percutaneous procedures for TN are mainly radiofrequency thermocoagulation of the branches of the trigeminal nerve introduced by Sweet and Wepsic in 1965, retrogasserian glycerol injection introduced by Hakanson in 1981, and balloon compression introduced by Mullan and Lichtor in 1983. Radiofrequency treatment is recommended in elderly patients or those with major comorbidities. Other techniques such as stereotactic radiosurgery and pulsed radiofrequency treatment are also discussed.

Recommendations are based on very low-quality evidence. MVD and radiofrequency are the preferred invasive treatments, although higher-quality evidence is necessary to better assess the risk-benefit ratios.

13. Trigeminal Neuralgia.

Pain Practice : the Official Journal of World Institute of Pain

Neutropenia is a hematologic condition characterized by an absolute neutrophil count&#x2009;&lt;&#x2009;1500/&#x3bc;L, associated with increased infection risk. This review aimed to provide an updated overview of the classification, pathophysiology, etiology, diagnosis, and management of neutropenia in congenital and acquired forms.

We conducted a comprehensive literature review of various causes of neutropenia, including genetic syndromes, autoimmune disorders, infections, and drug-induced mechanisms. Emphasis was placed on clinical manifestations, underlying mechanisms, diagnostic algorithms, and therapeutic approaches, including recent advances in molecular diagnostics and biologic therapies.

Neutropenia can result from decreased neutrophil production, immune-mediated destruction, or abnormal distribution. Congenital neutropenia is often linked to mutations in genes such as ELANE, HAX1, and SBDS. Acquired neutropenia can be caused by chemotherapy, infections, autoimmune diseases, or nutritional deficiencies. Diagnostic evaluation requires a stepwise approach incorporating clinical history, blood counts, peripheral smear, bone marrow biopsy, and molecular or serologic testing. Treatment depends on the etiology and severity and includes granulocyte colony-stimulating factor, immunosuppressants, antimicrobial prophylaxis, and hematopoietic stem cell transplantation in selected cases.

Neutropenia is a multifactorial disorder requiring individualized evaluation and management. Advances in genetic and immunological diagnostics combined with targeted therapies have improved risk stratification and outcomes. Early recognition and a multidisciplinary approach are essential to reduce infection-related morbidity and prevent progression to hematologic malignancies in high-risk patients.

Diagnosis and management of neutropenia.

Blood Research

Hypervolemia is associated with worse outcomes in critically ill patients with acute respiratory distress syndrome (ARDS), with early positive fluid balance linked to longer intensive care unit (ICU) stays, prolonged ventilatory support, and increased mortality risk due to cardiopulmonary complications, lung edema, and extrapulmonary organ dysfunction. However, a restrictive fluid management strategy is associated with hypoperfusion and distal organ dysfunction, including acute renal failure and cognitive impairment. Indeed, fluid administration in patients with ARDS represents a challenge, as it must take into account the underlying condition, such as sepsis or acute brain injury (ABI), where optimal fluid management is a major determinant of disease outcome. In such cases, the approach to fluid administration should be individualized based on hemodynamic and clinical parameters according to the course of the disease. The strategy of "salvage, optimization, stabilization, and de-escalation" can guide fluid administration in the initial therapeutic approach, whereas negative fluid balance with the use of diuretics or renal replacement therapy (RRT) should be the goal once hemodynamic stabilization has been achieved.

Fluid management strategies in critically ill patients with ARDS: a narrative review.

European Journal of Medical Research

A major public health concern gripping the nation is chronic kidney disease (CKD), and for individuals concomitantly diagnosed with type 2 diabetes mellitus (T2DM), the coexistence significantly increases the cardiovascular morbidity and mortality by two to three times higher than patients diagnosed without CKD. CKD management encompasses both non-pharmacological approaches, such as dietary sodium restriction and lifestyle modification for blood pressure control, and pharmacological approaches. Current pharmacological management focuses on four key pillars: renin-angiotensin system inhibitors (RASi), sodium-glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1RA), and mineralocorticoid receptor antagonists (MRAs), all of which have shown renoprotective and cardiovascular benefits. An incomplete block of aldosterone activity remains a challenge and is one of the factors contributing to the progression of kidney damage. Aldosterone synthase inhibitors (ASIs), such as vicadrostat, may represent a new horizon in selectively inhibiting aldosterone synthesis while preserving cortisol production. Early-phase trials have shown reductions in albuminuria and a potential for renal protection. The question is, could ASIs emerge as a fifth pillar in CKD management and help curb the progression?

Porokeratosis plantaris, palmaris, et disseminata.

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