Stria Research Articles

A COMPARATIVE STUDY BETWEEN THE FRACTIONAL CO2 LASER AND CARBOXYTHERAPY IN TREATMENT OF STRIAE DISTENSAE: A CLINICAL AND HISTOPATHOLOGICAL STUDY

Striae distensae (SD), commonly known as stretch marks, represent linear dermal scars associated with epidermal atrophy. It is prevalent in all races. Objective: The aim of this study was to compare the efficacy and the safety of use of ablative fractional CO2 laser therapy and carbon dioxide gas intradermal injection in treatment of striae distensae. Methods: The present study included 20 patients diagnosed with striae distensae who had never received any previous treatment for SD. There were three groups; each group composed of 10 patients: The first group was treated with ablative fractional CO2 laser resurfacing 10,600 nm The treatment parameters in this study were: energy (30-40 mJ), pulse duration (1.4-1.8 ms), scanning area (20 mm x 5 mm), depth level (1-2) and density level (8-16) according to each patient condition and skin type. Stria of the second group was treated with intradermal injection of carbon dioxide gas. 4-mm bunch biopsies were taken from patients before and after treatment by and results showed high percentage of excellent improvement with fractional CO2 laser.Results: Carbon dioxide laser showed significant higher percentage of excellent improvement after last session of treatment of SD, when compared with carbon dioxide injection.Conclusion: Treatment with CO2 laser showed significant higher frequency of striae with excellent improvement, with good improvement, when compared to treatment with CO2 injection (carboxytherapy). Fractional CO2 laser is promising tool in dermatology and in treatment of SD (safe and effective).

MO1023BARDET-BIEDL SYNDROME OR SENIOR-LOKEN SYNDROME? GOING BEYOND THE OBVIOUS

Abstract Background and Aims Nephronophthisis (NPHP), a ciliopathy which almost always causes end-stage kidney disease (ESKD), may have extrarenal symptoms such as Bardet-Biedl syndrome (BBS) and Senior-Loken syndrome (SLS), and these are called NPHP-related ciliopathies (NPHP-RC). Bardet-Bield syndrome and SLS share similar clinical features, so that definitive diagnosis might depend on genetic analysis. Bardet-Bield syndrome diagnosis is typically based on clinical manifestations, which comprise, for example, renal defects, polydactyly, obesity, retinitis pigmentosa (RP), learning difficulties, in addition to secondary manifestations such as development delay, speech defects, hypertension, among others. Senior-Loken syndrome classical encompasses familial NPHP and RP; additional variable features can include skeletal, liver, neurologic and other visual defects, as well as obesity. NPHP genes are the most commonly affected in NPHP. Although disruption of the NPHP5 and NPHP6 genes are the most frequent cause of SLS, at least variants in ten genes have been reported. We present a case of a young girl clinically diagnosed with BBS, later known to be a SLS based on genetic analysis, revealing an unusual affected gene. Method We reviewed this case based on medical records. Results The patient presented with polydactyly at birth and pre-obesity in the first six months of age. At the age of 4 years she was first evaluated by ophthalmology due to reduced visual acuity which evolved unfavorably with severe generalized retinal dysfunction and moderate maculopathy at the age of 9 years. Delayed development and poor social skills were increasingly evident, as wells as short stature, small hands and dysmorphic facial features. At the age of 12 years bilateral transmission hearing loss was diagnosed and two years later she was referred to Endocrinology due to hirsutism, stretch marks and cushingoid facies. In this context, blood work was performed and surprisingly revealed plasma creatinine of 2.19 mg/dL and urea of 65 mg/dL. Kidney ultrasound revealed reduced dimensions and increased parenchymal echogenicity; an obstructive component was excluded. She rapidly progressed to ESKD and dialysis dependence. Bardet-Biedl syndrome was considered. She was referred for transplant assessment and underwent genetic testing. A homozygous likely pathogenic variant was identified in TRAF3IP1 gene, compatible with SLS 9 (autosomal recessive inheritance). Conclusion Although phenotype-based diagnosis was common in ciliopathies, genetic testing is now regularly used for definitive diagnosis. Mutations in the geneTRAF3IP1 were only recently described, particularly in patients presenting with NPHP, RP, skeletal defects, hepatic fibrosis and hexadactyly; ESKD is frequent between 3 and 16 years and SLS is formally associated. Our patient had several clinical manifestations suggestive of BBS, and presumptive diagnosis was assumed (although noticeable phenotypic overlap with SLS exists). Genetic analysis was crucial; the identified mutation in TRAF3IP1 justifies some of the extra-SLS/BBS-like manifestations. Patients must be monitored carefully, namely related to ESKD and extrarenal manifestations; there is also the need for segregation analysis (divorced parents and half-brothers). Ultimately this case represents a consequence of genetics evolution, with a wide genetic and clinical variability now described within these syndromes.

The state of bone mineral density in the prolapse of the pelvic organs

Background. Plausible predictions of future mortality and disability are useful aids in making decisions about priorities for medical research. Recent advances in medicine have led to the fact that some countries, such as Japan, have the highest life expectancy in the world. Osteoporotic fractures make a significant contribution to the development of morbidity and mortality in the aging population. Despite an active study of the mechanisms of the development of pelvic organ prolapse and disorders of bone mineral density separately, the general background of these diseases has previously been little studied.
 Aim. To study bone density according to densitometry data in peri- and postmenopausal women.
 Materials and methods. To carry out this study, 2 groups of women were formed. The first (experimental) group included 76 women admitted for routine surgical treatment of genital prolapse, the second group (control) 68 women without clinical manifestations of pelvic floor descent, who underwent a medical examination by a gynecologist on an outpatient basis.
 Results. Analysis of extragenital diseases in women included in the study showed a high prevalence in the experimental group of hypertension (p=0.028), osteochondrosis (p=0.001), scoliosis (p=0.028), hemorrhoids (p=0.013). Also, women in this group more often noted stretch marks on the skin (p=0.002) and were more often operated on for other diseases (p=0.043), which indicates the association of genital prolapse with undifferentiated connective tissue dysplasia and hypertension. The diagnosed severe osteoporosis (according to 1 or more densitometry indicators, where the T-score is less than -2.5) had a direct correlation with the duration of menopause. For a detailed analysis of the factors influencing severe osteoporosis in peri- and postmenopausal women, logistic regression analysis and ROC analysis were performed. The independent variable was the presence of severe osteoporosis, and the dependent variables were: stage according to POP-Q, the presence of hypertension, the presence of diabetes mellitus in history.
 Conclusion. This study confirms the presence of a comorbidity decrease in bone density according to densitometry and the presence of hypertension (p=0.028) and genital prolapse. According to the ROC analysis, an increase in the stage of genital prolapse according to the POP-Q classification increases the risk of developing severe osteoporosis.

Clinical Relevance of Elastin in the Structure and Function of Skin.

Elastin is the main component of elastic fibers, which provide stretch, recoil, and elasticity to the skin. Normal levels of elastic fiber production, organization, and integration with other cutaneous extracellular matrix proteins, proteoglycans, and glycosaminoglycans are integral to maintaining healthy skin structure, function, and youthful appearance. Although elastin has very low turnover, its production decreases after individuals reach maturity and it is susceptible to damage from many factors. With advancing age and exposure to environmental insults, elastic fibers degrade. This degradation contributes to the loss of the skin’s structural integrity; combined with subcutaneous fat loss, this results in looser, sagging skin, causing undesirable changes in appearance. The most dramatic changes occur in chronically sun-exposed skin, which displays sharply altered amounts and arrangements of cutaneous elastic fibers, decreased fine elastic fibers in the superficial dermis connecting to the epidermis, and replacement of the normal collagen-rich superficial dermis with abnormal clumps of solar elastosis material. Disruption of elastic fiber networks also leads to undesirable characteristics in wound healing, and the worsening structure and appearance of scars and stretch marks. Identifying ways to replenish elastin and elastic fibers should improve the skin’s appearance, texture, resiliency, and wound-healing capabilities. However, few therapies are capable of repairing elastic fibers or substantially reorganizing the elastin/microfibril network. This review describes the clinical relevance of elastin in the context of the structure and function of healthy and aging skin, wound healing, and scars and introduces new approaches being developed to target elastin production and elastic fiber formation.

Imaging striae distensae: a comparison between PS-OCT and digital dermoscopy.

Stretch marks or striae distensae (SD) cause emotional distress and negatively affect the psychological well-being of patients. We investigate and compare two methods for quantifying the severity of SD: visual scoring of images captured using a clinical visible-light dermatological camera (C-Cube, Pixience Inc) and measuring the local birefringence of skin using polarization-sensitive optical coherence tomography (PS-OCT). Data on skin visually affected by SD and visually normal skin were collected from 19 human volunteers. Our results show a weak correlation between visual scores of the C-Cube images and the birefringence values obtained from the PS-OCT system. SD datasets have a significantly larger birefringence values compared to visually normal datasets.

Life cycle and morphological identification of Globodera spp. related to potato (Solanum tuberosum L.) phenology in Nariño, Colombia

Nematodes of Globodera genus are considered one of the most important and limiting pests for potato crops, since these pathogens are difficult to control and cause losses between 20 and 50% of production. The study was carried out in areas of Túquerres and Contadero, belonging to the department of Nariño, Colombia, where cysts were collected by taking soil samples and obtaining immature females after observing the potato plants roots. Photographic records of symptoms corresponding to the nematode presence during the phenological development of the crop were also taken. This study was carried out in order to determine the present specie in the mentioned areas by studying morphological characters such as: nodules shape of the stylet, stretch marks between the vulva and anus and the female color change towards the cyst formation and relate the biological cycle of the pathogen with the host. Cysts viability tests were carried out, obtaining active larvae in J2 state. The evaluated results corresponded to Globodera pallida species and no evidence Globodera rostochiensis was found in samples. Refering to symptoms observed in field, there was chlorosis, yellowish spots on the foliage and plants with little growth. The appearance of immature females coincides with the phenological stage of flowering, which occurs 90 days after the plant emergence.

Looking Beyond Diabetes: A Case of Worsening Hyperglycemia as a Manifestation of Ectopic Cushing’s Syndrome Secondary to an Adrenocorticotropic Hormone-Producing Pheochromocytoma

A 76-year-old woman presented with worsening fasting hyperglycemia on routine blood sugar measurement, previously well-controlled on Metformin, requiring initiation of insulin. Her medical history included type 2 diabetes mellitus, hypertension, and aortic stenosis. Over the next few weeks, she developed bilateral upper and lower extremity proximal muscle weakness, episodes of confusion, rapid weight loss and increasing lower extremity edema. She did not have typical Cushingoid features of moon facies, easy bruising, centripetal obesity, abdominal striae, dorsocervical fat padding, or hyperpigmentation. Laboratory data revealed severe hypokalemia, elevated cortisol of 138 (3.7–19.4 ug/dL) and ACTH of 368 (6–50 pg/mL) consistent with ACTH-dependent Cushing’s syndrome. She was hospitalized for emergent therapy with etomidate infusion, potassium supplementation, and started on spironolactone. 24-hour urinary analysis demonstrated elevated catecholamines and metanephrines: epinephrine 552 (2–16 mcg/g cr), norepinephrine 1881 (7-5 mcg/g cr), metanephrine 4095 (21–153 mcg/g cr), normetanephrine 3920 (108–524 mcg/g cr).CT abdomen showed 3.8 cm mass in the left adrenal gland with enhancing walls and central hypoattenuation and a normal contralateral adrenal gland. MR brain showed a partial empty sella without any mass. 123I-metaiodobenzylguanidine scintigraphy showed uptake in the left adrenal mass. Once cortisol was reduced to <25 ug/dL, she was transitioned from etomidate to metyrapone; alpha-methyltyrosine and prazosin was also begun. Following left laparoscopic adrenalectomy, ACTH decreased to <5 pg/mL confirming that the pheochromocytoma was the source of ectopic Cushing’s. Gross examination of the mass was notable for a spongy, tan, roughly spherical medullary neoplasm (3 cm in diameter) with a rim of brown and focally yellow adrenal cortex up to 4 mm thick. Marked diffuse adrenal cortical hyperplasia was noted. The tumor showed varied growth patterns, including solid areas and spongy, angioma-like areas with prominent small blood vessels. Immunohistochemical staining was positive for somatostatin receptor 2A, tyrosine hydroxylase and ACTH in tumor cells and negative for T-PIT. She was discharged on replacement hydrocortisone therapy, minimal insulin for diabetes and has shown substantial clinical improvement.Cushing’s syndrome due to ectopic ACTH-producing pheochromocytoma is rare. Worsening hyperglycemia in the presence of hypertension, even without typical clinical findings of Cushing’s, should prompt further hormonal work up. The absence of the transcription factor TPIT, which is a lineage determinant for pituitary corticotrophs, suggests that novel pathways are involved in differentiation of cells that produce ectopic ACTH.

Approaching High-Metabolic Risk Youth During a Pandemic: Severe Presentations of New Onset Type 2 Diabetes

Background: Delays in timely medical care due to the restrictions imposed by the COVID-19 pandemic have worsened patient outcomes with different disease conditions. Youth with obesity, insulin resistance, and dysglycemia are increasingly presenting with HHS and/or DKA, leading to increased morbidity and mortality. Case Descriptions:Case 1: A 17-year-old Hispanic female with history of obesity, insulin resistance, and hyperglycemia reported polyuria, polydipsia, and polyphagia for 2 months. The day of admission, EMS was called because patient was found unresponsive at home and required advanced CPR. At arrival to the ED, the patient was awake and responsive. She had acanthosis nigricans and abdominal striae. Initial labs showed elevated plasma glucose (1,256 mg/dL), sodium (153 mmol/L), bicarbonate (9 mmol/L), anion gap (35 mmol/L), phosphorus (7.5 mg/dL; N=3-4.8), lactate (4 mmol/L; N=0.5-2), BHB (11.4 mmol/L; N=0-0.3), venous pH (7.09), BUN (24 mg/dL), creatinine (1.63 mg/dL), and HbA1c (14.3%). She was admitted for DKA, hyperosmolarity, AKI, and metabolic encephalopathy. After IVF resuscitation, insulin drip at 0.05 U/kg/h was started. She recovered from DKA, AKI and hyperosmolarity after 5 days. T1D antibody tests were negative. C-peptide was low (0.7 ng/mL; N=0.8-3.5), and TSH was low (0.38 uIU/mL) with normal free T4 (0.88 mg/dL). Case 2: A 13-year-old Hispanic female with history of asthma, morbid obesity, premature adrenarche, and prediabetes started presenting polydipsia and polyuria 2 months before admission. One day before admission, she presented drowsiness, abdominal pain, and polyuria. Initial labs at the ED included glucose (792 mg/dL), bicarbonate (10.4 mmol/L), anion gap (28 mmol/L), venous CO2 (10.4 mmol/L; N=21-31), BHB (>22.5 mmol/L), sodium (153 mmol/L), BUN (29 mg/dL), and creatinine (1.37 mg/dL), consistent with DKA, hyperosmolarity, and AKI. Physical exam showed severe obesity, acanthosis nigricans, and hypertension. IV fluids and insulin drip at 0.075 U/kg/h were started. DKA and AKI resolved after 4 days. Labs showed negative T1D antibodies, normal C-peptide (1.2 ng/mL), HgA1C (>14%), microalbuminuria (16.22 mg/dL; N<2 mg/dL), elevated total cholesterol (230 mg/dL) and triglycerides (550 mg/dL). Both youth were negative for SARS-CoV2 and had been engaging in unhealthy lifestyle choices, such as sedentarism and excessive sugary drink intake, exacerbated by COVID-19-related lockdowns and school closures. There were delays in seeking medical care associated to fear of COVID-19. Conclusion: In the current context of a pandemic, it would be helpful to plan close evaluation and timely therapeutic interventions for youth with well-known high-metabolic risks to prevent hospitalizations, severe presentations of T2D and associated morbidity and/or mortality.

Deep Venous Thrombosis in a Patient With Cushing’s Syndrome

Abstract Introduction: Cushing’s syndrome (CS) is associated with a prothrombotic state due to increased activation of several clotting factors. As such, patients are more susceptible to development of post-operative venous thrombosis. We present the case of a patient who underwent pituitary surgery for CS and subsequently developed acute lower extremity deep venous thrombosis (DVT) after stopping anticoagulation upon discharge. Case Report: A 57-year-old female presented with abdominal pain 1 month after gastric bypass surgery. She was found to have intra-abdominal abscesses and started on IV antibiotics. Upon further questioning, she endorsed 2-week history of coarse hair over chin, difficulty climbing stairs, and easy bruising. She had type 2 diabetes and hypertension, both diagnosed 2 years prior. Blood pressure was 169/88 on admission. On exam she had coarse hair on chin, central obesity, scattered ecchymoses, proximal muscle weakness, and no abdominal striae. Labs revealed potassium level of 1.9 mmol/L despite supplementation with 60 meq/day of potassium chloride. Workup showed random cortisol 45 mcg/dl, ACTH 114 pg/ml, elevated urinary free cortisol to 898.6 ug/24 hours, unsuppressed cortisol to 30.6 mcg/dL with low-dose dexamethasone and partial cortisol suppression to 11 mcg/dl with high-dose dexamethasone. MRI brain showed pituitary adenoma measuring 6 x 9 x 2 mm. CRH stimulation test showed rise of ACTH to 302 pg/ml and cortisol to 81.5 mcg/dl consistent with ACTH-dependent hypercortisolism from pituitary tumor. While hospitalized, the patient received thromboprophylaxis with SQ enoxaparin 40 mg daily. Patient was started on ketoconazole and subsequently underwent transsphenoidal resection to remove the pituitary tumor, which effectively reduced her serum cortisol levels. She was started on hydrocortisone replacement. She was discharged to a skilled nursing facility 2 weeks later. However, she did not receive thromboprophylaxis at the facility and was diagnosed with acute lower extremity DVT soon after hospital discharge. Discussion: CS is associated with increased risk of thromboembolic events. Although our patient received DVT prophylaxis in the hospital until discharge 2 weeks after surgery, she developed DVT soon after discharge. This emphasizes the increased susceptibility to development of venous thrombosis even after normalization of cortisol levels following pituitary surgery. A recent retrospective study showed that patients with CS are at higher risk of thromboembolism for approximately 30 to 60 days during the postoperative period. This case highlights that the clotting risk remains elevated in patients with CS for an extended period after successful surgery. In conclusion, patients with CS are at high risk of thromboembolism even after surgery and extended thromboprophylaxis should be considered.

Ovarian Hyperthecosis: Hyperandrogenism in a Post-Menopausal Woman

Introduction: Ovarian Hyperthecosis (OH) is a disorder characterized by severe hyperandrogenism and insulin resistance. It is a rare cause of hyperandrogenism primarily among postmenopausal women. We present a case report about a patient with adrenal incidentalomas and later found to have ovarian hyperthecosis during her evaluation. Case Description: 62-year-old post-menopausal female was referred to the Endocrinology clinic for evaluation of adrenal incidentalomas which were discovered on imaging work-up for hematuria. MRI Abdomen and Pelvis revealed a 17mm right and 14mm left sided adrenal nodules, with signal dropout suggesting benign adenomas. Patient stated she had menopause at age 39 years old, one child, and multiple miscarriages during her reproductive years. Examination revealed BMI of 31.1 kg/m2, moderate hirsutism, and skin tags near the neck. There was no evidence of hyperpigmentation or abdominal striae. Patient had phenotype suggestive of insulin resistance-without diagnosis of diabetes. Results: Laboratory workup revealed normal levels of 24-hour metanephrines, cortisol, renin, aldosterone, and DHEA-S suggesting that the adrenal adenomas were not hyperfunctioning. Further workup revealed: Total Testosterone: 220 [2 - 45 ng/dL]; Free Testosterone 23.8 [0.1 - 6.4 pg/mL]; DHEA-S 43 [12 - 133 mcg/dL]. Prolactin 6.3 [Postmenopausal 2.0-20.0 ng/mL]. A1c 5.4 [<5.7%]. Serum FSH, LH, PRL, and IGF-1 were within normal reference ranges. The patient, with adrenal adenomas, elevated testosterone, and a normal DHEA-S suggested a non-adrenal source. Patient was evaluated by OB/GYN with finding of normal postmenopausal ovaries on transvaginal ultrasonography. Based on a high suspicion for OH, patient underwent hysterectomy with bilateral salpingo-oophorectomy which confirmed pathological diagnosis of Bilateral OH. On follow-up 2 months post-op, Total/Free Testosterone had normalized 36 [2 - 45 ng/dL] and 3 [0.1 - 6.4 pg/mL] respectively). Conclusion: In women presenting with elevated testosterone (>150 ng/dL) and clinical features of hyperandrogenism, proper laboratory and imaging evaluation is imperative to determine the source of excess androgen production. Untreated, OH is associated with increased mortality from type 2 diabetes, cardiovascular disease, and endometrial carcinoma. The diagnosis of OH can be confirmed only by histologic examination of the ovaries. Often, ovarian imaging is negative, therefore, surgical intervention is recommended. Hence, clinicians should rely on the clinical assessment in making management decisions in patients with OH.

Exogenous Cushing’s Syndrome, Hypogonadism and Diabetes Secondary to Megestrol Acetate

Introduction: Megestrol acetate (MA) is a synthetic progestin that is often prescribed for anorexic patients with HIV due to its effects on weight gain and appetite stimulation. It can cause several endocrine/metabolic abnormalities. Chronic use of MA can cause exogenous Cushing’s Syndrome (ECS) and iatrogenic adrenal insufficiency (AI) due to its stronger affinity for the glucocorticoid receptor (GR). It can also cause gonadotropin suppression, diabetes and hyperprolactinemia. We present a case of a young woman with perinatal HIV/AIDS that developed ECS secondary to MA treatment in the setting of fatigue, rapid weight gain and irregular menses. Case: A 19 year old female with perinatal HIV/AIDS (CD4<200) was treated with MA (200mg/day for 5 months) for anorexia and weight loss. On exam she was pre-hypertensive (BP 138/62), obese (BMI 43.07, SDS +2.25; weight 114kg, SDS +2.34) with increased fat deposition over upper back and abdominal striae, excessive weight gain (21.5 kg in 5 months) suggestive of ECS. She had menarche at 13 years of age and had regular menses until starting MA, upon which she developed oligomenorrhea. A random serum cortisol level was <0.5ug/dl at 1pm with a low ACTH <1.5pg/ml and DHEAS of 13.4ug/dl. Her FSH was 3.4 mIU/L and LH 0.82 mIU/L, estradiol was <2pg/dl and total testosterone <2.5ng/dl consistent with secondary hypogonadism. Liver/kidney function, prolactin and lipid profile were normal. HbA1c increased from 5.3 to 6.4% in 8 months so she was started on metformin. ECS with AI, central hypogonadism and diabetes were all attributed to MA therapy. MA was discontinued gradually over two weeks. Stress dosing of glucocorticoids were advised as needed. Results: Gradual recovery of HPA axis was noted after discontinuation of MA. Two months after taper, serum ACTH level rose to 2.5pg/ml but AM cortisol level remained low at <0.5ug.dl. Her HPA axis showed partial recovery by 5 months with ACTH level of 53.2pg/ml and AM cortisol level of 5.5ug/dl. By 8 months after discontinuing MA therapy, AM cortisol was 9.3ug/dl, suggesting complete HPA axis recovery. Her HPG axis also normalized by 8 months with FSH 6.6 mIU/L and LH of 14.6 mIU/L, estradiol 32pg/dl with regular menses. Metformin was discontinued at 4 months due to hypoglycemia and HbA1C of 5.7%. Subsequently, euglycemia was achieved (HbA1C of 5.4%) within 9 months. BMI was stable (BMI 43.07, SDS +2.25; weight 114kg, SDS +2.34). Conclusion: Multiple endocrine abnormalities may occur due to MA therapy due to its affinity to bind with glucocorticoid and progesterone/androgen receptors. ECS and AI are known to occur with various forms of glucocorticoid use, but rarely can be seen with MA therapy. HPA axis, HPG axis and metabolic parameters should be evaluated and monitored carefully during MA therapy.

A Case of Acute Psychosis as Manifestation of Ectopic ACTH Producing Pancreatic Neuroendocrine Tumor

Abstract Introduction: Ectopic adrenocorticotrophic hormone (ACTH) producing Pancreatic Neuroendocrine Tumor (p-NET) are extremely rare with incidence of 1.2% and confer a poor prognosis (5-year survival &amp;lt;20%). Case Report: 31-year old female with diabetes mellitus type 2 (DM-2) and hypertension (HTN) was found to be severely hypokalemic on routine labs and was sent to the Emergency Department for potassium replacement. Vitals; BP:139/87 mmHg, HR:108 bpm, RR:18, T:37°C and saturating 98% on ambient air. Examination revealed cushingoid features; hyperpigmented face, bilateral upper extremity pigmented papules, proximal muscle weakness, acanthosis nigricans, violaceous abdominal striae, truncal obesity, ecchymoses, bilateral lower extremity edema, memory impairment and anxiety. Initial labs; BG: 289 mg/dL, HbA1c: 9.5%, K: 2 mmol/L (N 3.5-5.2), WBC: 12.5 k/μL (N 4-10.8), Cortisol &amp;gt;150 mcg/dL (N 5-23), TSH: 0.325 μIU/mL (N 0.45-4.5), and FT4: 0.69 ng/dL (N 0.82-1.77). Diagnosis of Cushing’s syndrome was made based on elevated cortisol level and confirmed with elevated 24-hour urinary free cortisol: 13,294 μg (N&amp;lt;45), midnight salivary cortisol &amp;gt;15 ug/dL (N 0.09-1.5) and 1 mg dexamethasone suppression test (Cortisol &amp;gt;150 mcg/dL, ACTH: 621 pg/ml). Additional labs showed Chromogranin A: 717 ng/mL (N 0-160). She was started on prophylactic Enoxaparin &amp; Trimethoprim/Sulfamethoxazole and treated with Spironolactone, Basal/Bolus insulin, and Ketoconazole for hypercortisolemia. Pituitary MRI was negative for pituitary adenoma. Abdominal/Pelvic CT scan demonstrated a solid 5 cm pancreatic head mass with innumerable haptic metastases consistent with metastatic p-NET which was confirmed on PET-CT Ga68 Dotatate scan. Liver biopsy was positive for a well differentiated p-NET with ki-67 &amp;lt;5% and negative ACTH staining. Hospital course was complicated by fluctuating cortisol levels with intermittent psychotic manifestations despite up-titration of Ketoconazole, addition of Octreotide as well as anti-psychotics. She later developed transaminitis on maximum dose of Ketoconazole and thus underwent laparoscopic total adrenalectomy for treatment of her hypercortisolemia. Post-operatively, she was started on Hydrocortisone &amp; Fludrocortisone and Spironolactone was discontinued. She was transitioned to monthly Lanreotide and treated with Capecitabine and Temozolomide with adequate therapeutic response and subsequent down trending of her Chromogranin A: 188 ng/mL and ACTH: 228 pg/ml levels. Currently, she is doing well with significant improvement of her DM-2, HTN, psychiatric symptoms and overall clinical status. Conclusions: Symptoms of ectopic Cushing’s syndrome may be delayed, however given the rare and aggressive nature of ACTH producing p-NET, timely diagnosis, prophylaxis and individualized treatment approach is crucial in achieving favorable prognosis.

Exogenous Cushing Syndrome Associated With Homeopathic Cream (Boswellia Serrata)

Background: Cushing syndrome (CS) includes the signs and symptoms associated with prolonged exposure to abnormally elevated plasma levels of glucocorticoids, which can be either exogenous or endogenous (cortisol). Exogenous CS has been associated with homeopathic and allopathic products with anti-inflammatory properties, has been demonstrated in many of them, that there are steroid contributions in these drugs which are not reported in their inserts and in prolonged exposure generate BMS. Clinical Case: We present the case of a 23-year-old female with a history of polycystic ovarian syndrome in management with ciproterone acetate and metformin 500 mg dia, who has gained 12 kilos of weight in two months, Progressive appearance of violaceous stretch marks on the thighs, arms and abdomen, associated with diaphoresis, hyporexia, acneiform, rash and hirsutism. The symptoms were related to the use of natural anti-inflammatory cream, for joint pains in knee and shoulders based on natural extracts of Boswellia Serratia during the last three months. It presents paraclinics with post-dexamethasone serum cortisol levels in 1. 25, ACTH 1. 5, Urinary cortisol 20. 24 ug/24h, urinary volume 0. 88 L/24H, DHA -S 27. 1Ug/dl, Free testosterone <0.24 pg/ml, TSH 2. 59 ng/dl, Free-T4: 1. 16 ng/dl, Prolactin: 31 Ng/ml (0–23), Somatomedin C: 109 Ng/ml, (92.9–342.0), HBAC1: 5. 37%, preprandial and postprandial glycemia: 90–133 mg/dl, Am Cortisol:1.11 mcg/dl (6–18 Mcg/dl), Basal Insulin: 74 uUI/ml., Postprandial Insulin: 57 uUI/ml. Clinical findings and dynamic biochemical studies of the adrenal axis, with a positive dexamethasone suppression test and no findings suggesting ectopic production; it was confirmed that the diagnosis of exogenous CS is associated with the use of topical anti-inflammatory. With the of the drug’s suspension, clinical findings have improved, and cortisol levels have decreased. Conclusion: Exogenous hypercortisolism associated with the use of topical anti-inflammatory drugs is not frequent. The first case reported an association with the use of a topical drug based on Boswellia Serrata. In conclusion, with the presence of signs and symptoms of CS the recent use of herbal products by any route of administration and by excluding other causes of endogenous hypercortisolism (central or ectopic) and exogenous, the use of homeopathic products should be suspected as an etiology. Nowadays, there are no reports of exogenous Cushing by BS. The first case is described, without omitting the possibility of unknown compounds in the topical preparation.

PEMBERIAN SALEP KUNYIT DAPAT MENGURANGI STRIAE GRAVIDARUM PADA IBU NIFAS

GIVING Turmeric Ointment MAY REDUCE STRIAE GRAVIDARUM IN THE PUPERATIVE MOTHER Background:Striaegravidarum is a sign or stretch that occurs on the skin of 50% to 90% of women during the second half of pregnancy. Nearly half of women experience stretching of the skin, especially in the abdomen, as a result of increasing gestational age.The presence of striae gravidarum causes a lack of self-confidence in the post-partum mother, so this makes the postpartum mother have to undergo medication and even surgery to restore her skin to the state before she was pregnant.The purpose: of this study was to determine the effect of turmeric ointment in reducing Striaegravidarum in postpartum mothers at the Hj. DewiSesmeraS.Tr.Keb Aluminum IV TanjungMulia Medan in 2020.Methods: This study used a Quasy Experiment Design (Quasi-Experimental Design) using a One Group Pretest-Postest Design. The population and sample in this study were all postpartum mothers with 15 people. This study used Porposive sampling technique with univariate and bivariate analysis with T Test.Results: the research obtained from data analysis with the Wilcoxon test showed that post-partum mothers could conclude pre-test and post-test giving turmeric ointment. The results in the table show that the P-Value (0.001) &lt;α 0.05 then Ho is rejected and Ha is accepted, which means that there is an effect of pre-test and post-test on the administration of turmeric ointment in reducing striaegravidarum.Conclusion: This study shows that there is an effect of turmeric ointment in reducing striaegravidarum. Suggestions for the clinic mother Hj. Dewi Sesmera so that mothers can advise postpartum mothers to make their own products with ingredients derived from traditional turmeric in reducing striaegravivarum. Keywords: Key words: Turmeric ointment, Striae gravidarum, postpartum mother

Nonsurgical Postpartum Abdominal Rejuvenation: A Review and Our Experience.

A significant population of aesthetic patients are postpartum women motivated to achieve a more youthful abdomen. Although traditionally, abdominoplasty was the treatment of choice, minimally invasive procedures have grown in popularity because of minimal downtime and the favorable side effect profile. so many women share concerns regarding their postpartum abdominal appearance, a limited number of studies focus specifically on postpartum abdominal rejuvenation. To review pertinent aspects of abdominal anatomy, associated changes with pregnancy, available nonsurgical cosmetic procedures, and to provide our experience to help guide treatment combinations which comprehensively address the concerns of the postpartum patient. A review of the literature surrounding nonsurgical treatment options for postpartum abdominal lipohypertrophy, muscle changes, tissue laxity, and striae gravidarum, along with the authors' experience in this area are provided. This review summarizes available nonsurgical modalities to address postpartum abdominal defects, including procedures that tone muscles, reduce fat, tighten skin, and improve the appearance of striae. Both the published literature and the authors' experience favor a combination of treatments to address the various lamellae affected by pregnancy. Further clinical trials focusing on the postpartum patient would further help create a standardized approach for postpartum abdominal rejuvenation.

Prediction of intraperitoneal adhesions using striae gravidarum and scar characteristics in women undergoing repeated cesarean sections

BackgroundThe current fact of increasing rates of cesarean deliveries is a catastrophe. Recurrent cesareans result in intraperitoneal adhesions that would lead to maternal morbidity during delivery. Great efforts are directed towards the prediction of intraperitoneal adhesions to provide the best care for laboring women. The aim of the current study was to evaluate the role of abdominal striae and cesarean scar characters in the prediction of intraperitoneal adhesions.MethodsThis was a case- control study conducted in the emergency ward of the obstetrics and gynecology department of a tertiary hospital from June to December 2019. The study was carried on patients admitted to the ward fulfilling particular inclusion and exclusion criteria. The study included two groups, group one was assessed for the presence of striae, and the degree of intraperitoneal adhesions was evaluated during the current cesarean section. Group two included patients without evidence of abdominal striae. They were evaluated for the severity of adhesions also after evaluation of the previous scar. Evaluation of the striae was done using Davey’s scoring system. The scar was assessed using the Vancouver Scar Scale. The modified Nair’s scoring system was used to evaluate intraperitoneal adhesions.ResultsThe study group included 203 women, while the control group included 205 women. There were significant differences in the demographic characters of the recruited patients (p-value 0.001 for almost all variables). The mean Davey score in those with mild, moderate, and severe striae was 1.82 ± 0.39, 3.57 ± 0.5, and 6.73 ± 0.94, respectively (p-value < 0.001). Higher scores for the parameters of the Vancouver scale were present in patients with severe striae (1.69 ± 1.01, 1.73 ± 0.57, 2.67 ± 1.23, and 1.35 ± 1.06 for scar vascularity, pigmentation, pliability, and height respectively with a p-value of < 0.001 each). Thick intraperitoneal adhesions were noted significantly in women with severe striae [21 (43.75%), p-value < 0.001)]. The Davey’s and Vancouver scores showed highly significant predictive performance in the prediction of intraperitoneal adhesions (p-value < 0.001).ConclusionAbdominal striae and cesarean scar were significant predictors for intraperitoneal adhesions.

Efficacy of platelet‐poor plasma gel in combination with fractional CO2 laser in striae distensae: A clinical, histological, and immunohistochemical study

AbstractBackgroundPlatelet‐poor plasma gel is a semi‐solid plasma formulation that recently recommended as autologous bio‐filler for treatment of atrophic dermal scars.AimTo compare the therapeutic efficacy and safety of intradermal injection of plasma gel in combination with fractional CO2 laser versus fractional CO2 laser alone in striae distensae (SD).Patients and methodsThis study included 36 SD patients treated by three sessions (one session/1.5 months) of fractional CO2 laser on all SD lesions following intradermal injection of plasma gel on one side and saline (as placebo) on the other side.ResultsSignificant clinical improvements associated with remarkable narrowing of SD lesions and prominent enhancement of skin texture were observed on both treatment sides. Obviously, higher degrees of clinical improvements of SD lesions were reported following combined therapy with fractional CO2 laser and plasma gel rather than fractional CO2 laser monotherapy. However, post‐inflammatory hyperpigmentation (PIH) was reported more frequently with fractional CO2 laser monotherapy. Histopathological and immunohistochemical examinations revealed significant epidermal improvement, and homogenization, and orientation of dermal collagen bundles as a result of both therapeutic procedures.ConclusionPlasma gel in combination with fractional CO2 laser could be considered a promising novel treatment modality for SD. Plasma gel not only improves the efficacy of fractional CO2 laser but also decreases the frequency of PIH.

Topical oil formulation of plant extracts and vitamins as effective treatment for stretch marks and xerosis—An observational longitudinal study

BackgroundStretch marks are linear scars that result from elastic fiber destruction. They usually occur as the consequence of rapid change in the body mass (weight gain and loss, pregnancy, weightlifting), long‐term steroid use, or endocrinopathies. Treatment is challenging and mainly based on topical and procedural therapies, although the standard of care is still under debate.PurposeTo evaluate the efficacy and tolerance of a topical oil formulation of plant extracts and vitamins on the aesthetic improvement of stretch marks and xerosis.Materials and methodsFifty male and female patients, aged between 14 and 45 years, with stretch marks referring at the University Hospital Federico II, Naples, were enrolled between March and November 2019. Topical application of plant extracts and vitamin‐rich oil was performed twice daily on affected skin for 4 months. Patients were monitored at baseline (T0), and at two‐month (T1) and 4‐month (T2) follow‐ups, through clinical and dermoscopic assessment, confocal microscopy, cutaneous ultrasound, MoistureMeterEpiD, and X‐Rite spectrocolorimeter. Primary endpoints were as follows: 70% clinical improvement of stretch marks and 3‐point decrease in clinical score from baseline to T2. Secondary endpoints were as follows: change in the T0 parallel pattern of collagen fibers at confocal microscopy, cutaneous thickness increase at ultrasounds, cutaneous hydration increase at MoistureMeterEpiD, erythema reduction at X‐Rite spectrocolorimeter, and safety and adverse events (AEs).ResultsAt 4‐month follow‐up, stretch marks improved objectively and subjectively in all patients (p < 0.001). In detail, there was a 29% and 71% improvement in clinical appearance of stretch marks at T1 and T2, respectively, as documented dermoscopically and by the 3‐point reduction in the assessor's mean clinical score at each follow‐up visits [from 8.1±0.7 at baseline to 5.7±1.0 at T1 and 2.3 ±0.5 at T2 (p < 0.001)]. Erythema decreased by 15% and 30% and in parallel hydration increased by 25% and 71%, at T1 and T2, respectively (p < 0.001). At T2 confocal microscopy of stretch marks, dermal collagenous fibers assumed casual disposition with reticular pattern and refractivity, as signs of collagen remodeling and neocollagenesis, and also the T2 cutaneous ultrasound revealed increased epidermal thickness and decreased dermal hypoechogenicity as for a higher skin hydration.ConclusionOur study showed that a topical oil formulation rich in plant extracts and vitamins appears to be effective and safe in treating stretch marks and xerosis.

The selected stretch marks therapies used in beauty salons

Skin stretch marks are changes common to both women and men of all ages. Eliminating them is difficult and often does not bring the expected results. The aim of the study was to review methods that reduce visibility and eliminate stretch marks. Most treatments give visible results in the case of stretch marks in the inflammatory phase. In order to eliminate white stretch marks, combined therapies must be used in the atrophy phase. It is recommended to use exfoliating preparations, laser therapy, radiofrequency and more and more popular micro-needle methods, which, when used in accordance with the recommendations, give great hope for the effectiveness of the therapy. Individually selected cosmetology therapy can not only improve the appearance of the skin with stretch marks, but also restore self-confidence.

The use of microneedling in cosmetology

Mesotherapy is one of the minimally invasive methods that guarantee relatively quick and long-lasting effects. Its purpose can be considered on many levels, because the research conducted in this area points to more and more new applications for mesotherapy. This article presents skin areas that can be subjected to mesotherapy and examples of substances used to achieve a specific result. Currently, the most common reasons for people to take advantage of the procedure include: the progressive aging process, wrinkles, skin discoloration, acne scars, bruises under the eyes, flabbiness, dryness and loss of skin elasticity, lipodystrophy, stretch marks or excessive hair loss. For the effects of the treatment to be satisfactory and long-lasting, it is suggested to perform mesotherapy in series to maintain optimal skin condition.