Skin metastases are rare in the routine clinical practice of dermatology, but are of major clinical significance because they usually indicate advanced disease. We reviewed the literature on skin metastasis regarding recent trends in clinical presentation and diagnosis of the most common cutaneous lesions. An extensive literature review was conducted using PubMed from May 26, 2011 to July 16, 2013 relating cutaneous metastases. Articles chosen for reference were queried with the following prompts: "Cutaneous metastases", "clinical presentation", "histological features", and "immunohistochemistry". Further searches included "treatment" and "management" options for "metastatic breast", "metastatic colorectal", "metastatic melanoma", "metastatic lung", and "hematologic cancers." We also reviewed the literature on the current management of melanoma as a model for all cutaneous metastatic disease. Our own clinical findings are presented and compared to the literature. Additionally, we highlight the most useful immunohistochemical studies that aid in diagnoses. Several novel therapies and combination therapies such as electrochemotherapy, vemurafenib, and imiquimod will be discussed for palliative treatment of cancers that have been found to improve cutaneous lesions. We review these notable findings and developments regarding skin metastases for the general dermatologist.

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Background: Candida species are one of the most common causes of blood stream infections among neonates and account for 9-13% of such infections. Although Candida albicans remains the most common fungal isolate from neonatal candidemia, longitudinal studies have detected a shift towards non-albicans Candida (NAC) species. Aim: To examine the prevalence and epidemiology of candidemia among infants admitted to our hospital. Materials and Methods: Blood samples were collected from 548 neonates and only those which yielded pure growth of Candida spp. were included in the study. The isolates were identified as per standard mycological techniques and antifungal susceptibility (AFS) was done by disc diffusion method. Results: Of the total 132 neonates included in the study, NAC species were responsible for 80.30% cases with C. parapsilosis (25.0%) and C. tropicalis (21.97%) as the most predominant species; whereas 19.70% of cases were caused by C. albicans. AFS results revealed that 65.91, 73.49, and 96.21% isolates were sensitive to fluconazole (FLK), itraconazole (ITR), and amphotericin B (AMB), respectively. Conclusion: Candidemia in neonates is an ominous prognostic sign and is an important entity in our hospital. Strict infection control strategies, appropriate preventive and therapeutic measures such as prophylactic antifungal use and a restrictive policy of antibiotic use should be implemented.

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Background: Hemodialysis patients usually experience high levels of psychological stress, anxiety, and depression. Reducing these matters in patients provides more psychological resources to cope with their physical situation. Aim: The present study aimed to explore the efficacy of Benson's relaxation technique for stress, anxiety, and depression of patients with hemodialysis. Materials and Methods: Eighty hemodialysis patients were selected from two hospitals as an intervention and control groups. Then Benson relaxation training was implemented in the intervention group for 15 min twice a day during 4 weeks. The patients were assessed by depression, anxiety, and stress scale; which was completed before and after the intervention. Results: There were significant differences between stress and anxiety levels in case group before and after intervention (P < 0.001) and there is no meaningful difference between the mean of depression value in case group before and after intervention (P < 0.22). Conclusion: Instructing Benson's relaxation technique is accompanied by reducing stress and anxiety level of hemodialysis patients. Reducing stress and anxiety levels can provide more calmness for the patients so that pursuing medical therapy would be accompanied with more tranquility. Authors have suggested to improve and prevent the patients' psychological problems as well as other chronic disorders by applying this practice.

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Dendritic cells are arguably the most potent antigen-presenting cells and may be the only cells capable of initiating the adaptive immune response. The epithelial residents of dendritic cells are Langerhans cells, which serve as the "sentinels" of the mucosa, altering the immune system not only to pathogen entry but also of tolerance to self antigen and commensal microbes. Oral mucosal Langerhans cells are capable of engaging and internalizing a wide variety of pathogens and have been found responsive to nickel in patients with nickel allergies, oral Candida species, oral lichen planus, lichenoid drug eruptions, graft versus host diseases, periodontal diseases median rhomboid glossitis, human immunodeficiency virus infection, hairy leukoplakia of the tongue, and oral squamous cell carcinoma. Review focuses on the role of antigen-presenting cells in particular Langerhans cells to better understand the mechanisms underlying immune responses. In this review, comprehensive detail about mucosal diseases has been compiled using the PubMed database and through textbooks.

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Background: Haptoglobin is an acute phase protein with antioxidant and immunomodulatory properties. Gene polymorphism may be a risk factor for diabetic vascular disease in Iranian population. Aims: The study investigates the existence or not of an association between haptoglobin genotypes and prevalence of diabetic microangiopathy in individuals with type 2 diabetic microangiopathy. Materials and Methods: We included 206 type 2 diabetic patients (>5 years duration) categorized into two groups according to the presence or absence of diabetic microvascular complications. The cases of interest were diabetic neuropathy, retinopathy, and nephropathy identified during clinical and or laboratory examination. In addition, 114 age- and sex-matched individuals were selected to serve as a control group. Haptoglobin genotyping was done using an amplification gel electrophoresis. Results: The frequency of haptoglobin phenotype 2-1 in diabetic patients was 70/206 (33.9%) as compared with 54/114 (47.3%) in nondiabetics (P = 0.01). However, the frequency of haptoglobin phenotype 2-2 was greater in diabetics (126/114, 61.1%) than in those without diabetes (56/114, 49.1%; P = 0.02). Patients with diabetic microangiopathy; however, did not differ significantly between haptoglobin phenotype groups. Conclusions: Haptoglobin phenotype 2-2 is considered to be a major susceptibility gene for type 2 diabetic patients. Moreover, haptoglobin phenotype 2-1may be good prognostic factors for the development of diabetes mellitus.

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Background: In diabetic patients, persistent hyperglycemia and poor glycemic control cause disturbances of lipid profiles, especially an increased production of oxygen free radicals. Lipid peroxidation has been considered to be a pathogenic factor of diabetic complications in Type-1 Diabetes mellitus. Aims: The aim of the present study was to investigate the effect of glycemic control on blood viscosity, lipid profile, and lipid peroxidation in Type-1 Diabetic subjects. Materials and Methods: The study included three groups; Group-I (age-matched healthy control subjects, n = 50), Group-II (Type-1 Diabetics with good glycemic control, n = 10), and Group-III (Type-1 Diabetics with poor glycemic control, n = 15). The Type 1 diabetic patients with duration of diabetes for more than 5 years were taken. Blood samples of all subjects were analyzed for all biochemical, hematological, and oxidative stress parameters. Results: The Erythrocyte malondialdehyde level was non-significantly changed (P = NS) in group-II patients but significantly increased (P > 0.001) in group-III patients, and no significant changes were found (P = NS) in Blood viscosity of both the groups (group-II and group-III), as compared to healthy control subjects (group-I). Conclusions: Our findings suggest that the monitoring of Oxidative stress and Blood Viscosity in poorly controlled Type-1 diabetic patients may be very useful marker of diabetic complications.

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Background: Fibromyalgia (FM) is a complex chronic pain condition that is difficult to treat. The prevailing approach is an integration of pharmacological, psycho-educational, and behavioral strategies. Information technology offers great potential for FM sufferers to systemically monitor symptoms as well as potential impacts of various management strategies. Aims: This study aimed to evaluate effects of a web-based, self-monitoring and symptom management system (SMARTLog) that analyzes personal self-monitoring data and delivers data-based feedback over time. Materials and Methods: Subjects were self-referred, anonymous, and recruited via publicity on FM advocacy websites. Standardized instruments assessed health status, self-efficacy, and locus of control at baseline and monthly during participation. Subjects were encouraged to complete the SMARTLog several times weekly. Within-subject, univariate, and multivariate analyses were used to derive classification trees for each user associating specific behavior variables with symptom levels over time. Results: Moderate use (3 times weekly x 3 months) increased likelihood of clinically significant improvements in pain, memory, gastrointestinal problems, depression, fatigue, and concentration; heavy use (4.5 times weekly x five months) produced the above plus improvement in stiffness and sleep difficulties. Conclusions: Individualized, web-based behavioral self-monitoring with personally-tailored feedback can enable FM sufferers to significantly reduce symptom levels over time.

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Background: Cardiovascular morbidities have been reported in hypothyroidism. Aims: The objective of this study is to investigate the link of sympathovagal imbalance (SVI) to cardiovascular risks (CVRs) and the plausible mechanisms of CVR in hypothyroidism. Materials and Methods: Age-matched 104 females (50 controls, 54 hypothyroids) were recruited and their body mass index (BMI), cardiovascular parameters, autonomic function tests by spectral analysis of heart rate variability (HRV), heart rate response to standing, deep breathing and blood pressure response to isometric handgrip were studied. Thyroid profile, lipid profile, immunological and inflammatory markers were estimated and their association with low-frequency to the high-frequency ratio (LF-HF) of HRV, the marker of SVI was assessed by multivariate regression. Results: Increased diastolic pressure, decreased HRV, increased LF-HF, dyslipidemia and increased high-sensitive C-reactive protein (hsCRP) were observed in hypothyroid patients and all these parameters had significant correlation with LF-HF. BMI had no significant association with LF-HF. Atherogenic index (β 1.144, P = 0.001) and hsCRP (b 0.578, P = 0.009) had independent contribution to LF-HF. LF-HF could significantly predict hypertension status (odds ratio 2.05, confidence interval 1.110-5.352, P = 0.008) in hypothyroid subjects. Conclusions: SVI due to sympathetic activation and vagal withdrawal occurs in hypothyroidism. Dyslipidemia and low-grade inflammation, but not obesity contribute to SVI and SVI contributes to cardiovascular risks.

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Background: Sentinel surveillance reported high human immunodeficiency virus positivity rates among men who have sex with men. The current study has described the high-risk behavior and self-reported sexually transmitted infection(s) among self-identified men who have sex with men. Aims: The present study was to find out the extent of high-risk behavior and prevalence of self-reported sexually transmitted diseases among self-identified men who have sex with men, registered with selected nongovernmental organizations in Delhi. Materials and Methods: A facility-based cross-sectional study was done among 250 men who have sex with men during March 2009 to February 2010, through consecutive sampling strategy. Results: Majority (80%) were anal-receptive, received money for sex (61%) and were involved in all types of sexual intercourse with men (oral-86%, manual-97%, and anal-94%). Consistent condom use with male partner was low (46%), most common reason (52%) for not using condom was, that either the condoms were not available or the partner objected. Self-reported sexually transmitted infection(s) was 41% in the past 12 months. Conclusions: This study underscores the increased vulnerability of men who have sex with men of Delhi and need for sustained interventions.

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Background: An alternative to intravenous is nasogastric fluid administration through normal functioning gut. Though not common, this practice has significance in mass causalities and elective situations. Aim: The study was designed to compare nasogastric and intravenous fluid resuscitation in malignant obstructive jaundice (OJ) and their effect on endotoxemia. Materials and Methods: Sixty patients with malignant OJ undergoing endoscopic biliary drainage were randomized into two groups. A total of 4 l of fluid (Ringer's lactate) was administered to Group A through nasogastric tube and to Group B through intravenous route for 48 h. Vital parameters, serum bilirubin, serum creatinine, creatinine clearance rate, electrolytes, and endotoxemia were monitored. Results: Significant improvement in blood pressure (Group A, P = 0.014; Group B, P = 0.020) and significant decrease in serum bilirubin level (Group A, P = 0.001; Group B, P < 0.0001) was observed in both groups after resuscitation. Significantly decreased (P = 0.036) post hydration endotoxin level was observed in Group A as compared to Group B. Febrile events were significantly higher (P = 0.023) in Group B as compared to Group A (6 vs 0). Electrolyte abnormalities were found more in Group B, however statistically insignificant. Conclusion: In OJ patient undergoing biliary drainage, preoperative fluid resuscitation through nasogastric tube may be helpful in reducing postoperative septic complications and endotoxemia.

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