Dermatitis artefacta and artefactual skin disease: the need for a psychodermatology multidisciplinary team to treat a difficult condition.

BACKGROUND: Dermatitis artefacta (DA) is a factitious skin disorder caused by the deliberate production of skin lesions by patients with a history of underlying psychological problems. The patient may not be fully aware of this, and the true extent of this disorder, especially in children, is currently unknown. Management of these patients is challenging as many fail to engage effectively with their dermatologist. OBJECTIVES: To explore the various clinical presentations and strategies employed to treat DA in our local population, and note outcomes in order to evaluate effectiveness of our management. METHODS: A retrospective case note review was conducted of 28 patients attending the regional psychodermatology clinic at the Royal London Hospital from January 2003 to December 2011. RESULTS: Out of 28 patients identified with DA, the majority of patients were female, and the most frequent sites for skin lesions were the face and upper body. Anxiety, depression and personality disorders were common underlying psychiatric diagnoses. Ninety-three per cent of patients were successfully managed (i.e. the DA resolved or was in remission at the time of writing) in our combined psychodermatology clinic by a multidisciplinary psychocutaneous medicine team. Thirty-two per cent of our cases were children (aged < 16 years) and one of these was referred to local child protection services; 46% of patients had a concomitant mental health disease at the time of presentation with DA. CONCLUSIONS: A multidisciplinary psychocutaneous team is important in this condition particularly as the patient is likely to require psychological intervention (to facilitate the resolution of the precipitant), in addition to dermatological (to make the diagnosis and, importantly, to exclude organic disease) and psychiatric (to manage concomitant psychiatric disease) input. Our findings indicate that our model of a psychodermatology multidisciplinary team will achieve greater successful treatment of patients with DA and we are the first to describe this important service in the U.K.

Arteriovenous fistula of the lateral superior and inferior geniculate arteries. A unique cause of a "recurrent prepatellar bursa.

We report a previously undocumented case of an arteriovenous fistula of the superior and inferior lateral geniculate arteries presenting with what was thought to be a recurrent prepatellar bursa requiring repeated drainage and excision. The diagnosis was made by arteriography. Surgical exploration and ligation of the feeding and draining vessels, via a posterior approach, alleviated the symptoms. Vascular injury should be suspected in patients presenting with recurrent postoperative hematomas or hemarthroses following surgery on the knee.

Detection of embryonic stem cell markers in adult human adipose tissue-derived stem cells.

BACKGROUND: Bone marrow transplantation is already an established therapy, which is now widely used in medicine to treat leukemia, lymphoma, and several inherited blood disorders. The culture of multilineage cells from easily available adipose tissue is another source of multipotent mesenchymal stem cells, and is referred to as adipose tissue-derived stem cells (ADSCs). While ADSCs are being used to treat various conditions, some lacuna exists regarding the specific proteins in these. It was therefore decided to analyze the specific proteins of embryonic cells in ADSCs. AIMS: To analyze the specific protein of embryonic stem cells (ESCs) in ADSCs. MATERIALS AND METHODS: Adult human adipose tissue-derived stem cells (ADSCs) were harvested from 13 patients after obtaining patients' consent. The specific markers of ESCs included surface proteins CD10, CD13, CD44, CD59, CD105, and CD166, and further nucleostemin, (NS) NANOG, peroxisome proliferator-activated receptor-gγ, collagen type 1 (Coll1), alkaline phosphate, (ALP) osteocalcin (OC), and core binding factor 1 (Cbfa1) were analyzed using by reverse transcription-polymerase chain reaction, (RT-PCR) immunofluorescence (IF), and western blot. RESULTS: All the proteins were expressed distinctly, except CD13 and OC. CD13 was found individually with different expressions, and OC expression was discernable. CONCLUSIONS: Although the ESC with its proven self-renewal capacity and pluripotency seems appropriate for clinical use, the recent work on ADSCs suggests that these adult stem cells would be a valuable source for future biotechnology, especially since there is a relative ease of procurement.

Surface proteins and osteoblast markers: characterization of human adipose tissue-derived osteogenic cells.

INTRODUCTION: In adipose tissue-derived osteogenic cells (ADOC), osteoblast markers and surface proteins were determined and compared with osteoblasts harvested from cancellous bone (OB). METHOD: Osteocalcin (OC), core binding factor 1 (CBFA1), collagen type 1 (Coll1), alkaline phosphatase (ALP), nucleostemin (NS), and surface proteins CD 10, CD44, CD 59 and CD 105 were analyzed using RT-PCR, immunofluorescence and Western blot. RESULTS: Osteocalcin expression was more distinct in OB than in ADOC, but the other markers and surface proteins showed no differences. CONCLUSION: These data support the use of adipose tissue for future regenerative medicine; however, further studies are necessary to establish the role of long-term differentiation.

Optimizing for head height, head offset, and canal fit in a set of uncemented stemmed femoral components.

When inserting an uncemented hip stem, the objectives are to obtain a close fit of the stem in the canal and anatomic head placement. Our goals were to formulate a set of stems which would satisfy these two objectives, and to test the resulting templates on sequential radiographs of hip replacement patients. Using 98 cases for which a custom primary hip had been designed, thirteen dimensional parameters for a hip stem were defined, most importantly proximal medial width (PMW), proximal lateral width (PLW), head offset (HOF), head height (HHT), mid-stem diameter (BD), and distal diameter (DD). These parameters were analyzed in 155 patients' radiographs, and the resulting data were evaluated to obtain the optimal combinations of parameters. A 14-size stem system was defined and evaluated on the AP radiographs of 103 successive hip replacement patients. For each stem diameter between 11 and 17 mm, two pairs of PMW and PLW values, equivalent to 'varus' and 'valgus' shapes, provided the best fit for the population of radiographs. The template analysis showed that out of 103 cases, 93% of offsets were within 4mm of ideal, while 81% of heights were within 1mm of ideal, and 99% were within 4mm of the ideal. Canal fit was within 1.5mm in the proximal-medial Gruen Zone 7 in 58% of the cases. The dimensional parameters of the 14 size system enabled the close matching of the important dimensional parameters simultaneously. The error that did occur could largely be corrected by modular heads and by minor canal broaching. By providing two stem shape variations for each stem diameter, our system achieved an accurate head center position while simultaneously obtaining a sufficiently close fit in the canal.

Pseudoxanthoma Elasticum.

Three cases of pseudoxanthoma elasticum are described. One case has features of Gronblad Strandberg syndrome with lepromatous leprosy. The other two cases are reported in siblings. A short review of literature is given.