The psychological impact of Stevens-Johnson syndrome and toxic epidermal necrolysis on patients' lives: a Critically Appraised Topic.

CLINICAL SCENARIO: A 65-year-old man presented with a 12-h history of deteriorating rash. Two weeks previously he had completed a course of neoadjuvant chemotherapy for ductal carcinoma of the breast. On examination there were bullae, widespread atypical targetoid lesions and 15% epidermal detachment. There was no mucosal involvement on presentation, but subsequently it did evolve. Skin biopsy showed subepidermal blistering with epidermal necrosis. This confirmed our clinical diagnosis of overlap Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). On transfer to intensive care he was anxious and fearful. MANAGEMENT QUESTION: What are the psychological impacts of SJS/TEN on this man's life? BACKGROUND: SJS and TEN have devastating outcomes for those affected. OBJECTIVES: To conduct a Critically Appraised Topic to (i) analyse existing research related to the psychological impact of SJS and TEN and (ii) apply the results to the clinical scenario. METHODS: Seven electronic databases were searched for publications focusing on the psychological impact of SJS/TEN on adults over 18 years of age. RESULTS: Six studies met the inclusion criteria. Healthcare practitioners' (HCPs') lack of information around the disorder was highlighted. Patients experienced undue stress and fear. Some patients had symptoms aligned to post-traumatic stress disorder (PTSD), anxiety and depression. DISCUSSION AND RECOMMENDATION: The evidence suggests that SJS and TEN impact psychologically on patients' lives. Education of HCPs, to address their lack of awareness and information on SJS/TEN, should facilitate their capacity to provide information and support to patients, thereby reducing patient anxiety. On discharge, a follow-up appointment with relevant HCPs to reduce the possibility of PTSD occurring should be considered.

Planning, guidance, and quality assurance of pelvic screw placement using deformable image registration.

Percutaneous pelvic screw placement is challenging due to narrow bone corridors surrounded by vulnerable structures and difficult visual interpretation of complex anatomical shapes in 2D x-ray projection images. To address these challenges, a system for planning, guidance, and quality assurance (QA) is presented, providing functionality analogous to surgical navigation, but based on robust 3D-2D image registration techniques using fluoroscopy images already acquired in routine workflow. Two novel aspects of the system are investigated: automatic planning of pelvic screw trajectories and the ability to account for deformation of surgical devices (K-wire deflection). Atlas-based registration is used to calculate a patient-specific plan of screw trajectories in preoperative CT. 3D-2D registration aligns the patient to CT within the projective geometry of intraoperative fluoroscopy. Deformable known-component registration (dKC-Reg) localizes the surgical device, and the combination of plan and device location is used to provide guidance and QA. A leave-one-out analysis evaluated the accuracy of automatic planning, and a cadaver experiment compared the accuracy of dKC-Reg to rigid approaches (e.g. optical tracking). Surgical plans conformed within the bone cortex by 3-4 mm for the narrowest corridor (superior pubic ramus) and >5 mm for the widest corridor (tear drop). The dKC-Reg algorithm localized the K-wire tip within 1.1 mm and 1.4° and was consistently more accurate than rigid-body tracking (errors up to 9 mm). The system was shown to automatically compute reliable screw trajectories and accurately localize deformed surgical devices (K-wires). Such capability could improve guidance and QA in orthopaedic surgery, where workflow is impeded by manual planning, conventional tool trackers add complexity and cost, rigid tool assumptions are often inaccurate, and qualitative interpretation of complex anatomy from 2D projections is prone to trial-and-error with extended fluoroscopy time.

Melanoma diagnosis and management after the introduction of a pigmented lesion clinic in the Mid-West of Ireland.

BACKGROUND: A pigmented lesion clinic (PLC) was introduced and Consultant Dermatology posts were increased in the Mid-West of Ireland with the aim of improving early detection of melanoma. METHODS: We analysed retrospectively the invasive melanomas excised in the Mid-West of Ireland over a 2-year period prior to (2010-2011) and after (2013-2014) the advent of the PLC. RESULTS: The number of melanomas excised almost doubled from 54 (2010-2011) to 107 (2013-2014). There was a significant rise in the rate of excision biopsies performed by Dermatologists compared to non-dermatology clinicians from 19 to 56% (p < 0.0001). There was a significant difference in the diagnostic accuracy of excised melanomas by Dermatologists compared to non-dermatology clinicians during both time periods (2010-2011: p = 0.001; 2013-2014: p < 0.0001). There was a non-significant decrease in the median Breslow thickness of melanomas from 1.3 mm (0.6-2.6) (2010-2011) to 1.0 mm (0.5-2.3) (2013-2014) (n = 145, p = 0.48). CONCLUSION: The PLC has led to an increase in the number of melanomas excised by Dermatologists in the Mid-West of Ireland which has led to higher diagnostic accuracy.

An analysis of inpatient dermatologic consultations at University Hospital Limerick: inadequate infrastructure leads to acute skin failure.

BACKGROUND: Approximately 15-20 % of the general population have skin diseases and it is therefore clear that inpatients can also present with various skin conditions that require dermatology input and in some cases the primary reason for admission to hospital. Inpatient hospital care is more expensive than outpatient care. Recent trends are moving towards outpatient care, as there is huge pressure on hospital bed availability. AIMS: The main aim of this study was to analyse patients referred with dermatological complaints and how soon after admission, were patients assessed by the dermatology team. Most dermatologic work is outpatient based and inpatient workload can be underestimated. METHODS: We retrospectively reviewed our inpatient consultations with a total of 220 consultations (males 113, females 107) between August 2014 and April 2015, to document this significant area of work over an eight-month period. RESULTS: The services requesting consultations were mostly general medicine 45.9 % (101/220), surgery 25.4 % (56/220) and paediatrics 24 % (53/220). Dermatologist's diagnosis was different from the referral team diagnosis in 60 % (132/220) of consults, with prompt inpatient assessment by the dermatologist within 24 h of admission. Most common dermatoses diagnosed included eczema 21.8 % (48/220) and psoriasis 7.3 % (16/220). CONCLUSION: Timely diagnosis and inpatient care has important implications on appropriate treatment, duration of hospital stay and patient outcome.

Pyoderma gangrenosum associated with subcorneal pustular dermatosis and IgA myeloma.

We report a 57-year-old woman with a 12-year history of ulcerative pyoderma gangrenosum (PG). Five years after the onset of PG, she developed subcorneal pustular dermatosis (SPD) and biclonal IgA and IgG gammopathy. She developed PG at two bone-marrow biopsy sites, showing pathergy. Finally, she developed multiple myeloma. Although PG and SPD may occur without associated underlying malignancy, these patients should be followed up for any prospective malignancy because of the association between these disorders.

Primary cutaneous B-cell lymphoma: an association of chronic hepatitis C infection.

Primary cutaneous B-cell lymphoma is a low-grade malignancy, distinct from other lymphomas in terms of biological activity and response to treatment. We describe a 77-year-old woman with a five-year history of chronic hepatitis C infection who developed a lower-limb lesion over a period of 3 months which was diagnosed as a high-grade cutaneous B-cell lymphoma. Despite a lack of definitive evidence implicating hepatitis C virus (HCV) in the aetiology of lymphomas, there is considerable research which establishes a strong association between these two diseases. On the basis of published research and the demonstration of HCV RNA in the lymphomatous tissue, we consider this to be a rare case of primary cutaneous lymphoma in association with hepatitis C.

Woody hands in a patient with pancreatic carcinoma: a variant of cancer-associated fasciitis--panniculitis syndrome.

We report an elderly woman with rapidly progressive painless, woody induration of the hands. Mild diabetes mellitus was demonstrated. Skin biopsy features included broad fibrous bands extending deeply into subcutaneous fat, a mild mononuclear cell infiltrate, and post-thrombotic recanalization of a deep vessel in one specimen. The patient developed uncontrolled haematemesis and was demonstrated at laparotomy to have disseminated pancreatic carcinoma. The unusual clinical features and temporal relationship between the skin changes and the tumour suggest a paraneoplastic eruption. Which appears best classified as an example of cancer-associated fasciitis-panniculitis syndrome.

Systemic effects of S-nitroso-glutathione in the human following intravenous infusion.

Nitric oxide (NO) is a potent vasodilator and inhibitor of platelet aggregation. At present the clinical use of NO donors as inhibitors of platelet activation is limited by their concomitant hypotensive effect. The new NO donor S-nitroso-glutathione (GSNO) has a significant antiplatelet effect at doses that cause only a small decrease in blood pressure in rats. We have examined the antiplatelet and vasodilator properties of this nitrosothiol following systemic intravenous infusion in the human. GSNO was administered intravenously to 10 normal females of reproductive age noting changes in blood pressure, pulse and reported side effects. Ex vivo platelet aggregation to ADP was then performed in a platelet-ionized calcium lumiaggregometer on blood samples taken both before and after the infusions. Side effects such as headache or palpitations occurred only in two subjects at the highest infusion rate of 250 micrograms min-1. Blood pressure and pulse did not vary significantly during the study. Ex vivo platelet aggregation in response to ADP was significantly reduced by the infusion. These results suggest that GSNO is a more potent inhibitor of platelet activation than it is a vasodilator and therefore potentially represents a more clinically useful NO donor than has so far been available where an anti-thrombotic effect is required.

The role of relaxin in the development of the uteroplacental circulation in early pregnancy.

OBJECTIVE: To evaluate the relation between the development of the uteroplacental circulation as assessed by Doppler velocimetry and the maternal blood relaxin concentration. METHODS: Transvaginal color Doppler investigation of the uteroplacental circulation was performed in 42 healthy women at 6-15 weeks' gestation before termination of pregnancy for psychosocial reasons. The resistance index (RI), pulsatility index (PI), and maximum peak velocity were recorded at the level of the main uterine artery, and the presence of intervillous flow was noted. Relaxin, hCG, 17 beta-estradiol (E2), and progesterone levels were measured in maternal venous blood. RESULTS: Limited intervillous flow was noted from 10 weeks' gestation and continuous intervillous flow from 12 weeks. An inverse relation was observed between the circulating levels of both E2 and progesterone and uterine artery RI and PI, whereas the relaxin level correlated positively with uterine RI and PI. Estradiol and progesterone levels also correlated positively with uterine peak systolic velocity and intervillous blood flow. Multiple linear regression analysis indicated that both hormones contributed to the decrease in downstream resistance to uterine blood flow with advancing gestational age, as assessed by uterine RI. In addition, relaxin contributed to the uterine RI and PI and to the intervillous blood flow. CONCLUSION: These data suggest that relaxin, E2, and progesterone may influence the changes in uterine blood flow that occur in early pregnancy. The role played by E2 and progesterone in the development of the uteroplacental circulation may be modulated by relaxin, constituting a novel function for this ovarian peptide.

The effect of indomethacin on anthralin inflammation.

The effect of prostaglandin inhibition, using topical indomethacin, on anthralin inflammation was studied. Indomethacin gel and gel base were applied to opposite flexor forearm skin sites of 11 volunteers for 2 h and then washed off. Anthralin and UVB were then applied to the gel-treated skin and the anthralin- and UVB-induced erythema and oedema were measured at 2, 6, 24 and 48 h using Harpenden callipers and a reflectance erythrometer. Prostaglandin inhibition was demonstrated by a significant reduction of UVB erythema at the indomethacin-treated sites compared to the gel-base-treated sites. There was a small but significant reduction in anthralin erythema, but not oedema, at the indomethacin-treated sites compared to the gel-base sites. This study demonstrates that prostaglandins, and other inflammatory mediators because the inhibitory effect was small, are involved in anthralin inflammation.

Reversible plane xanthoma, vasculitis, and peliosis hepatis in giant lymph node hyperplasia (Castleman's disease): a case report and review of the cutaneous manifestations of giant lymph node hyperplasia.

A patient is described who had generalized plane xanthomas, cutaneous vasculitis, peliosis hepatis, and intraabdominal giant lymph node hyperplasia of the plasma cell type. After excision of the abdominal mass, the xanthomas resolved and the liver returned to its normal size, but the patient continued to develop skin lesions. A review is presented of the cutaneous manifestations of giant lymph node hyperplasia.

Continuous Production of Long-Side-Chain Poly-beta-Hydroxyalkanoates by Pseudomonas oleovorans.

Shake flask experiments showed that Pseudomonas oleovorans began to be growth inhibited at 4.65 g of sodium octanoate liter, with total inhibition at 6 g liter. In chemostat studies with 2 g of ammonium sulfate and 8 g of octanoate liter in the feed, the maximum specific growth rate was 0.51 h, and the maximum specific rate of poly-beta-hydroxyalkanoate (PHA) production was 0.074 g of PHA g of cellular protein h at a dilution rate (D) of 0.25 h. When the specific growth rate (mu) was <0.3 h, the PHA composition was relatively constant with a C(4)/C(6)/C(8)/C(10) ratio of 0.1:1.7:20.7:1.0. At mu > 0.3 h, a decrease in the percentage of C(8) with a concomitant increase in C(10) monomers as mu increased was probably due to the effects of higher concentrations of unmetabolized octanoate in the fermentor. At D = 0.24 h and an increasing carbon/nitrogen ratio, the percentage of PHA in the biomass was constant at 13% (wt/wt), indicating that nitrogen limitation did not affect PHA accumulation. Under carbon-limited conditions, the yield of biomass from substrate was 0.76 g of biomass g of octanoate consumed, the yield of PHA was 0.085 g of PHA g of octanoate used, and 7.9 g of octanoate was consumed for each gram of NH(4) supplied. The maintenance coefficient was 0.046 g of octanoate g of biomass h. Replacement of sodium octanoate with octanoic acid appeared to result in transport-limited growth due to the water insolubility of the acid.

Measurement of glomerular filtration rate with a portable cadmium telluride detector.

The plasma clearance rate constant of 99Tcm-DTPA was measured with a portable cadmium telluride detector over anterior chest wall and lateral leg sites to obtain an empirical estimate of glomerular filtration rate (GFR). Thirteen patients with a range of renal dysfunction were studied to compare the accuracy of the estimates over various time periods compared to GFR estimated from plasma sampling. The chest site was more accurate for GFR assessment over all time periods assessed up to 4 h following injection. The clearance rate constants obtained up to 1 h after injection from the chest site were not significantly less accurate then those from later time periods.