Risk factors for complicated Mohs surgery in the South Sweden Mohs Cohort.

BACKGROUND: Mohs micrographic surgery (MMS) is a precise, tissue-sparing surgical technique that offers superior cure rates compared to traditional surgical excision. However, the degree of difficulty of MMS depends on many variables, and consequently, the number of surgical stages required for each case is quite unpredictable. OBJECTIVES: To identify risk factors for complicated MMS, defined as MMS requiring ≥3 stages. METHODS: In a cohort study design, data were prospectively collected from 612 patients that underwent MMS for basal cell carcinoma (BCC) at the Department of Dermatology, Skåne University Hospital, Lund, between 2009 and 2020. Univariate and multivariate logistic regression were used to estimate the risk of MMS requiring ≥3 stages. Due to the risk of multicollinearity between recurrent or incompletely excised BCC and previous treatments, a partially and a fully adjusted multivariate logistic regression model were constructed. RESULTS: In fully adjusted multivariate analyses, age (odds ratio (OR) 1.02; confidence interval (CI) 95% 1.00-1.04), previous cryotherapy (OR 2.3; CI 95% 1.1-4.8), and >1 previous surgery (OR 3.4; CI 95% 1.5-7.7) were significantly associated with risk of complicated MMS. Recurrent BCC was associated with the risk of complicated MMS in partially adjusted multivariate analyses, but not in the fully adjusted analyses. In this highly selected cohort, histopathological subtype, and tumour localization were not associated with the risk of complicated MMS. CONCLUSIONS: Older age and tumours previously treated with cryotherapy or multiple prior surgeries increased the risk of MMS requiring ≥3 stages. Whether recurrent BCC is an independent risk factor for complicated MMS needs further evaluation. Knowledge of these risk factors may ameliorate the planning of Mohs surgeries.

[Infections and use of antibiotics in nursing homes]. / Infeksjoner og antibiotikabehandling ved sykehjem.

BACKGROUND: The number of elderly people is constantly increasing in the western world. Many of these elderly spend their last years in a nursing home. Long-term care residents frequently have infections. However, there is only limited knowledge with regard to the spectrum of infections and the usage of antibiotics in nursing homes, in Norway and also in other European countries. MATERIAL AND METHODS: Prevalence of infections, risk factors related to infections and antibiotic usage were studied in four nursing homes in Baerum county. RESULTS: Of all 262 nursing home residents, 8.4% had an infection; 3.4% received antibiotic treatment. 66% of residents were more than 80 years old, 98% had a private room. Of all residents 3.4% had a urinary tract infections, 1.9% a skin infection, 1.1% a respiratory tract infection, and 1.9% an eye infection. 42% of all residents were treated with psychopharmacological drugs. 3.9% had an urinary catheter, and 11% skin ulcers. INTERPRETATION: Our study did not discover any extraordinary problems with infections or antibiotic overuse in the nursing homes investigated. However, further studies are warranted in order to learn more about this issue in these institutions, which may represent an important but frequently underestimated source of resistant bacteria in a community.

Immunohistochemical studies on proteoglycan expression in normal skin and chronic ulcers.

BACKGROUND: Proteoglycans (PGs) represent a large family of complex molecules. They are found either as integral membrane components or constituents of the extracellular matrix. Their protein backbones are linked to different glycosaminoglycans, such as dermatan-, chondroitin-, keratan- or heparan sulphate. The molecules have specific functions during developmental processes as well as in diseases, such as cancer and inflammation. OBJECTIVES: The expression patterns of various cell-associated heparan and chondroitin/dermatan-sulphate PGs in human skin and chronic venous ulcers were investigated. METHODS: Tissue sections from 11 patients with chronic venous ulcers were used in this study. Monoclonal antibodies were used for detection of the proteoglycans syndecan-1, -2 and -4, glypican, CD44 and perlecan. RESULTS: The different PGs exhibited individual staining patterns. Syndecan-1 and -4 and glypican expression in chronic ulcers differed from the staining in normal skin. Whereas the expression of syndecan-4 and glypican in intact skin was mostly in the pericellular regions of keratinocytes, the epidermal cells from the wound edge contained mostly intracellular PGs. In the wound edge, syndecan-4 was predominantly expressed by epidermal basal layer cells. Syndecan-1 was less expressed at the epidermal wound margins. PGs bind growth factors, regulate proteolytic activity and act as matrix receptors. CONCLUSIONS: The altered expression patterns of glypican and syndecan-1 and -4 in chronic ulcers reflect their possible roles during inflammation and cell proliferation. Hence, analysis of PG expression should be of interest in future studies on normal as well as defective wound healing.

Laser Doppler perfusion imaging for the documentation of flare-up in contact allergy to gold.

A healed or healing allergic contact dermatitis is easily reactivated to a flare-up if the patient is provoked systemically with his particular allergen. 5 patients with contact allergy to gold were patch tested with a serial dilution of gold sodium thiosulfate. 1 to 2 months later, when positive test reactions were healed, the patients were given 1 intramuscular injection of gold sodium thiomalate. This resulted in a flare-up of patch tests as well as a transient fever and toxicoderma-like reactions. The flaring tests were registered by digital photographs and laser Doppler imaging (LDI). An increased cutaneous blood flow in the formerly positive patch tests was discernible within 1 h after provocation, increased to a vigorous maximum after 4-6 h, and subsided during the following few days. The earliest increase and the highest peak of blood flow were observed in the test areas of the strongest original test concentration. LDI provides a most suitable technique for studying the dynamics of this rapidly developing inflammation of a mainly dermal character.

Differences in colonic disease activity in patients with ulcerative colitis with and without primary sclerosing cholangitis: a case control study.

PURPOSE: A small group of patients with ulcerative colitis (UC) also suffer from primary sclerosing cholangitis (PSC). Genetic and immunologic differences exist between UC patients with and without concomitant PSC. Furthermore, UC patients with PSC are more prone to developing colonic dysplasia/aneuploidy compared with patients with UC only. Because colonic disease activity and treatment with sulfasalazine have been found to be of independent importance for development of colonic carcinoma in UC, this study aims to determine if differences exist concerning colonic disease activity in UC patients with and without PSC. METHODS: Twenty-nine PSC patients with total colitis were matched to two UC patients with total colitis but without liver disease. Case records and questionnaires were used to gain information on pharmacologic treatment and disease activity. RESULTS: Observation time was 20 (PSC group) and 23 years (UC only). Number of patients taking prophylactic treatment did not differ between groups. Patients with UC only had received treatment with systemic and local corticosteroids significantly more often than UC patients with PSC (P < 0.05 and P < 0.02). Patients with UC only were hospitalized because of colonic activity significantly more often (P < 0.02). Number of patients undergoing colectomy because of disease activity or number of patients with chronic continuous symptoms did not differ between the two groups. CONCLUSION: UC in patients with PSC runs a milder course than UC in patients without this complication, although the number of patients taking prophylactic treatment was the same. If lower disease activity reflects differences in pathogenesis of UC in patients with PSC or if it can explain increased risk to develop colonic malignancy in patients with both PSC and UC needs further elucidation.

Subclinical time span of inflammatory bowel disease in patients with primary sclerosing cholangitis.

PURPOSE: This study is designed to describe colonic histology in patients with primary sclerosing cholangitis (PSC) without clinical symptoms of inflammatory bowel disease (IBD) and to do a follow-up study of these patients to find the time span from first detection of histologic signs until development of clinical symptoms of IBD. METHODS: In a cohort of 76 patients with PSC treated at Huddinge University Hospital, 11 patients did not have any clinical symptoms of IBD at the time of PSC diagnosis. Nine of these patients underwent diagnostic colonoscopy with multiple biopsies. RESULTS: In the group of nine PSC patients, without clinical signs of IBD undergoing colonoscopy, histologic signs of IBD were found in seven patients (6 ulcerative colitis and 1 Crohn's disease). Among them one had dysplasia, and another had epithelial changes probably positive for dysplasia. Two other patients had histologic signs of inflammation, however, not fully compatible with IBD. Three of 11 patients developed clinical symptoms of IBD after one, three, and seven years of follow-up since diagnostic colonoscopy. CONCLUSIONS: In patients with PSC, histologic signs of IBD, including premalignant changes, may precede development of clinical symptoms of IBD by as much as seven years. This indicates that IBD onset may have a substantial subclinical phase of IBD far longer than previously appreciated. This finding may be of clinical importance because underestimation of disease duration may delay inclusion of PSC patients with extensive colitis in colonoscopic surveillance programs. The subclinical phase may also allow the studies of early pathogenesis in vivo.

Physical training in rheumatoid arthritis: a controlled long-term study. I.

Twenty-three patients with rheumatoid arthritis (RA) have been given physical training for 4 to 8 years. To compare, we have had a control group of equal size and with the same disease severity. The training program consisted of home-training and for most of the patients also group-training led by a physiotherapist. During the observation period we have found a significantly less pronounced progress of X-ray changes in the joints of the active patients compared with control patients. Physiological tests and clinical parameters, including sick-pension and sick-leave, show unanimously a better disease outcome in the active group of patients. There is probably a risk of overuse or disuse of the joints in RA but we believe that it is better to be overactive rather than the reverse. As in many other diseases, the general prescription of rest in RA is not adequate.