A review of the selection process and decontamination methods with the use of face shields in UV phototherapy during the SARS-CoV-2 pandemic.

Targeted ultraviolet (UV) phototherapy has been used in the management of a wide variety of dermatological clinical conditions including moderate to severe psoriasis unresponsive to topical therapies, vitiligo, severe atopic dermatitis and lymphoproliferative disorders. To date there are no uniform, standardised guidelines for the selection and decontamination process for UV personal protective equipment (PPE) and facial shields used in phototherapy. In the current climate, Coronavirus 2019 (COVID-19) pandemic, standards regarding all decontamination and disinfection processes are under significant scrutiny. In terms of the UV-PPE and facial shields used in phototherapy, careful disinfection procedures need to be implemented to ensure that the decontamination practice is effective enough to neutralise the virulent virus whilst maintaining maximal protection to the user from UV-rays and safeguard the equipment from damage during the cleaning process. The aim of this report is to provide an evidence based review of the current and international practice standards guiding the selection, use and decontamination processes of UV facial shields in phototherapy. The complications and concerns that the COVID-19 pandemic has had on this practice is highlighted. As such, we performed a comprehensive evaluation of the literature to provide recommendations as to the most effective, time efficient and safest practices for disinfection and decontamination of UV facial shields used in phototherapy during these unprecedented times.

Muir-Torre syndrome: a case of unusual coexisting genetic mutations.

Patients with Muir-Torre syndrome (MTS) commonly have germline mismatch repair mutations in MLH1, MSH2 or MSH6, with a strong predominance in MSH2. A subset of approximately one-third of patients will instead have an autosomal recessive base excision repair mutation in MUTYH called MUTYH polyposis. To the best of our knowledge, this is the first report of coexisting germline MSH2 and MUTYH mutations in a patient with MTS.

The treatment of hidradenitis suppurativa with the glucagon-like peptide-1 agonist liraglutide.

Hidradenitis suppurativa (HS) is a cutaneous disease associated with systemic inflammation, obesity and metabolic syndrome. Effective treatment options are limited. The antidiabetic agents, incretins, have been used successfully to treat psoriasis - a disease also associated with metabolic syndrome. We report the use of liraglutide, a glucagon-like peptide-1 agonist, in a patient with HS, leading to subsequent weight loss and improvement in disease control. To our knowledge, this is the first report of liraglutide used in the treatment of HS.

Multiple cutaneous, oropharyngeal and pulmonary nodules.

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis defined by heterogeneous multiorgan involvement. Due to the rarity of this disease strong evidence-based therapies have yet to be established and prognosis has previously been considered to be poor, with more than half of patients dying within 3 years of initial presentation. We describe an 86-year-old woman with a 34-year history of extensive cutaneous and internal nodules with typical pathological and immunophenotypical (CD68(+) /CD1a(-) ) features of ECD without evidence of the BRAF V600E mutation. The cosmetic appearance of cutaneous nodules and hoarse voice caused by vocal cord nodules has been managed surgically. More aggressive therapies reported for ECD were trialled for this patient, such as radiotherapy and interferon-α, with no response. This case demonstrates a relatively good prognosis in ECD that has been managed conservatively.

Generalized pustular psoriasis associated with Epstein-Barr virus.

Generalized pustular psoriasis (GPP) is a rare and severe variant of psoriasis. We report a case of a 79-year-old woman who presented with generalized pustular psoriasis and significant Epstein-Barr virus (EBV) viraemia. Serial measurements of EBV DNA showed a correlation with the deterioration in her clinical condition. We speculate that EBV reactivation triggered the development of GPP, and propose that further investigation is required into the association between EBV and GPP.

Practical experience of ustekinumab in the treatment of psoriasis: experience from a multicentre, retrospective case cohort study across the U.K. and Ireland.

BACKGROUND: There are limited data on the use of ustekinumab outside of clinical trials. OBJECTIVES: To assess the efficacy and safety of ustekinumab in patients with severe psoriasis attending 10 dermatology centres in the U.K. and Ireland. METHODS: A retrospective case-note review of 129 patients with psoriasis treated with ustekinumab. RESULTS: Baseline Psoriasis Area and Severity Index (PASI) was 22·9±10·1 (mean±SD). After 16weeks of treatment with ustekinumab PASI 75 (75% reduction in PASI) was observed in 63·0% (n=80/127) of patients, although four patients required concomitant therapy at the 16-week time point. Previous biologic use did show a small, non-significant trend towards treatment failure. A PASI 75 response was seen in 29·4% (n=5/17) of individuals weighing 90-100kg and treated with the standard 45mg ustekinumab dose compared with PASI 75 of 70·3%, 71·4%, 75·0% and 55·6% for weight groups <80, 80-90, 100-110 and >110kg, respectively (P=0·024). Ustekinumab therapy was well tolerated; serious adverse events were observed in 2·3% (n=3/129) of patients. CONCLUSIONS: Ustekinumab is a novel biologic agent for psoriasis. When used in everyday clinical practice it demonstrates high levels of short-term therapeutic efficacy with an acceptable short-term safety profile.

Pott's puffy tumor following an insect bite.

Pott's puffy tumor, a feature of osteomyelitis of the frontal bone, is a rare entity, especially in adults. Sir Percival Pott originally described this condition as a complication of trauma to the frontal bone. This is also a recognized complication of fronto-ethmoidal sinusitis. We present a rare case of Pott's puffy tumor caused by an insect bite presenting initially as a preseptal cellulitis and explore its pathogenesis and management.

Sarcoidosis of the external ear--literature review and report of a case.

External ear manifestations of sarcoidosis are rare. We review six cases in the literature and also report a case. The otolaryngologist plays an important role in making the diagnosis because of the ease of biopsy in all cases of sarcoidosis of the external ear.

Modified laser DCR for paediatric nasolacrimal duct obstruction.

AIMS: To evaluate the efficacy, safety, and long-term outcome of modified laser dacryocystorhinostomy (DCR) for primary nasolacrimal duct obstruction, unresponsive to probing. METHODS: Retrospective, noncomparative case-note review of all paediatric cases operated between September 2000 and November 2003. PROCEDURE: A fibre optic light, inserted through the canaliculi into the lacrimal sac was visualized endonasally. Nasal mucosa was incised using a keratome and a bony ostium was created with the Holmium : YAG laser. Bicanalicular silicone tubes were inserted. RESULTS: Five children with a mean follow-up of 25.6 months (range 21-48 months) and a mean age of 7 years were reviewed. Silicone tubes were used in four patients and were removed at a mean 6.5 months (range 3-9 months). One patient developed a mucocele 6 months after the procedure requiring excision of the membrane covering the ostium. There were no other immediate or late postoperative complications. Complete cure of symptoms was achieved in all patients and was maintained at final follow up. CONCLUSION: Modified paediatric laser DCR appears to be an encouraging technique for primary nasolacrimal duct obstruction unresponsive to probing. This may be attributable to the modification of excision of mucous membrane, which may prevent regrowth.

Explosion and fire in the expiratory limb of a Fisher and Paykel "three in one" respiratory care system.

We report an incident involving a Fisher and Paykel "There in One Respiratory Care System" (Fisher and Paykel Healthcare, Auckland, New Zealand). This is a new ventilator circuit designed to be adaptable to the needs of ventilator, intubated CPAP, and mask therapies. In this case the patient had received eight hours of CPAP therapy overnight, during which time the "Three in One" circuit had been broken down to the CPAP configuration. The expiratory limb heater element, normally disconnected, was inadvertently left connected to the heater base. Under the extreme conditions of heating under "no gas flow" mode, the heater element malfunctioned. As a result when the circuit was reconfigured to provide pressure-supported ventilation, in the high oxygen environment of the expiratory limb (FiO2 0.5), ignition and combustion of the respiratory circuit occurred. The case is reported because of the potentially serious consequences and because the incident prompted the manufacturer to redesign and change componentry in parts of the circuit implicated.

The importance of self-efficacy as a mediating variable between learning environments and achievement.

The purpose of this research was to investigate the extent to which self-efficacy acts as a mediating variable between the learning environment and achievement. Seven year 5 classes (N = 179 students aged 9 to 10 years) were allocated randomly to cooperative, competitive or individualistic environments for twice-weekly social studies lessons, changing environments after five weeks. Data collected on self-efficacy and achievement in weeks 5 and 10 indicated that co-operative environments led to higher self-efficacy and achievement as well as more appropriate behaviour. The performance of particular tasks under competition appears to be enhanced when students have previously worked co-operatively, but may be difficult to sustain as self-efficacy and behaviour standards decline.

Studies of the blood-aqueous barrier in diabetes mellitus.

We measured the breakdown of the blood-aqueous barrier in 63 patients with diabetes (126 eyes) by using a laser flare meter. Of 126 eyes, 40 had no retinopathy, 34 had proliferative retinopathy, 24 had regressed proliferative retinopathy, 14 had background retinopathy, and 14 had maculopathy. Eyes were classified into one category only. Mean flare was greater for proliferative retinopathy compared to background retinopathy (P = .0065), no retinopathy (P = .0001), and maculopathy (P = .0189). Flare values were greater for regressed proliferative retinopathy compared to no retinopathy (P = .0118) (paired Student's t-test). Diabetic eyes without demonstrable retinopathy still had higher flare values than control eyes without diabetes. The length of diabetes was greater for those eyes with proliferative diabetic retinopathy (P = .0195), regressed proliferative diabetic retinopathy (P = .0625), and background diabetic retinopathy (P = .006) compared to those with no retinopathy. No significant difference was noted in duration of diabetes for eyes with diabetic maculopathy when compared to those with no retinopathy (P = .5788). Breakdown of the blood-aqueous barrier precedes the development of retinopathy, and the more severe proliferative forms have greater blood-aqueous barrier dysfunction.