Breaking bad news: a descriptive study of physicians' perspective of Sindh, Pakistan.

OBJECTIVE: To assess the perception and attitude of physicians related to breaking bad news. METHODS: The cross-sectional study was conducted at three teaching hospitals in Karachi and Mirpurkhas, Pakistan, from April 2019 to February 2020, after approval from Hamdard University, Karachi, and comprised physicians of either gender having direct patient contact. Data was collected using a questionnaire based on literature. The questionnaire was pilot-tested before distribution among the subjects. The responses were categorised with respect to age, gender and professional experience. Data was analysed using SPSS 25. RESULTS: Of the 230 subjects, 119(51.7%) were females. The overall mean age was 34.5±8.8 years and mean professional experience was 9.1±8.2 years. Overall, 19(8.3%) subjects believed they had a very good ability to deliver bad news, while 26(11.3%) avoided telling the patient the truth about diagnosis, prognosis and treatment. Age had a significant association with correctly defining breaking bad news (p<0.05). CONCLUSIONS: The skill level related to breaking bad news was found to be deficient.

Carbon Dioxide Laser Plus Topical 5% Luliconazole: A Better Combination Therapeutic Modality for Onychomycosis.

BACKGROUND: Onychomycosis has always been a therapeutic challenge because of longer treatment duration, potential adverse effects of oral antifungals, and limited efficacy of topical agents. During the past few years, the emergence of laser therapy has been the topic of discussion as a newer, safe, minimally invasive modality of treatment. AIM: The aim of this study was to evaluate the role of fractional CO2 laser and topical luliconazole 5% lotion in the treatment of onychomycosis, as a combined treatment and as independent modalities. MATERIALS AND METHODS: This was a prospective, randomized, triple-limb comparative observational study in which 106 patients with KOH and culture-proven onychomycosis were randomly assigned to three groups. Group A received fractional CO2 laser (10,600nm) triweekly for four sessions (0, 3, 9, and 12 weeks) plus topical luliconazole 5.0% lotion applied twice daily on the affected nail plates and nail folds for 12 weeks. Group B received only fractional CO2 with the same frequency of sessions and laser parameters as in group A. Group C received only topical luliconazole 5.0% solution twice daily for 12 weeks. Treatment outcome was evaluated using onychomycosis severity index (OSI) score, mycological parameters, and level of satisfaction of patients. RESULTS: The degree of clinical improvement, mycological cure, and patient's satisfaction was significantly better in the combined group than individual modalities. There were no severe adverse effects that warranted the discontinuation of the treatment in any of these patients. CONCLUSION: Fractional CO2 laser combined with topical luliconazole 5% lotion is a safe and effective treatment for onychomycosis especially in those who have contraindications to oral antifungals.

Beliefs and knowledge of osteoporosis amongst female graduate students in Karachi, Pakistan: A cross-sectional study.

OBJECTIVE: To assess the knowledge, belief and preventive measures taken regarding osteoporosis by students of different non-medical educational backgrounds. METHODS: The descriptive cross-sectional study was conducted from January to March, 2018, at one private-sector and two public-sector universities in Karachi, and comprised female participants aged >15 years from engineering, commerce, social and pure sciences background. Osteoporosis Knowledge Assessment Tool questionnaire was self-administered to collect data which was analysed using SPSS 23. RESULTS: There were 400 females with a mean age of 20.55±1.66 years. The overall mean score was 46.49±12.83 and 43(10.8) subjects had a good score, 204(51%) had an average score and 150(37%) had a poor score regarding knowledge about osteoporosis. Also, 186(47%) subjects identified previous studies as their source about osteoporosis, 103(26%) gained knowledge by health professionals and 62(16%) did it through electronic media. The knowledge on risk factors, protective factors and perceived susceptibility were significant (p<0.05) when compared by type of study and age. CONCLUSIONS: The knowledge of the disease was found to be insufficient, indicating need for generating awareness regarding osteoporosis.

Prevalence of Cold Dermatoses in Kashmir Valley: A Cross-Sectional Study from North India.

BACKGROUND: Often quoted as "heaven on earth," Kashmir forms one of the two divisions of the Union territory of Jammu and Kashmir. A high-altitude region with abundant precipitation and snowfall, the people of Kashmir experience peculiar dermatoses not commonly seen in the majorly tropical subcontinent of India. In this study, we focussed on cold dermatoses as a comprehensive cluster and attempted to study them as a group. AIMS: To determine the prevalence of cold dermatoses in Kashmir valley and study their epidemiological characteristics. METHODS: This observational, cross-sectional community-based study was conducted on native Kashmiri population in three districts of the valley, exclusively during the winter season of the year 2016-17 and 2017-18. The data were tabulated and analyzed with Chi-square test for discrete variables and t-test for continuous variables, using OpenEpi. A P value of less than 0.05 was taken as significant. RESULTS: The study included a total of 1200 cases with 602 males and 598 females. Perniosis was most commonly encountered dermatoses in our study with a prevalence of 12.2%. Frostbite had a prevalence of 0.83%. Raynaud's phenomenon and asteatotic eczema were seen in 1.5% and 1.67% of the population, respectively. Cold panniculitis, cold urticaria, and livedo reticularis were each seen in 0.08% of the population. CONCLUSIONS: Cold dermatoses form an important source of morbidity among the native population of Kashmir. These can be easily prevented by ensuring adequate protection against cold. Creating awareness regarding these disorders and probable association with connective tissue disorders is also imperative.

Clinicoepidemiological and Patch Test Profile of Patients Attending the Contact Dermatitis Clinic of a Tertiary Care Hospital in North India: A 7-Year Retrospective Study.

INTRODUCTION: Allergic contact dermatitis (ACD) is a growing concern due to increased use of cosmetics and topical medications routinely and exposure to a large number of allergens on day-to-day basis. Patch testing is a reliable method for detecting the causative antigens in suspected cases. AIMS AND OBJECTIVES: To assess the demographic profile, pattern of ACD, and patch test profile of suspected cases of ACD attending contact dermatitis clinic of our department. MATERIALS AND METHODS: It was a retrospective study in which all the data enrolled in the contact dermatitis clinic of our department over a 7-year period were analyzed. Patch testing was done using the Indian Standard Series of 20 antigens primarily, and other batteries were used depending on patient requirement and availability. RESULTS: A total of 582 patients were enrolled in the contact dermatitis clinic over a period of 7 years. Hand eczema was the most common pattern seen in 268 cases followed by feet eczema, hand and foot eczema, facial eczema, forearm and leg eczema and photoallergic contact eczema. A total of 177 patients (30.4%) gave positive patch test results, with nickel sulfate being the most common allergen identified followed by potassium dichromate, cobalt sulfate, paraphenylenediamine, neomycin sulfate, and fragrance mix. CONCLUSION: Common allergens identified in our study were more or less similar to studies from other parts of India. However, due to the unique climate of the valley, the profile of parthenium sensitivity was low in our study when compared to the rest of the country.

Common Contact Allergens in Patients with Palmoplantar and Scalp Psoriasis and Impact of their Avoidance on Dermatology Life Quality Index: A Hospital-Based Study.

BACKGROUND: Scalp psoriasis and psoriasis limited to palms and/or soles have been referred to as difficult to control psoriasis. Contact allergy has long been suspected to aggravate existing lesions and cause resistance to therapy in these psoriasis variants. OBJECTIVES: The objective of the study was to assess common contact allergens in patients with palmoplantar and scalp psoriasis and the impact of their avoidance on dermatology life quality index (DLQI). MATERIALS AND METHODS: A total of 54 patients with palmoplantar and scalp psoriasis were patch tested with Indian Standard Series. The patch test results were read on day 2 and day 4. DLQI was calculated before patch testing and at 1 month and 3 month in patch test positive patients after instructing allergen avoidance. RESULTS: Sixteen out of fifty-four patients (29.62%) showed positive patch test reactions. Metal antigens like nickel and cobalt were the most common sensitizers identified. Statistically significant improvement in DLQI was observed at 1 month and at 3 month of allergen avoidance. CONCLUSION: Patch testing is a useful test to determine the triggering or aggravating antigens in patients with palmoplantar and scalp psoriasis and subsequent allergen avoidance should be stressed on.

Treatment of post-burn and post-traumatic atrophic scars with fractional CO2 laser: experience at a tertiary care centre.

Scars are abnormal wound responses in predisposed individuals. They occur after any kind of wound and skin inflammation in predisposed individuals. Despite their benign nature, they can be aesthetically disabling. Although several approaches have been tried in their management, most of them have produced poor results. This study aims to assess the efficacy and safety of fractional CO2 laser treatment in the management of post-burn and post-traumatic scars. One hundred consecutive patients (77 females and 23 males) affected by post-burn scars as well as post-traumatic atrophic scars were treated with monthly sessions of fractional CO2 laser treatment. Patient's response to treatment was assessed clinically as well as improvement of scars by comparing the photographs taken before treatment with those taken 6 months after the last treatment session. Changes in skin texture, surface irregularity and pigmentation were assessed on a quartile grading scale and scored individually from 0 to 4. A mean of the three individual scores was calculated and the response was labelled as 'excellent' if the mean score achieved was > 3. A score of 2-3 was labelled as good response while a score below 1 was labelled as 'poor' response. A mean of six treatments per scar were required and all patients, followed up for 1 year after the last treatment, had optimum results and no recurrence. Response to treatment was excellent in 53.75%, good in 16.25% patients, and poor in 30% patients. Fractional CO2 laser gives a very good result in the management of patients with post-burn scars as well as post-traumatic scars with minimal adverse effects.

Contact dermatitis caused by tulips: identification of contact sensitizers in tulip workers of Kashmir Valley in North India.

BACKGROUND: Tulip, belonging to the genus Tulipa and family Liliaceae, is a spring-blooming perennial that grows from bulbs. Owing to manual handling, contact dermatitis can occur in professionals at any stage of the growth cycle of the tulip plant. OBJECTIVES: To determine the clinical pattern of contact dermatitis resulting from tulip plant cultivation, and to assess contact allergy in workers coming into contact with this plant. METHODS: One hundred and sixty-four tulip workers were screened, and 48 patients with suspected contact dermatitis were patch tested with 39 allergens, including haptens from the Indian baseline series, a plant series, and extracts from different parts of the tulip plant. RESULTS: Thirty-nine positive patch test reactions were observed in 21 patients. Seventeen patients showed positive reactions to either α-methylene-γ-butyrolactone or to tulip plant extract. Clinical relevance was observed for 13 of 17 positive patch test reactions. CONCLUSIONS: Contact dermatitis is an important health hazard in workers dealing with tulip bulbs. Further studies to identify and isolate other possible tulip allergens, and to quantify the amounts of allergens in different parts of the tulip plant, are recommended.

Cutaneous changes in internal malignancy: Study from a tertiary care center.

BACKGROUND: A wide variety of systemic diseases and internal malignancies have cutaneous manifestations. In the context of internal malignancy, many cutaneous changes are highly specific to the underlying malignancy, while other changes are nonspecific. Some changes are also due to the modalities employed in the treatment of malignancies. METHODS: Two hundred and fifty patients who were diagnosed with internal malignancy and who were attending the department of radiation oncology, were evaluated at the Department of Dermatology, Sexually Transmitted Diseases and Leprosy of Government Medical College, Srinagar. The study was conducted over a period of 5 months. Relevant investigations, wherever needed, were carried out. RESULTS: Among the 250 cases examined, nonspecific cutaneous changes were seen in 39 (15.6%) cases, whereas specific skin lesions in the form of cutaneous metastases were seen in two (0.8%) patients. Nail changes and hair changes were also seen in some patients. LIMITATIONS: As this was a cross-sectional study and most of the patients were lost to follow up, we could not assess the outcome of the dermatological changes seen in the affected patients. CONCLUSION: Many dermatological changes are noticed early in the course of malignancy, reflecting a strong association of the cutaneous change with malignancy. Few manifestations occur late in the course of the disease, indicating dissemination or immunosuppression. Some changes reflect radiation-induced or chemotherapy-induced toxicity, indicating the need for treatment modifications.

Evaluation of Carbon Dioxide Laser in the Treatment of Epidermal Nevi.

BACKGROUND: Epidermal naevi are benign hamartomatous growths of the skin which are generally asymptomatic with a benign course but are cosmetically disagreeable. Topical treatments such as steroids, calcipotriol, 5 fluorouracil, podophyllin, retinoids and cryotherapy are ineffective and surgical excision results in scar formation. Therapy is often challenging. AIM OF THE STUDY: To study the response of carbon dioxide (CO2) laser in the management of epidermal naevi. SUBJECTS AND METHODS: We conducted a study of CO2 laser treatment on 15 patients of epidermal naevi, eight with verrucous epidermal naevi and seven with sebaceous naevi. A thorough history and examination was done to rule out any epidermal naevus syndrome. The diagnosis was confirmed by histopathology. The number of treatment sessions varied from 1 to 8. RESULTS: Response was excellent (>90% reduction in lesion size) in three patients, very good (>75% reduction) in five, good (>50% reduction in lesion size) in five and poor (<50% reduction in lesion size) in two patients. The side effects were hyperpigmentation and scarring. Long-term follow-up over a period of 10 months showed a recurrence rate of 20%. CONCLUSION: We conclude that CO2 laser treatment might be an effective option with long-term safety, minimal discomfort and rapid recovery.

Pattern of sexually transmitted infections in a Muslim majority region of North India.

BACKGROUND: Changing trends of sexually transmitted infections (STI) and HIV/AIDS has been noted in the literature over years, depending to some extent on the geographical and cultural factors of the region. In Kashmir Valley also, the pattern of STI may be different from the rest of the country. AIMS OF THE STUDY: The aim was to present the experience with patterns of STI in Kashmir. MATERIALS AND METHODS: Retrospective hospital-based study carried out by detailed analysis of case records of 5-year period. RESULTS: A total of 184 patients, 100 males and 84 females, had specific STI. Genital ulcer disease was the presentation in 54 patients (29.35%), out of which herpes genitalis was found in 27 patients (50%), followed by chancroid in 13 (24.07%) and syphilis in 10 (18.52%) patients. 42 female patients (22.83%) presented with vaginal discharge, out of which, 24 (57.14%) had vaginal candidiasis. 24 males (13.04%) presented with urethral discharge, out of which, 15 (62.5%) had nongonococcal and 9 (37.5%) gonococcal urethritis. Genital molluscum contagiosum (MC) was found in 19 patients (10.33%), and warts in 15 (8.15%). HIV positive serology was detected in 3 patients (1.63%). CONCLUSION: The most common STI encountered in our study was genital ulcer, followed by vaginal discharge, urethritis, genital MC, and genital warts. Herpes genitalis was the commonest genital ulcer; candidiasis was the most common cause of vaginal discharge and nongonococcal urethritis the most common cause of urethritis. These findings are by and large similar to those noted in other parts of our country.

Dexmedetomidine and ketamine combination for a patient with xeroderma pigmentosa.

Patients of xeroderma pigmentosa (XP) have increased sensitivity to ultraviolet light and a defective nucleotide excision repair (NER) mechanism in their DNA. Several types of neurological, dermatological, and ophthalmological complications are common in these patients. There is increasing evidence of delayed recovery and worsening of neurological status following general anesthesia in such patients. Some reports have shown uneventful conduct of total intravenous anesthesia in patients of XP. The authors report a case of XP in a young girl for surgery, previously anesthetized with delayed recovery, managed successfully with a combination of intravenous dexmedetomidine and ketamine.

Mycosis Fungoides: Tumour d'emblee.

Mycosis Fungoides is a Cutaneous T-cell lymphoma characterized by infiltration of skin with patches, plaques, and nodules composed of T-lymphocytes. It is the most common type of Cutaneous T-Cell Lymphoma and accounts for almost 50% of all primary cutaneous lymphoma. Tumour d' emblee is the term used for the patient presenting with skin tumors not preceded by patches or plaques. We report a rare case of mycosis fungoides d' emblee variant with tumors of only 3 months duration without any preceding skin lesions.