UK psychodermatology services in 2019: service provision has improved but is still very poor nationally.

BACKGROUND: Psychodermatology is an emerging subspeciality of dermatology. Psychodermatology clinics use a multidisciplinary approach to deal with psychological or psychiatric elements related to skin disease. Two previous studies in 2004 and 2012 highlighted the deficiency of psychodermatology services in the UK, despite the evidence that these services have high demand and are cost-effective. AIMS: To reassess psychodermatology service provision in the UK and outline the developments that have been made. METHODS: In conjunction with BBC Radio 5 Live, a survey questionnaire was distributed via email to the UK membership of the British Association of Dermatologists (BAD) and Psychodermatology UK. The survey consisted of 13 questions asking about the availability of psychodermatology services. RESULTS: Basic percentages were used to analyse quantitative data, and content analysis was used for qualitative data. Our results showed that less than a quarter of the respondents (24%) have access to a nearby dedicated psychodermatology service. Additionally, the psychodermatology units do not have a unified configuration and clinical provision model differs nationally. Only around 5% of the clinicians have access to a clinic that provides psychology-dermatology-oncology service, and even fewer have access to a paediatric psychodermatology (4.8%). Engagement in psychodermatology research was reported by around 12% of the participants. CONCLUSIONS: The psychocutaneous services in the UK have improved to some extent over the past decade; the service has become more widely available nationally, and the investment in research is promising. However, it is still insufficient and unable to fulfil patient demand, especially for vulnerable individuals such as children and dermato-oncology patients.

OH 83: A new early modern human fossil cranium from the Ndutu beds of Olduvai Gorge, Tanzania.

OBJECTIVE: Herein we introduce a newly recovered partial calvaria, OH 83, from the upper Ndutu Beds of Olduvai Gorge, Tanzania. We present the geological context of its discovery and a comparative analysis of its morphology, placing OH 83 within the context of our current understanding of the origins and evolution of Homo sapiens. MATERIALS AND METHODS: We comparatively assessed the morphology of OH 83 using quantitative and qualitative data from penecontemporaneous fossils and the W.W. Howells modern human craniometric dataset. RESULTS: OH 83 is geologically dated to ca. 60-32 ka. Its morphology is indicative of an early modern human, falling at the low end of the range of variation for post-orbital cranial breadth, the high end of the range for bifrontal breadth, and near average in frontal length. DISCUSSION: There have been numerous attempts to use cranial anatomy to define the species Homo sapiens and identify it in the fossil record. These efforts have not met wide agreement by the scientific community due, in part, to the mosaic patterns of cranial variation represented by the fossils. The variable, mosaic pattern of trait expression in the crania of Middle and Late Pleistocene fossils implies that morphological modernity did not occur at once. However, OH 83 demonstrates that by ca. 60-32 ka modern humans in Africa included individuals that are at the fairly small and gracile range of modern human cranial variation.

An endophenotype approach to the genetics of alcohol dependence: a genome wide association study of fast beta EEG in families of African ancestry.

Fast beta (20-28 Hz) electroencephalogram (EEG) oscillatory activity may be a useful endophenotype for studying the genetics of disorders characterized by neural hyperexcitability, including substance use disorders (SUDs). However, the genetic underpinnings of fast beta EEG have not previously been studied in a population of African-American ancestry (AA). In a sample of 2382 AA individuals from 482 families drawn from the Collaborative Study on the Genetics of Alcoholism (COGA), we performed a genome-wide association study (GWAS) on resting-state fast beta EEG power. To further characterize our genetic findings, we examined the functional and clinical/behavioral significance of GWAS variants. Ten correlated single-nucleotide polymorphisms (SNPs) (r2>0.9) located in an intergenic region on chromosome 3q26 were associated with fast beta EEG power at P<5 × 10-8. The most significantly associated SNP, rs11720469 (ß: -0.124; P<4.5 × 10-9), is also an expression quantitative trait locus for BCHE (butyrylcholinesterase), expressed in thalamus tissue. Four of the genome-wide SNPs were also associated with Diagnostic and Statistical Manual of Mental Disorders Alcohol Dependence in COGA AA families, and two (rs13093097, rs7428372) were replicated in an independent AA sample (Gelernter et al.). Analyses in the AA adolescent/young adult (offspring from COGA families) subsample indicated association of rs11720469 with heavy episodic drinking (frequency of consuming 5+ drinks within 24 h). Converging findings presented in this study provide support for the role of genetic variants within 3q26 in neural and behavioral disinhibition. These novel genetic findings highlight the importance of including AA populations in genetics research on SUDs and the utility of the endophenotype approach in enhancing our understanding of mechanisms underlying addiction susceptibility.

Delusional infestation may be caused by recreational drug usage in some patients, but they may not disclose their habit.

BACKGROUND: Patients with delusional infestation (DI) believe that their skin is infested with organisms or inanimate particles, despite objective evidence to the contrary. Previous studies indicate a higher rate of recreational drug use among patients with DI. It is known that symptoms of infestation such as formication can be secondary to use of recreational drugs and alcohol. We carried out a pilot study observing the prevalence of recreational drug use in patients with DI. AIM: To observe the prevalence of recreational drug use in patients with DI. METHODS: A retrospective review of 86 consecutive patient records was carried out over a 3-year period (1 March 2012 to 1 March 2015) to determine current or previous recreational drug use. Additionally, 24 consecutive patients with DI attending clinic between 1 December 2014 and 1 March 2015 were prospectively offered a urine test for recreational drugs. RESULTS: Of the 86 patients, 19 had recreational drug use documented in their medical notes (22.1%). Of the 24 patients offered a urine test, 18 accepted (75%); the remaining 6 patients agreed to provide a urine sample immediately after consultation, but did not do so. Of the 18 samples collected, 6 were positive (33.3% of completed tests) for recreational drugs. Cannabis was the most commonly used drug. CONCLUSIONS: This study indicates that the prevalence of recreational drug use in patients with DI is high, and that patients do not always disclose their habit. It is hoped that this pilot study will lead to further research into this finding.

Sleep-disordered breathing and nocturnal hypoxemia in young adults with sickle cell disease.

Sleep-disordered breathing (SDB) is reported in up to 69% of adolescents and children with sickle cell disease (SCD) [1], but data regarding the prevalence of SDB in adults with SCD are limited. In order to obtain a preliminary assessment of the frequency and degree of sleep-related hypoxemia and potential associations with cardiovascular function in adults with SCD, we conducted overnight sleep studies, 6-min walk tests, echocardiograms, and hematologic and chemistry panels, calculated the Pittsburgh sleep quality index (PSQI), and conducted fatigue- and health-related quality-of-life measurement in 20 young adults with SCD visiting a sickle cell clinic for routine care. Sleep apnea, defined as an apnea-hypopnea index (AHI) > 5 events/h, was found in 50% of patients. Traditional clinical indicators, such as obesity, the presence of snoring, and reported sleep complaints, did not reliably differentiate them. The patients with AHI > 5 had higher mean systolic blood pressure (p = 0.03), evidence of impaired left ventricular diastolic function (i.e., increased mitral valve E/A ratio, p = 0.05), a trend toward higher reduction in 6-min walk distances (p = 0.06), and lower health-related quality-of-life scores (p ≤ 0.01). Three of nine patients with more severe anemia (total Hb < 9.0) showed nocturnal hypoxemia in the absence of sleep apnea. As prolonged and frequent hypoxemic episodes likely increase risks for vaso-occlusive, cardiovascular, and neurologic complications of SCD, these results suggest that the prevalence and severity of SDB should be investigated further in studies of larger patient populations. If confirmed, these findings could identify opportunities to prevent or reduce nocturnal hypoxia and improve outcomes.

Dysaesthetic penoscrotodynia may be a somatoform disorder: results from a two-centre retrospective case series.

BACKGROUND: Dysaesthetic penoscrotodynia (DPSD) is a poorly understood disorder, in which men experience distressing symptoms such as burning pain in their genital skin. Drugs for neuropathic pain are often used, but with little success. AIM: To review a series of patients with DPSD to highlight common themes and response to treatment. METHODS: Ten consecutive patients with DPSD were identified from specialist male genital dermatology and psychodermatology clinics at two centres. Clinical details, including psychiatric history, were reviewed retrospectively. Patients with no previously diagnosed psychiatric illness completed either the Generalized Anxiety Disorder (GAD)-7 scale and the Patient Health Questionnaire (PHQ)-9 depression scale, or the Hospital Anxiety and Depression Scale (HADS) and the Dermatology Life Quality Index (DLQI). RESULTS: Of the 10 patients, 9 had known or newly diagnosed psychopathology. All patients were offered psychodermatological treatment, of which 7 of 10 accepted. All of those who accepted psychodermatological treatment experienced an improvement in their genital symptoms. When post-treatment scores were collected, improvement in psychiatric symptoms accompanied improvement in genital symptoms. CONCLUSIONS: Psychopathology is almost invariably present in individuals with DPSD, yet these patients rarely volunteer such information. DPSD is most likely to constitute a functional somatic symptom disorder, hence psychodermatological treatment is indicated for its management. This concept reflects a significant change in the approach to this condition.

Sensations of skin infestation linked to abnormal frontolimbic brain reactivity and differences in self-representation.

Some patients experience skin sensations of infestation and contamination that are elusive to proximate dermatological explanation. We undertook a functional magnetic resonance imaging study of the brain to demonstrate, for the first time, that central processing of infestation-relevant stimuli is altered in patients with such abnormal skin sensations. We show differences in neural activity within amygdala, insula, middle temporal lobe and frontal cortices. Patients also demonstrated altered measures of self-representation, with poorer sensitivity to internal bodily (interoceptive) signals and greater susceptibility to take on an illusion of body ownership: the rubber hand illusion. Together, these findings highlight a potential model for the maintenance of abnormal skin sensations, encompassing heightened threat processing within amygdala, increased salience of skin representations within insula and compromised prefrontal capacity for self-regulation and appraisal.

Mechanical coordination in motor ensembles revealed using engineered artificial myosin filaments.

The sarcomere of muscle is composed of tens of thousands of myosin motors that self-assemble into thick filaments and interact with surrounding actin-based thin filaments in a dense, near-crystalline hexagonal lattice. Together, these actin-myosin interactions enable large-scale movement and force generation, two primary attributes of muscle. Research on isolated fibres has provided considerable insight into the collective properties of muscle, but how actin-myosin interactions are coordinated in an ensemble remains poorly understood. Here, we show that artificial myosin filaments, engineered using a DNA nanotube scaffold, provide precise control over motor number, type and spacing. Using both dimeric myosin V- and myosin VI-labelled nanotubes, we find that neither myosin density nor spacing has a significant effect on the gliding speed of actin filaments. This observation supports a simple model of myosin ensembles as energy reservoirs that buffer individual stochastic events to bring about smooth, continuous motion. Furthermore, gliding speed increases with cross-bridge compliance, but is limited by Brownian effects. As a first step to reconstituting muscle motility, we demonstrate human ß-cardiac myosin-driven gliding of actin filaments on DNA nanotubes.

Management of central nervous system tumours in children.

This article reviews current approaches to management of central nervous system tumours of childhood, highlighting aspects particularly pertinent to the paediatric population.

Planar patterned stretchable electrode arrays based on flexible printed circuits.

For stretchable electronics to achieve broad industrial application, they must be reliable to manufacture and must perform robustly while undergoing large deformations. We present a new strategy for creating planar stretchable electronics and demonstrate one such device, a stretchable microelectrode array based on flex circuit technology. Stretchability is achieved through novel, rationally designed perforations that provide islands of low strain and continuous low-strain pathways for conductive traces. This approach enables the device to maintain constant electrical properties and planarity while undergoing applied strains up to 15%. Materials selection is not limited to polyimide composite devices and can potentially be implemented with either soft or hard substrates and can incorporate standard metals or new nano-engineered conductors. By using standard flex circuit technology, our planar microelectrode device achieved constant resistances for strains up to 20% with less than a 4% resistance offset over 120,000 cycles at 10% strain.

Delusional infestation and the specimen sign: a European multicentre study in 148 consecutive cases.

BACKGROUND: Systematic studies of delusional infestation (DI), also known as delusional parasitosis, are scarce. They lack either dermatological or psychiatric detail. Little is known about the specimens that patients provide to prove their infestation. There is no study on the current presentation of DI in Europe. OBJECTIVES: To determine the number of true infestations, to assess with which pathogens patients believe themselves to be infested, and to gather details about the frequency and nature of the specimens and the containers used to store them, based on European study centres. METHODS: Retrospective study of consecutive cases with suspected DI from six centres (Dermatology, Psychiatry, Tropical Medicine) in four European countries (U.K., Germany, Italy, France). RESULTS: In total, 148 consecutive cases of suspected DI were included, i.e. the largest cohort reported. None of the patients had evidence of a genuine infestation, as shown by examinations by dermatologists and/or infectious disease specialists. Only 35% believed themselves to be infested by parasites; the majority reported a large number of other living or inanimate (17%) pathogens. Seventy-one patients (48%) presented with what they believed was proof of their infestation. These specimens were mostly skin particles or hair, and rarely insects (only very few of which were human pathogenic or anthropophilic, and none of these could be correlated with the clinical presentation), and only 4% were stored in matchboxes (three of 71). CONCLUSIONS: This first multicentre study of DI in Europe confirms that the term 'delusional infestation' better reflects current and future variations of this entity than 'delusional parasitosis'. The presentation of proofs of infestation, commonly referred to as 'the matchbox sign', is typical but not obligatory in DI and might better be called 'the specimen sign'.

Insecure attachment and frequent attendance in primary care: a longitudinal cohort study of medically unexplained symptom presentations in ten UK general practices.

BACKGROUND: In primary care frequent attenders with medically unexplained symptoms (MUS) pose a clinical and health resource challenge. We sought to understand these presentations in terms of the doctor-patient relationship, specifically to test the hypothesis that such patients have insecure emotional attachment. METHOD: We undertook a cohort follow-up study of 410 patients with MUS. Baseline questionnaires assessed adult attachment style, psychological distress, beliefs about the symptom, non-specific somatic symptoms, and physical function. A telephone interview following consultation assessed health worry, general practitioner (GP) management and satisfaction with consultation. The main outcome was annual GP consultation rate. RESULTS: Of consecutive attenders, 18% had an MUS. This group had a high mean consultation frequency of 5.24 [95% confidence interval (CI) 4.79-5.69] over the follow-up year. The prevalence of insecure attachment was 28 (95% CI 23-33) %. A significant association was found between insecure attachment style and frequent attendance, even after adjustment for sociodemographic characteristics, presence of chronic physical illness and baseline physical function [odds ratio (OR) 1.96 (95% CI 1.05-3.67)]. The association was particularly strong in those patients who believed that there was a physical cause for their initial MUS [OR 9.52 (95% CI 2.67-33.93)]. A possible model for the relationship between attachment style and frequent attendance is presented. CONCLUSIONS: Patients with MUS who attend frequently have insecure adult attachment styles, and their high consultation rate may therefore be conceptualized as pathological care-seeking behaviour linked to their insecure attachment. Understanding frequent attendance as pathological help seeking driven by difficulties in relating to caregiving figures may help doctors to manage their frequently attending patients in a different way.

Delusional infestation with unusual pathogens: a report of three cases.

Delusional infestation (DI) is a psychiatric disorder characterized by a fixed, false belief that the patient is infested with extracorporeal agents. It is known by several names, including the more commonly used term 'delusional parasitosis'. The psychiatric disease is responsible for the cutaneous pathology. About 90% of patients with DI seek help from dermatologists, and most reject psychiatric referral. Thus, effective management requires incorporation of psychiatric principles. We report three cases of DI with inanimate materials, and examine 'Morgellons' disease. We believe that patients with unusual presentations of DI are likely to be seen more commonly in the future. These patients appear to be a subgroup of DI, and may be even more difficult to treat than other patients with DI.

Symmetry and dynamics of molecular rotors in amphidynamic molecular crystals.

Rotary biomolecular machines rely on highly symmetric supramolecular structures with rotating units that operate within a densely packed frame of reference, stator, embedded within relatively rigid membranes. The most notable examples are the enzyme FoF1 ATP synthase and the bacterial flagellum, which undergo rotation in steps determined by the symmetries of their rotators and rotating units. Speculating that a precise control of rotational dynamics in rigid environments will be essential for the development of artificial molecular machines, we analyzed the relation between rotational symmetry order and equilibrium rotational dynamics in a set of crystalline molecular gyroscopes with rotators having axial symmetry that ranges from two- to fivefold. The site exchange frequency for these molecules in their closely related crystals at ambient temperature varies by several orders of magnitude, up to ca. 4.46 x 10(8) s(-1).