Occupational asthma in teachers.

BACKGROUND: Work-related asthma symptoms are common in teachers and teaching assistants, there are few studies evaluating their causes. AIMS: To identify causes of occupational asthma in teachers and teaching assistants referred to the Birmingham Occupational Lung Disease clinic 2000-20 using evaluation of serial Peak Expiratory Flow (PEF) records. METHODS: Teachers and teaching assistants with possible occupational asthma were asked to record PEF 2-hourly at home and work for 4 weeks. Their records were evaluated with the Oasys programme. Those with a positive score for any of the three scores (area between curves (ABC), timepoint and Oasys score from discriminant analysis) were included. Repeat records were made as indicated to help identify the cause and the effects of remedial actions. RESULTS: Thirty-eight teachers or teaching assistants met the inclusion criteria with all three Oasys scores positive in 24, 2/3 scores in nine and 1/3 in five. The building was the likely cause in 17 (in new builds particularly acrylates from carpet adhesives and in old buildings mould and construction dust), bystander exposure to agents in the schools in 12 (cleaning agents, acrylates from photocopiers and chloramines from indoor pools) and materials used in the classroom in 9 (most commonly MDF in design and technology classes). We illustrate how the PEF records helped identify the cause. CONCLUSIONS: Oasys analysis of PEF records is a useful method of evaluating occupational asthma in teachers and identified difficult to confirm causes where successful remediation or redeployment was achieved.

Disability and disability benefit seeking in chronic low back pain.

BACKGROUND: Numerous studies suggest psychosocial factors contribute to functional disability in patients with chronic low back pain (CLBP). However, less is known about the association of psychosocial factors, such as depression, with seeking medical disability benefits and their prevalence in benefit seekers compared with patients already receiving such payments. AIMS: To determine if characteristics of disability benefit seekers differ from patients receiving disability benefits and if both differ from patients not dependent on such payments. METHODS: Questionnaire data on pain, health-related quality of life, depression, social support, substance abuse, adverse childhood experiences and disability seeking were obtained from CLBP respondents recruited at 10 primary care clinics throughout Texas. A multinomial logistic regression model was computed using variables significantly associated with disability status and pain severity in univariate models. RESULTS: There were 213 participants. In full models, compared with those not on disability benefits, only depression symptoms were significantly associated with seeking disability benefits (odds ratio [OR] = 1.13; 95% confidence interval [CI] 1.01-1.26) and only duration of pain was significantly associated with being on such benefits (OR = 1.05; 95% CI 1.01-1.09). CONCLUSIONS: Patient characteristics differ between disability benefit seekers and those established on disability benefit payments. Depression may be a modifiable correlate of disability benefit seeking that if treated may reduce the number of patients who eventually come to depend on disability benefits. Additional data collection involving other pain syndromes is warranted to determine if these results are unique to CLBP or apply to other painful conditions.

More than skin deep? Emerging therapies for chronic cutaneous GVHD.

The options for treating skin disease after haemopoietic progenitor cell transplant (HPCT) have broadened considerably over the last decade to include much more than topical steroids and emollients. This article reviews current and emerging therapies for chronic cutaneous GVHD, a well-recognised complication of HPCT. Alongside skin-directed therapies, there is now a wide range of systemic agents with differing targets for which an evidence base is emerging. Of particular interest, we summarise the role of electrocorporeal photopheresis, a therapy increasingly used in the United Kingdom to treat severe sclerodermoid manifestations of GVHD. We include a discussion of the expanding knowledge of the pathogenesis of cutaneous GVHD, which is informing our understanding and development of second line therapies (for example, the role of B cells and the utility of rituximab). Additionally, we draw attention to challenges encountered in the evaluation of chronic GVHD treatments and highlight recommendations for further research that may enable haematologists and dermatologists to provide better care for these patients. Finally, we present a clinical algorithm to aid the approach to treating limited and extensive disease and steroid refractory or persistent disease where steroid sparing may be necessary.

Medium-density fibreboard and occupational asthma. A case series.

BACKGROUND: Medium-density fibreboard (MDF) is a wood composite material, composed primarily of softwood, bonded with a synthetic formaldehyde-based resin. It is increasingly used, as it has various advantages over natural woods. METHODS: Enquiry of the national reporting scheme data and three case reports were used to further the evidence base linking this exposure to occupational asthma (OA). RESULTS: From 1991 to 2007, 21 cases of occupational sensitization to MDF were reported to the UK voluntary reporting scheme, Surveillance of Work Related Occupational Respiratory Disease (SWORD): 18 reported as occupational asthma (OA) and 3 as occupational rhinitis. All workers were male, with a mean age of 48 years, working in education, furniture manufacturing or joinery among other employments. CONCLUSIONS: Whilst reporting scheme data identified relatively small numbers of cases of OA likely to be due to MDF, the evidence base supporting this link is generally lacking. The three cases presented, where OA was attributed to MDF exposure, add to this evidence.

A novel missense mutation in GJB2, p.Tyr65His, causes severe Vohwinkel syndrome.

Gap junctions are intercellular channels which are permeable to ions and small molecules up to about 1 kDa in size. They are prominent in the skin, but their precise function there is largely unknown. Mutations in skin-expressed gap junction genes disrupt epidermal growth and differentiation. A relatively minor epidermal connexin, connexin 26 (Cx26), is associated with a wide variety of phenotypes, each specifically associated with a particular amino acid residue. How the different mutations in GJB2 lead to such distinctive phenotypes is poorly understood. Analysis of new GJB2 mutations can shed new light on pathogenesis and the apparently vital role of Cx26 in maintaining epidermal integrity.

The neuropsychiatric phenotype in Darier disease.

BACKGROUND: Darier disease (DD) is a rare autosomal dominantly inherited skin disorder in which co-occurrence of neuropsychiatric abnormalities has been frequently reported by dermatologists. It is caused by mutations in a single gene, ATP2A2, which is expressed in the skin and brain. OBJECTIVES: To conduct the first systematic investigation of the neuropsychiatric phenotype in DD. METHODS: One hundred unrelated individuals with DD were assessed using a battery of standardized neuropsychiatric measures. Data were also obtained on a number of clinical features of DD. RESULTS: Individuals with DD were found to have high lifetime rates of mood disorders (50%), specifically major depression (30%) and bipolar disorder (4%), and suicide attempts (13%) and suicidal thoughts (31%). These were more common in DD when compared with general population data. The prevalence of epilepsy (3%) in the sample was also higher than the prevalence in the general population. There was no consistent association of specific dermatological features of DD and presence of psychiatric features. CONCLUSIONS: These findings highlight the need for clinicians to assess and recognize neuropsychiatric symptoms in DD. The results do not suggest that neuropsychiatric symptoms are simply a psychological reaction to having a skin disease, but are consistent with the pleiotropy hypothesis that mutations in the ATP2A2 gene, in addition to causing DD, confer susceptibility to neuropsychiatric features. Further research is needed to investigate genotype-phenotype correlations between the types and/or locations of pathogenic mutations within ATP2A2 and the expressed neuropsychiatric phenotypes.

Career choices in dermatology.

Reforms to both undergraduate and postgraduate training have resulted in limited exposure to clinical dermatology, and therefore we need to target advice and clinical attachments to the most appropriate stages of training to ensure that dermatology is considered as a career option by medical students. A questionnaire survey was undertaken to determine when and how doctors chose their career in dermatology. An electronic questionnaire was sent to 709 dermatologists (response rate 44%). Of the respondents, 49% considered dermatology after medical school attachment and 61% were influenced by the jobs they had done as a pre-registration house officer (PRHO) or senior house officer (SHO). Careers advice was lacking, with only 11% receiving it while at medical school and 29% during their PRHO/SHO years. Contact with an inspiring clinician was the most influential factor in choosing dermatology. Both medical students and junior doctors, should have opportunities to learn from and work with clinical dermatologists.

Poromas and porokeratosis in a patient treated for solid-organ and haematological malignancies.

We describe a patient with previous solid-organ (testicular, oesophageal) and haematological (acute myeloid leukaemia) malignancies, in whom chronic cutaneous graft-versus-host disease was complicated by poromas and porokeratosis. Chemotherapy, total body irradiation, longstanding immunosuppression and ultraviolet radiation may all have played a part in the pathogenesis of the skin tumours.

Audit of dermatological content of U.K. undergraduate curricula.

BACKGROUND: Recommendations for the dermatology content (learning outcomes) of the core undergraduate curriculum were sent to all U.K. medical schools in June 2006. OBJECTIVE: To carry out an audit of the content of the core curriculum in each U.K. medical school against the recommendations for a core undergraduate dermatology curriculum (the criteria) published by the British Association of Dermatologists, to identify areas of good practice and to gather evidence for developing the learning and teaching of dermatology. METHODS: A questionnaire was circulated to the dermatology teaching leads of all U.K. medical schools (29) and one Irish medical school. Questions which the teaching leads were unable to answer were sent to the relevant deans and responses incorporated into the results. All curricula should include the essential learning outcomes that focus on clinical skills; as this was an audit to benchmark current practice, we did not set standards for the other recommendations for a core curriculum. RESULTS: Replies were received from teaching leads in 29 of the 30 medical schools and from 16 of the deans. Essential clinical skills such as taking a dermatological history and examining the skin were included in the curricula of most, but not all, medical schools. Areas of good practice include teaching on tumours, acne and psoriasis, but we found some surprising omissions including the diagnosis of meningococcaemia. Our data suggest that some students have little exposure to dermatology, but dermatology teaching takes place in secondary care in all medical schools. Knowledge-based assessments are used by 27 medical schools. CONCLUSIONS: Curricula should be strengthened so that the recommended learning outcomes feature in the core curricula of all medical schools. Teaching leads in all specialties, including those in the community, should communicate so that learning and teaching are integrated horizontally and vertically. The results should provide a baseline for future audits.

Care of patients with psoriasis: an audit of U.K. services in secondary care.

BACKGROUND: Medical professionals require data about the structure and delivery of dermatological services in primary and secondary care in order to identify and tackle variations in standards and monitor the impact of healthcare reforms. The British Association of Dermatologists (BAD) commissioned an audit of the provision of care for patients with psoriasis. OBJECTIVES: To assess the staffing and facilities in dermatology units in the U.K. with a focus on the provision of care for patients with psoriasis. METHODS: Data were collected from 100 dermatology units in the U.K. for 1 year using a questionnaire and a web-based collection system. RESULTS: Key results are as follows. Eighteen per cent (18/98) of units had fewer than 2.0 whole-time equivalent consultants and 20% had no specialist dermatology nurse. Only 23% of units collected diagnostic data on outpatients, and half were unable to supply details about the number of attendances for psoriasis. Seventy-seven units reported admitting patients to dedicated dermatology beds, general medical beds, or both; three-quarters of units had access to dedicated adult dermatology beds. Pharmacy services were not always available for dermatology patients. Only 21 units (21%) had dedicated clinics for patients with psoriasis and 56% of units lacked a clinical psychology service willing to accept adult dermatology patients; 59% (55/93) lacked psychological services for children. Fifty-five per cent had no systemic drug monitoring clinic. Phototherapy was run by dermatology nurses in 93% (88/95) of the units and by physiotherapists in 11% (10/94). Biologics for psoriasis were prescribed in 75% (73/97) of units and in 88% (64/73) of these the BAD guidelines for the use of biologics were known to be followed. Of the seventy-three units prescribing biologic therapies, 64% had a nurse trained in the assessment and administration of biologics, 71% had facilities for outpatient infusions (e.g. for infliximab) and 39% were restricted in prescribing biologic agents because of financial constraints. A quality-of-life score was either inadequately or never recorded in outpatient records in 81% of units, increasing to 88% for inpatient records. The Psoriasis Area and Severity Index score was inadequately or never recorded in 79% of outpatient records and 82% of inpatient records. CONCLUSIONS: Units varied in their capacity to meet BAD guidelines and standards. Among the most significant deficiencies identified were a shortage of specialist dermatology nurses, treatment delivery by untrained nurses and financial constraints on the prescription of biologics for psoriasis. Gaps in data collection and record keeping jeopardize efforts to improve standards of care.

Multiple aggressive squamous skin cancers in association with nonbullous congenital ichthyosiform erythroderma.

Nonbullous congenital ichthyosiform erythroderma (NBCIE) is one of the autosomal recessive inherited non-syndromic ichthyoses and is currently diagnosed on clinical grounds alone. Skin cancer is not a recognized complication of NBCIE. We report here two NBCIE patients who have developed multiple aggressive nonmelanoma skin cancers, predominantly cutaneous squamous cell carcinoma. NBCIE may be a risk factor for skin cancer development.

Attributes of an effective trainer: implications of the views of UK dermatology trainees.

BACKGROUND: Trainers have a critical influence on the education of specialist registrars (SpRs) and the quality of training programmes. OBJECTIVES: This study gathered the opinions of U.K. dermatology SpRs on the attributes they felt were important in a trainer. METHODS: The questionnaire was sent to all U.K. dermatology SpRs (n=216). It comprised the stem: 'A good trainer (supervising consultant or educational supervisor)', followed by statements such as '...has realistic expectations of the trainee'. Respondents ranked each statement in importance using a five-point Likert scale. A free-text box was also included for respondents to list the least desirable attributes. RESULTS: Completed questionnaires were received from 146 trainees (68%). Four attributes were identified as most important: having an encouraging and supportive attitude, using feedback to identify specific areas for attention, being approachable, and being willing to answer questions. Least important attributes included openness to criticism of teaching skills, auditing of own clinical practice, sense of humour and place of work (district general vs. teaching hospital). Eighty-seven respondents indicated the least desirable attributes of a trainer. Most comments related to being uninterested in training, being unapproachable or unavailable, or undermining the trainee and using unconstructive criticism. CONCLUSIONS: The results highlight the importance to trainees of constructive feedback, and dialogue with trainers. Some of the stated undesirable characteristics in a trainer appeared to derive from personal experience. This is of serious concern, and ways in which the trainer-trainee relationship can be improved are discussed.

Defining the dermatological content of the undergraduate medical curriculum: a modified Delphi study.

BACKGROUND: Dermatological problems are common, but in undergraduate medical courses time for learning dermatology and teaching dermatology is limited. The Delphi technique has been used in other specialties to define undergraduate and postgraduate curricula and to reach consensus on what is important. OBJECTIVES: To identify the core dermatological content of the undergraduate medical curriculum. METHODS: Modified Delphi technique. A questionnaire was designed after review of previous recommendations made by dermatologists. Items were written as explicit learning outcomes. A multidisciplinary panel of 66 individuals responded. Outcomes were rated using a Likert scale (1-5). RESULTS: Fifty-three learning outcomes were rated 'very important'. We recommend that these are included in the content of U.K. undergraduate medical core curricula. CONCLUSIONS: A multidisciplinary panel identified dermatological learning outcomes that should be achieved by all medical graduates. Undergraduate medical curricula must provide sufficient resources for learning, teaching and assessment of dermatology so that graduates achieve these outcomes.