Hospitals' Food Services Quality and Factors Associated with Patients' Satisfaction in University Hospitals in the North of Iran.

This cross-sectional study evaluated patients' satisfaction with hospital meals in seven urban public hospitals using a validated questionnaire. The quality of food services based on the hospital standards was assessed using a checklist prepared by Iran's ministry of health. Of 800 subjects, the quality and quantity aspects of hospital meals, in general, were nearly satisfactory to the patients (mean score: 2.13, range: 1-3, SD: 0.39, 40% good and 36% moderate). The mean score of hospitals' food service quality based on hospital standards was 2.17 (range: 0-4, SD: 0.59). Females, younger patients and those with higher education level reported to be less pleased with hospital meal services. No relationship between patients' satisfaction and hospital food quality assessment based on hospital standards was found.

Treatment of Imiquimod Resistant Epidermodysplasia Verruciformis With Ingenol Mebutate.

BACKGROUND: Epidermodysplasia verruciformis (EV) is a rare genetic disorder characterized by widespread human papillomavirus (HPV) associated lesions and an increase susceptibility to cutaneous malignancies. A host of medications traditionally used to treat warty lesions have been used with variable results and limited success. To our knowledge, we describe the first reported case of a patient with Imiquimod resistant EV successfully treated with topical ingenol mebutate (Picato). CASE: A patient with a 5 year history of EV failed to respond to a 6 week course of 5% imiquimod on the forehead and was subsequently treated with a 3 day course of 0.015% Picato gel which resulted in significant clinical improvement. A one month follow-up examination showed no reoccurrence of the lesions with the patient reporting continued satisfaction of the outcome. CONCLUSION: Our case provides insight into the potential use of ingenol mebutate for EV patients unresponsive to traditional medical treatments.

Multicentric primary extramammary Paget disease: a Toker cell disorder?

Toker cells are epithelial clear cells found in the areolar and nipple areas of the breast, vulvar region, and other apocrine gland-bearing areas of the skin. Toker cells have been implicated in the pathogenesis of clear cell papulosis, cutaneous hamartoma with pagetoid cells, and rare cases of primary extramammary Paget disease (EMPD) but not in secondary EMPD with underlying adenocarcinoma. The pathogenesis of primary EMPD is not well defined. We report a case of multicentric primary EMPD with evidence of Toker cell proliferation and nonaggressive biologic behavior in a 63-year-old white man. A detailed description of the morphologic and biologic features of Toker cells and their possible carcinogenetic links also are discussed. Based on the observation and follow-up of our patient, we hypothesize that multicentric primary EMPD starts with Toker cell hyperplasia and can potentially evolve to carcinoma in the genital region.

The debate between gadolinium versus erythropoietin in a renal transplant patient with nephrogenic systemic fibrosis.

Nephrogenic systemic fibrosis (NSF), previously known as nephrogenic fibrosing dermopathy, is a debilitating skin condition that causes fibrotic changes in the setting of renal failure. Gadolinium-based contrast agents (GBCA), erythropoietin (EPO), and vascular intervention are the most widely known associated factors in the pathogenesis. A 53-year-old female with chronic renal insufficiency secondary to fibrillary glomerulonephritis (FGN) presented with generalized hardening of skin 1 week after her renal transplant. Due to her numerous medical and surgical health problems, she had received six imaging procedures with GBCA with the last being eight months prior to the onset of her skin symptoms. She had also historically been treated with high doses of EPO. Histopathologic examination was consistent with NSF. In susceptible renal failure patients who develop NSF after GBCA exposure, the onset of symptoms is usually within a 2-3 month time frame, which undermines but not eliminates the proposed role of GBCA in our patient. It can be proposed that despite having various risk factors, while being exposed to high doses of EPO, vascular trauma during renal transplant facilitated the onset of her symptoms.

Necrobiotic xanthogranuloma of the extremities with paraproteinemia and without periorbital involvement at presentation.

We report a rare case of necrobiotic xanthogranuloma (NXG) of the extremities with paraproteinemia and without periorbital involvement at presentation in a 58-year-old white woman. A combination of oral cyclophosphamide and oral dexamethasone was attempted, but the patient then developed a left intraorbital lesion. Treatment was not successful in that the gammopathy did not improve and the patient continued to develop more lesions.

Langerhans cells and melanocytes share similar morphologic features under in vivo reflectance confocal microscopy: a challenge for melanoma diagnosis.

BACKGROUND: Intraepidermal Langerhans cells (ILC) are difficult to differentiate from melanocytes under reflectance confocal microscopy (RCM) and their presence may simulate pagetoid spread of melanocytes on RCM images. OBJECTIVE: We sought to correlate bright round and dendritic cells in a pagetoid pattern identified on RCM with findings of conventional histopathology and immunohistochemistry for lesions that were falsely diagnosed as melanoma by RCM. METHODS: This retrospective study included histopathologically proven nevi, imaged by RCM, which displayed bright cells in a pagetoid pattern (BCPP) under RCM, resulting in the incorrect RCM diagnosis of melanoma. Morphological comparisons were made between RCM images of nevi showing BCPP, histopathologically proven melanomas displaying BCPP, and biopsy-proven nevi without BCPP. RESULTS: We identified 24 nevi that were falsely diagnosed as melanoma by RCM because of the presence of BCPP. These pagetoid cells on RCM corresponded on histopathology to ILC with a high density in 23 of the 24 nevi (95%) and to melanocytes in 7 of the 24 nevi (29%). Among 6 melanomas displaying BCPP on RCM, ILC with high density were observed histopathologically in 5 of the 6 cases (83%) and pagetoid melanocytes were seen in all 6 cases (100%). LIMITATIONS: The results cannot be generalized to clinically banal-appearing nevi. CONCLUSIONS: Although the finding of BCPP is a useful RCM feature for the diagnosis of melanoma, it does not always imply the presence of pagetoid melanocytes but may at times represent ILC.

Noninvasive imaging technologies in the diagnosis of melanoma.

The incidence of melanoma has increased during the last few years. Melanoma care and survival can be improved by early diagnosis, which can be facilitated by the use of noninvasive imaging modalities. Here we review 5 modalities available in clinical practice. Total body photography is used to follow patients at high risk for melanoma by detecting new lesions or subtle changes in existing lesions. Dermoscopy is an effective noninvasive technique for the early recognition of melanoma by allowing clinicians to visualize subsurface structures. Computer-assisted diagnostic devices are fully automated analysis systems with the capacity to classify lesions as benign or malignant with limited involvement from clinicians. Confocal scanning laser microscopy is an in vivo and noninvasive technology that examines the skin at a resolution comparable to that of histology. High-resolution ultrasound is an adjunct diagnostic aid mainly for the early detection of lymph node metastasis. Applications and limitations of each technology are discussed.

Randomized trial of pimecrolimus cream versus triamcinolone acetonide paste in the treatment of oral lichen planus.

BACKGROUND: Lichen planus is a common chronic inflammatory mucocutaneous disease, affecting 0.1% to 4% of the general population. There is no published randomized active control clinical trial on pimecrolimus for the treatment of oral lichen planus (OLP). OBJECTIVE: The purpose of this study was to compare the efficacy and safety of pimecrolimus 1% cream with triamcinolone acetonide 0.1% paste in treating OLP. METHODS: In this investigator-blinded parallel-group randomized clinical trial, 40 patients were randomly assigned in two equal groups to receive either pimecrolimus 1% cream or triamcinolone acetonide 0.1% paste 4 times daily for a total of 2 months and followed up for another 2 months. The patients were assessed for painful symptoms measured by visual analog scale, the Oral Health Impact Profile score, and objective clinical score. Nonparametric tests were used to assess the main outcomes. Intention-to-treat analysis was used. RESULTS: Eighteen patients in pimecrolimus group and 17 patients in triamcinolone group finished the 4-month trial course. Both pimecrolimus and triamcinolone groups showed significant improvement in all measured efficacy end points throughout the visits. There was no significant difference between changes from baseline median values of pimecrolimus and triamcinolone groups after treatment termination in terms of visual analog scale score (-9.8 +/- 11.3 vs -8.4 +/- 18.3, P = .70), Oral Health Impact Profile score (-1.5 +/- 2.6 vs -1.6 +/- 2.1, P = .38), and clinical score (-0.7 +/- 0.6 vs -0.8 +/- 0.7, P = .86), respectively. Two patients in pimecrolimus group experienced prominent but transient burning sensation whereas none of the patients in triamcinolone group had any prominent adverse event (P = .24). LIMITATIONS: Blood levels in pimecrolimus group were not measured and carcinogenicity of pimecrolimus, especially in its long-term use for OLP, is yet to be determined. CONCLUSION: This study showed that patients with OLP may benefit from both topical pimecrolimus and triamcinolone acetonide therapy with minimal side effects. Further studies should be conducted to assess the maintenance effects and long-term safety of both drugs (Cochrane skin group identifier: CSG TrialNo. 22).