Cardiorespiratory Physiotherapy around the Clock: Experience at a University Hospital.

Purpose: To document and describe the use of a hospital-wide, 24-hour cardiorespiratory physiotherapy service run by an intensive care unit (ICU) team of physiotherapists. Methods: We prospectively collected data on all non-ICU hospital patients who used the 24-hours-per-day cardiorespiratory physiotherapy service over a 1-year period between July 2013 and June 2014. The ICU physiotherapists documented the reason, origin of referral, time of call, and type and frequency of treatment of each patient. Results: Over the 1-year period, the ICU physiotherapists administered 2,192 out-of-hours cardiorespiratory physiotherapy treatments (n=685 patients) outside the ICU. Most referrals originated from the emergency department (25%), the cardiopulmonary transplant unit (20%), and the pulmonology department (16%). Referrals were from a physiotherapist in 49% of cases, from a nurse in 32%, and from a physician in 19%. Of these, 89% were made between 4:00 p.m. and 8:00 a.m., and sputum retention was the most frequent reason (86%). Conclusion: Although proving its cost effectiveness is difficult, organizing a 24-hours-per-day, 7-days-per-week cardiorespiratory physiotherapy service in a large hospital is feasible.

Objectif : documenter et décrire la pratique d'un service de physiothérapie cardiorespiratoire 24 heures sur 24, 7 jours sur 7, destiné à tous les patients de l'hôpital et assuré par l'équipe de physiothérapeutes de l'unité des soins intensifs (USI). Méthodes : nous avons collecté des données de manière prospective auprès de l'ensemble des patients hospitalisés en dehors de l'USI qui ont eu recours au service de physiothérapie cardiorespiratoire 24 heures sur 24, 7 jours sur 7 sur une période d'un an, de juillet 2013 à juin 2014. Les physiothérapeutes de l'USI ont consigné le motif, l'origine et l'heure de l'appel, le type, la durée et la fréquence du traitement pour chaque patient. Résultats : au cours de la période d'un an, les physiothérapeutes de l'USI ont administré 2 192 traitements de physiothérapie cardiorespiratoire en dehors des heures normales (n=685 patients) à l'extérieur de l'USI. La plupart des patients étaient hospitalisés aux urgences (25%), dans l'unité de transplantation cardiopulmonaire (20%) et dans le département de pneumologie (16%). Les appels provenaient d'un physiothérapeute dans 49% des cas, d'un infirmier dans 32% et d'un médecin dans 19%. Parmi ceux-ci, 89% ont été faits entre 16 h et 8 h. Le désencombrement bronchique était le motif le plus fréquent (86%) de demande de traitement. Conclusion : bien qu'il soit difficile d'en prouver la rentabilité, l'organisation d'un service de physiothérapie cardiorespiratoire 24 heures sur 24, 7 jours sur 7, dans un grand hôpital est faisable.

Psoriasis patients with diabetes type 2 are at high risk of developing liver fibrosis during methotrexate treatment.

BACKGROUND/AIMS: We investigated the impact of diabetes mellitus type 2, overweight, alcohol over-consumption, and chronic hepatitis B or C as risk factors, for liver fibrosis in psoriasis patients treated with methotrexate. METHODS: One hundred and sixty-nine liver biopsies from 71 patients who underwent liver biopsies as part of the monitoring of methotrexate treatment for psoriasis were reviewed. Fibrosis, steatosis and inflammation were staged according to the NAFLD activity score. RESULTS: Twenty-six patients had one or more of the risk factors and 25 (96%) of these (median cumulative dose methotrexate 1500 mg) developed liver fibrosis. Of those without risk factor, 26 (58%) (p=0.012) developed fibrosis (median cumulative dose methotrexate 2100 mg). Ten (38%) of the patients with risk factor(s) had severe fibrosis (stage 3-4) (mean cumulative dose methotrexate 1600 mg), while four (9%) (p=0.0012) of those without risk factors had severe fibrosis (median cumulative dose methotrexate 1900 mg). CONCLUSIONS: Patients with methotrexate treated psoriasis and risk factors for liver disease, especially diabetes type 2 or overweight, are at higher risk of developing severe liver fibrosis compared to those without such risk factors, even when lower cumulative methotrexate doses are given.

Important factors for pain during photodynamic therapy for actinic keratosis.

Photodynamic therapy (PDT) is an efficient treatment for actinic keratosis. A common problem, however, is pain. The aim of this study was to investigate pain during PDT for actinic keratosis. The possibility of using capsaicin cream for pain relief was also assessed. Pain was investigated during aminolaevulinic acid PDT in 91 patients. Size, redness, scaling and induration of the lesions were recorded. Maximum pain during treatment was registered, using a visual analogue scale (0-10). The pain-reducing efficacy of capsaicin was tested in a pilot study in six patients (10 lesions). These patients were pre-treated with capsaicin cream for one week before commencing PDT. Pain was found to be normally distributed around a mean value of visual analogue scale 4.6. Larger lesions gave more pain (p=0.001). The redness of the actinic lesions was found to be related to PDT-induced pain (p=0.01), the reduction of actinic area (p=0.007), and the cure rate (p=0.01). The redder the actinic area, the better the treatment outcome and the more pain experienced. Patients with the largest reduction in the actinic area experienced more pain (p=0.053). The most important factors for presence of pain seem to be the size and the redness of the lesion. No significant pain relief was experienced after pre-treatment with capsaicin.

Congenital plaque-type glomuvenous malformations presenting in childhood.

BACKGROUND: Glomuvenous malformations (GVMs) are now considered a separate entity from venous malformations. The rarest type of GVM is the generalized congenital plaque-type GVM. OBSERVATIONS: We present 10 new cases of congenital plaque-type GVM and describe their clinical progression and treatment. Mutations in the glomulin gene were found in those patients who participated in the genetic study. CONCLUSIONS: Congenital plaque-type GVMs are unique in their congenital nature, extensive distribution, difficult to diagnose and treat, and progressive involvement after birth. Most cases are familial, yet affected relatives usually have only minor lesions. The lesions of congenital plaque-type GVM are severe, visible at birth, and usually mistaken for extensive venous malformations. Vascular malformations are divided by hemodynamic type into slow-flow and fast-flow lesions. Slow-flow lesions are subcategorized as capillary, lymphatic, and venous.(1) Capillary malformations are flat, sharply demarcated, red-pink vascular stains of the skin commonly referred to as port-wine stains. These persist throughout life and are characterized histologically by dilated capillaries within the dermis. They slowly increase in size with age. Lymphatic malformations are spongelike collections of abnormal channels and spaces that contain clear lymphatic fluid, causing an excess of fluid to accumulate and dilate the lymphatic channels. This results in swelling of the affected area and, if extensive, can cause enlargement of soft tissues and bones.

Clinical and immunohistochemical evaluation of psoriatic plaques treated with topical 5-aminolaevulinic acid photodynamic therapy.

BACKGROUND/PURPOSE: The aims of this study were to investigate the clinical and immunohistochemical events of psoriatic plaques during photodynamic therapy (PDT) using topical application of 5-aminolaevulinic acid (ALA). METHODS: Twelve psoriatic patients were recruited for this study. Four of them dropped out because of pain during treatment. The effect of PDT was evaluated in the remaining eight. One plaque was selected in each patient and treated once weekly with PDT 10-30 J/cm(2) two to five times. It was evaluated by using the scale, erythema and induration (SEI) index (maximal score per patient=9). Pain during treatment was assessed by a visual analogue scale (VAS), ranging from 0 to 10. Skin biopsies were taken before treatment, after two treatments and after completion of treatment, and were evaluated by immunohistochemistry. RESULTS: Median SEI scores were significantly reduced from 7 (range 5-9) before to 1.5 (range 0-3) following treatment (P<0.0001). The median pain during PDT was 7. The number of vessels in the subpapillary dermis, identified by antibodies against Factor VIII and endoglin, increased during and/or after treatment in six of eight patients. Before treatment, the epidermal growth factor (EGF) receptor was displayed throughout the epidermis, keratin 16 suprabasally, involucrin from the stratum granulosum to the lower spinous layers and filaggrin in stratum granulosum with focal absence. There was a moderate dermal infiltrate of CD4(+) cells and a sparse one of CD8(+). Following treatment, the EGF receptor was still displayed throughout the epidermis in seven of eight specimens. Cytokeratin 16 expression decreased markedly. Involucrin was not seen as deep in the spinous layers as before PDT. Filaggrin was expressed throughout the stratum granulosum and often weakly in the upper stratum spinosum. The number of CD4(+) and CD8(+) dermal cells decreased. CONCLUSION: PDT improved psoriasis and induced dermal neovascularization. Although a good clinical response was seen in most of our patients, the high frequency of discomfort during treatment limits the usefulness of ALA-PDT for psoriasis. The mechanism of the neovascularization is unknown. It may be owing to an indirect effect of PDT on the microvasculature and immune system or recovery phenomena.

The prevalence of hepatitis C in patients with porphyria cutanea tarda in Stockholm, Sweden.

In many countries hepatitis C virus infection has been considered a major factor triggering overt porphyria cutanea tarda. The prevalence of hepatitis C virus infection was retrospectively studied in 87 patients who during a period of 11 years were diagnosed with porphyria cutanea tarda in Stockholm. Among patients with the sporadic form of porphyria cutanea tarda, the prevalence of hepatitis C virus infection was 36.4%. As hepatitis C virus infection may today be successfully treated and as the infection may be clinically silent and thus unknown to the patient, it is important to screen all patients with porphyria cutanea tarda for hepatitis C virus infection.

Laser treatment of rosacea: a pathoetiological study.

OBJECTIVE: To study the effect of laser treatment on rosacea, a common facial skin disease with symptoms of blushing, redness, telangiectasis, papules, pustules, and diffuse swelling of the skin, we focused on the stinging sensation and performed immunohistochemical evaluation of nerve density and neuropeptide expression. DESIGN: Clinical investigation as well as the lactic acid (stinger) test was performed before and 3 months after the treatment with flashlamp pulsed dye laser, when skin biopsy specimens were also taken. SETTING: University hospital. PATIENTS: Thirty-two patients with rosacea, all with positive results from the lactic acid "stinger" test, were treated by flashlamp pulsed dye laser. MAIN OUTCOME MEASURES: The biopsy specimens were taken from the stinger-positive areas in the nasolabial folds, fixed in Lanas fixative (10% formalin and 0.4% picric acid), and analyzed for the expression of protein gene product 9.5 (general nerve marker), substance P, calcitonin gene-related peptide, and vasoactive intestinal polypeptide, using a biotinylated streptavidin technique. RESULTS: Thirty-one patients who were stinger positive before treatment showed decreased scores after treatment, and 1 patient had the same stinger test score before and after treatment. The number of protein gene product 9.5-positive fibers in the epidermis (P< .05) as well as the papillary dermis (P< .01) was decreased. This was also the case for substance P in the papillary dermis (P< .001), whereas no evident difference was noted for vasoactive intestinal polypeptide and calcitonin gene-related peptide. No difference was found for contact between nerves and vessels (factor VIII positive). CONCLUSIONS: Laser treatment of rosacea that destroys small vessels has a good medical relevance because it reduces the unpleasant symptoms of the sensitive skin. A neurogenic etiology of stinging may be possible.

The mutagenic effect of ultraviolet-A1 on human skin demonstrated by sequencing the p53 gene in single keratinocytes.

BACKGROUND: Sun exposure is accepted as the major risk factor for developing skin cancer, the most common cancer in the western world. Ultraviolet-B (UV-B) radiation is considered the causative agent, but recently several findings suggest a role also for ultraviolet-A (UV-A) radiation. Repeated suberythemal doses of ultraviolet-A1 (UV-A1) on healthy human skin induce an increase of p53 immunoreactive cells in epidermis, which may indicate cell cycle arrest and/or occurrence of p53 mutations. METHODS: We have investigated the possible mutagenic effect of UV-A1 on skin by sequencing exons 4-11 and adjacent intron sequence of the p53 gene in immunoreactive single cells from three healthy individuals. Previously unexposed buttock skin was irradiated three times a week for 2 weeks with physiological fluences (40 J/cm2) of UV-A1. Punch biopsies were taken before and at different time-points after the exposure, and from these single p53 immunoreactive cells were isolated by using laser-assisted microdissection. RESULTS: Three mutations--all being indicative of oxidative damage and most likely related to UV-A exposure--were found among the 37 single cells from exposed skin, whereas no mutations were found in the 22 single cells taken before exposure. CONCLUSIONS: The findings indicate a mutagenic effect of low-dose UV-A1 on healthy human skin, which further demonstrates the importance of considering UV-A when taking protective measures against skin cancer.