Dermatology outpatient case-mix survey for all Welsh Trusts, 2007.

Background In 2006 a U.K. government White Paper recommended making NHS care in England more accessible by shifting services from secondary care into community settings. There is a shortage of contemporary activity data for U.K. dermatology units to allow benchmarking for service development. This study will not only provide useful comparative data for the future in Wales, but will also serve to highlight the impact of changes made in England. Objective To provide an overview of 1 week's dermatology outpatient activity for the whole of Wales. Methods All dermatology units in Wales collected data for 1 week in early 2007. The case mix, appropriateness of referral, requirement for surgery or second-line therapies and follow-up requirements were all determined. Results A total of 2142 patients were seen. Of new patients, 21% had skin cancer. Seventeen per cent of skin cancers had no diagnosis suggested by the general practitioner (GP) and 10% of basal cell carcinomas, 33% of squamous cell carcinomas and 17% of malignant melanomas were inappropriately diagnosed. In all, 26% of new patients had benign lesions, and this group caused the greatest diagnostic difficulty for GPs. Seventy-one per cent of these patients were diagnosed, reassured and discharged at their first visit without the need for biopsy or surgery. Thirty-seven per cent of new patients required surgery, of which 21% required complex intervention. Twenty-six per cent of follow-up patients were receiving second-line therapies. The new to follow-up ratio varied considerably according to diagnosis, the mean ratio being 1 : 0.21 for benign lesions through to 1 : 5.53 for psoriasis. This highlights the inappropriate nature of a 'one fits all' ratio. The majority of follow-up patients in secondary care required this level of input for monitoring of cancer, complex second-line therapies or surgery. Conclusions This study provides evidence to support logical planning of dermatological services and to assess the impact of proposed changes on different healthcare systems in the U.K.

Cyclosporin for severe childhood atopic dermatitis: short course versus continuous therapy.

Cyclosporin (CyA) has been shown to be highly effective and well tolerated in the short-term treatment of severe childhood atopic dermatitis; however, there is limited experience in its longer-term use. The aim of this study was to compare multiple short courses of CyA with continuous therapy for 1 year, with respect to efficacy, safety, tolerability and quality of life. Children aged 2-16 years, with a diagnosis of severe atopic dermatitis refractory to topical steroid therapy, were randomly assigned to receive short course therapy (multiple courses of 12 weeks) or continuous therapy. The starting dose and maximum dose for all patients was 5 mg/kg per day. Disease activity was monitored using the Six Area Six Sign Atopic Dermatitis score and the 'Rule of Nines' area score. Pruritus, sleep disturbance and irritability were measured using visual analogue scales, and topical therapy was monitored. Safety measurements included monitoring of serum creatinine, blood pressure and adverse events. Forty patients were included in the efficacy analysis, 21 of whom were randomized to the short course group (of whom six were withdrawn) and 19 to the continuous group (of whom five were withdrawn). Significant improvements were seen in all efficacy parameters at every time-point. There were no significant differences between groups, although the improvement was more consistent in the continuous arm. In the short course arm, 7 out of 21 patients could be managed by at least two short courses. The remaining 14 patients includes 12 who could not be controlled by at least two short courses, one patient who failed to return after week 12 and another patient who was withdrawn at week 4 due to an adverse event. Quality of life improved for both the children and their families. Tolerability was considered good or very good in at least 80% of the patients at week 12 and at the end of the study. No clinically significant change was seen in mean serum creatinine and no change was seen in mean blood pressure in either group. CyA is effective in controlling severe atopic dermatitis in children over a 1-year period and is well tolerated. More consistent control is achieved with continuous treatment; however, short course therapy was adequate for some patients, indicating that treatment should be tailored to the individual patient's needs. Short course treatment may produce prolonged remission in some cases and reduce the cumulative exposure to the drug.

Sarcoidosis presenting with a granulomatous reaction confined to red tattoos.

A patient with sarcoidosis who presented with a granulomatous tattoo reaction is described. Although tattoo granulomata usually represent a local hypersensitivity reaction to tattoo pigments, they can be a manifestation of systemic sarcoidosis. In this case the lesions were confined to the red areas of tattoos suggesting that tattoo sarcoid may be more than just an example of the Koebner response.

Selective activation of circulating CD4+ lymphocytes in severe adult atopic dermatitis.

An analysis of peripheral blood lymphocyte subsets and their expression of activation markers was performed using flow cytometry in 12 adult patients with severe atopic dermatitis, and compared with 14 normal individuals. Repeated measurements were made over an 8-week period during which disease activity was also assessed. Increased percentages of activated and unactivated CD4+ lymphocytes, and decreased percentages of CD8+ cells were observed in atopic dermatitis. Increasing disease activity was associated with an increase in the proportion of activated and unactivated CD4+ lymphocytes and a fall in the proportion of CD8+ cells. This study demonstrates that in adults with severe atopic dermatitis, increasing disease activity is associated with selective activation of CD4+ lymphocytes and a relative expansion of the CD4+ cell subset.

Double-blind, controlled, crossover study of cyclosporin in adults with severe refractory atopic dermatitis.

A few patients remain severely affected by atopic dermatitis into adult life despite treatment with systemic steroids, azathioprine, and photochemotherapy. 33 patients took part in a double-blind, placebo-controlled, crossover study to assess the efficacy and safety of cyclosporin (5 mg/kg per day) in adults with severe refractory atopic dermatitis. Treatments were given for eight weeks each with one group (n = 16) receiving placebo followed by cyclosporin and another (n = 17) receiving cyclosporin and then placebo. Disease activity, extent of disease, sleep and itch, topical steroid use, and adverse events were assessed every two weeks. Both extent and activity of dermatitis were significantly improved (p less than 0.001) as were subjective measures of disease. 20 patients receiving cyclosporin reported adverse events compared with 8 taking placebo, although no patient required withdrawal from the study. Cyclosporin therapy led to an increase in the mean serum urea, creatinine, and bilirubin concentrations, although only the rise in bilirubin was significant (p = 0.001). Our results confirm that cyclosporin is a safe and effective short-term treatment for severe, refractory atopic dermatitis.

Red tattoo reactions: X-ray microanalysis and patch-test studies.

Eighteen patients who developed cutaneous reactions to red tattoos were studied to identify the chemicals responsible for the reactions to modern red tattoo pigments. Biopsies from the tattoos were examined histologically and the chemical composition of the red pigments was analysed by X-ray microanalysis. A variety of metallic elements including aluminium, iron, calcium, titanium, silicon, mercury and cadmium were detected. Patch tests were performed to the relevant chemicals in nine cases, and only one patient reacted to mercury. This study demonstrates that although reactions to mercury still occur, other red dyes containing a variety of inorganic pigments may provoke a cutaneous inflammatory response.

Multifocal fixed drug eruption mimicking erythema multiforme.

A 38-year-old woman presented with a widespread bullous eruption that recurred during menstruation. Skin biopsy suggested erythema multiforme. As she was receiving synthetic progesterones for dysmenorrhoea the diagnosis of an auto-immune progesterone dermatitis was considered. However, subsequent investigations confirmed the diagnosis to be a fixed drug eruption to mefenamic acid taken for dysmenorrhoea.

Isolated lichen planus of the nails associated with primary biliary cirrhosis.

Lichen planus is a relatively common inflammatory dermatosis with characteristic lesions affecting the skin, nails and mucous membranes. Nail changes are present in approximately 10% of patients and can occasionally occur in the absence of skin involvement. The association of lichen planus with primary biliary cirrhosis is now well recognized. We report the first case of lichen planus confined to the nails in a patient with primary biliary cirrhosis.

Inhibition of normal and psoriatic epidermal phospholipase A2 by picomolar concentrations of recombinant human lipocortin I.

Normal human and psoriatic epidermal phospholipase A2 (PLA2) was inhibited by human recombinant lipocortin I when the substrate was present in a several million-fold molar excess. Inhibition was not total, even at relatively high concentrations of lipocortin I. It is therefore suggested that human epidermis contains two species of PLA2: one that is controlled by lipocortin I and one that is not.

Hyperkalaemic periodic paralysis: a rare presentation of Addison's disease.

A 44 year old man with longstanding diabetes mellitus gave a 6-month history of periodic attacks of flaccid quadriplegia. Following one of these episodes he was admitted for assessment. In view of persistent hyperkalaemia, hypoadrenalism was suspected and Addison's disease was confirmed biochemically. Adrenal replacement therapy restored the potassium levels to normal and resulted in no further attacks of paralysis.

A prime number approach to biological sequencing.

Computational sequencing of nucleic acid and amino acid sequences is placing increasing demands on computer resources. The use of prime numbers is explored as a convenient means of improving program speed and reducing storage requirements. It is concluded that the application of the prime number approach leads to significant increases in speed and some reduction in storage requirements.

Defective phagocytosis in insulin controlled diabetics: evidence for a reaction between glucose and opsonising proteins.

Neutrophils from diabetic patients controlled with insulin showed impaired phagocytosis of a yeast, Candida guilliermondii. The defect was detected by measuring the initial rate of phagocytosis at optimal concentrations of phagocytes and organisms in autologous plasma. By mixing normal neutrophils in diabetic plasma and vice versa both cellular and plasma abnormalities were shown. The defect was reproduced by incubating normal plasma at a D-glucose concentration of 15 mmol/l for 3 h or for shorter periods at higher concentrations of glucose. The data suggest that defective phagocytosis is partly due to a reaction between glucose and the plasma proteins concerned with opsonisation. Defective phagocytosis may be important not only in coping with infections but also in other diabetic complications as plasma proteins are concerned with the removal of damaged or effete cells as well as foreign antigens.

Shapes of carcinogenic benz[a]anthracenes: the crystal and molecular structure of 1-methylbenz[a]anthracene.

The crystal structure of 1-methylbenz[a]lanthracene, which is weakly carcinogenic, has been determined by application of direct methods to single-crystal X-ray diffractometric data and refined by least squares to R = 0.09 over 845 independent reflections. Crystals are monoclinic, space group P2(1), with a = 8.491(2), b = 7.138(2), c = 10.500(2)ABEta = 95.06(01), Z = 2. As in other benz[a]anthracenes, the K-region bond C(5)-C(6) is short [1.34(1)A]. The distinctive bay geometry, with a methyl group opposite to a hydrogen, H(12), peri to another hydrogen, H(11), has a long bond C(13)--C(18) = 1.47(1)A in the bay, and the angular benz-ring is inclined at 16.5 degrees to the mean plane of the anthracene fragment. The methyl carbon atom is 0.79 A out of the mean molecular plane (or 0.19 A out of the plane of the benz-ring) and the 1.50 A long C(1)-methyl bond makes angles of 117 degrees and 125 degrees at C(1).

Shapes of carcinogenic benz[alpha]anthracenes: an x-ray crystal structure analysis of 12-methylbenz[alpha]anthracene.

The crystal structure of the moderately active carcinogen 12-methylbenz[alpha]anthracene (12-MBA) has been determined by application of direct methods to X-ray single-crystal diffraction data. Least-squares refinement to a residual R = 0.09 over 929 independent reflections enabled carbon positions to be established with apparent e.s.d.s. of atomic coordinates about 0.008 A. Deviation from planarity is exemplified by the 15.5 degrees inclination of the benz ring (A) to the anthracene nucleus and by the 0.89 A distance of the methyl carbon out of the best plane through the whole benzanthracene nucleus. Comparison with the structure of the highly carcinogenic 7,12-dimethylbenz[alpha]anthracene (7,12-DMBA), and with the recently solved structures of the weak carcinogen 1-MBA and the extremely weak carcinogen 1,12-DMBA, shows a close similarity in the anthracene parts; in 1-MBA, and 1,12-DMBA, the phenanthrenic K-region bond is close to 1.34 A and the M-region bond about 1.38 A. In 12-MBA, overcrowding in the 'bay' region causes the central anthracene ring C and the benz ring A each to be bent about 10 degrees in opposite directions from the phenanthrenic B ring, much as in 1-MBA and 7,12-DMBA, but less than in 1,12-DMBA; the 12-methyl carbon lies about the same distance (0.55 A) above the anthracene plane in 12-MBA as in 1,12-MBA and 7,12-DMBA.