Cutaneous larva migrans: an unusual souvenir from a Scottish holiday.

Cutaneous larva migrans acquired in western Scotland. A reminder that with a warming climate, conditions conventionally restricted to the tropics may be contracted in the British Isles in the absence of foreign travel.

Frontal fibrosing alopecia: survey of severity assessment methods in routine clinical practice and validation of the International Frontal Fibrosing Alopecia Cooperative Group measurement guidance.

BACKGROUND: The lack of validated and responsive outcome measures in the management of frontal fibrosing alopecia (FFA) significantly limits assessment of disease progression and treatment response over time. AIM: To understand how FFA extent and progression is currently assessed in UK specialist centres, to validate components of the International FFA Cooperative Group (IFFACG) statement on FFA assessment, and to identify pragmatic advice to improve FFA management in clinic. METHODS: Consultant dermatologists with a specialist interest in hair loss (n = 17) were invited to take part. Preferred FFA assessment methods were explored using questionnaires and clinical scenarios. Participants were asked to identify and mark the current hairline in 10 frontal and 10 temporal hairline images (Questionnaire 1), with assessment repeated 3 months later to assess intraindividual variability (Questionnaire 2) and 12 months later to test whether interindividual accuracy could be improved with simple instruction (Questionnaire 3). RESULTS: All 17 clinicians (100%) completed the questionnaire at each time interval. We identified a wide variation in assessment techniques used by our experts. Measurements were perceived as the most accurate method of assessing frontal recession whereas photography was preferred for temporal recession. Inter-rater reliability between clinicians measuring the frontal hairline scenarios indicated a moderate strength of agreement [intraclass coefficient (ICC) = 0.61; 95% CI 0.40-0.85], yet intrarater reliability was found to be poor with wide limits of agreement (-8.71 mm to 9.92 mm) on follow-up. Importantly, when clear guidance was provided on how the hairline should be identified (Questionnaire 3), inter-rater reliability improved significantly, with ICC = 0.70, suggesting moderate agreement (95% CI 0.51-0.89; P < 0.001). A similar pattern was seen with temporal hairline measurements, which again improved in accuracy with instruction. CONCLUSION: We found that accuracy of measurements in FFA can be improved with simple instruction and we have validated components of the IFFACG measurement recommendations.

Delayed linkage to care in one-third of HIV-positive individuals in the Netherlands.

OBJECTIVES: To determine time to linkage to HIV care following diagnosis and to identify risk factors for delayed linkage. METHODS: Patients newly diagnosed with HIV at sexually transmitted infections (STI) clinics in the Netherlands were followed until linkage to care. Data were collected at the time of diagnosis and at first consultation in care, including demographics, behavioural information, CD4+ counts and HIV viral load (VL) measurements. Delayed linkage to care was defined as >4 weeks between HIV diagnosis and first consultation. RESULTS: 310 participants were included; the majority (90%) being men who have sex with men (MSM). For 259 participants (84%), a date of first consultation in care was known; median time to linkage was 9 days (range 0-435). Overall, 95 (31%) of the participants were not linked within 4 weeks of diagnosis; among them, 44 were linked late, and 51 were not linked at all by the end of study follow-up. Being young (<25 years), having non-Western ethnicity or lacking health insurance were independently associated with delayed linkage to care as well as being referred to care indirectly. Baseline CD4+ count, VL, perceived social support and stigma at diagnosis were not associated with delayed linkage. Risk behaviour and CD4+ counts declined between diagnosis and linkage to care. CONCLUSIONS: Although most newly diagnosed patients with HIV were linked to care within 4 weeks, delay was observed for one-third, with over half of them not yet linked at the end of follow-up. Vulnerable subpopulations (young, uninsured, ethnic minority) were at risk for delayed linkage. Testing those at risk is not sufficient, timely linkage to care needs to be better assured as well.

[Austrian interdisciplinary recommendations on pediatric perioperative pain management: background, aims, methods and key messages]. / Österreichische interdisziplinäre Handlungsempfehlungen zum perioperativen Schmerzmanagement bei Kindern : Hintergrund, Ziel, Methodik und Kernaussagen.

These recommendations were originally commissioned by the"Österreichische Gesellschaft für Anästhesiologie, Reanimation und Intensivmedizin" (ÖGARI, Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine). Against this background, Austrian experts from the disciplines anesthesiology, pain management, pediatrics and the "Berufsverband Kinderkrankenpflege" (Professional Association of Pediatric Nursing) have with legal support developed evidence-based and consensus recommendations for the clinical practice. The recommendations include key messages which cover the most important recommendations for the individual topics. The complete recommendations on pediatric perioperative pain management consist of seven separate articles which each deal with special sub-topics with comments on and explanations of the key messages. The target groups of the recommendations are all medical personnel of the individual disciplines involved in the treatment of perioperative and posttraumatic pain for neonates, infants and children up to 18 years old.

Management of granulomatous common variable immunodeficiency diagnosed in pregnancy: a case report.

Common variable immunodeficiency (CVID) is a rare condition that affects women of childbearing age with important implications in pregnancy. It is characterised by low immunoglobulins (Igs), poor antibody response and a susceptibility to recurrent infections. The cornerstone of management of CVID is Ig replacement. As the transfer of IgG across the placenta in the third trimester of pregnancy is necessary for protection of the infant in the first months of life, failure to recognise this condition and treat it appropriately can have adverse consequences for the neonate, as well as the mother. Here we describe the complex perinatal medical management of a 34-year-old woman who was diagnosed with CVID in the 26th week of pregnancy.

Amlodipine-induced linear IgA disease.

A 58-year-old woman presented with a 3-week history of a pruritic rash, which had started a week after commencing treatment with amlodipine. On physical examination, large, well-demarcated erythematous plaques, surrounded by small clusters of clear vesicles, were seen on the patient's torso. Subepidermal blisters with neutrophils and eosinophils were seen in a skin biopsy, and direct immunofluorescence showed deposition of IgA along the basement membrane, in keeping with a diagnosis of linear IgA dermatosis (LAD). Amlodipine was discontinued, and the patient was started on prednisolone 30 mg, supplemented shortly afterwards by dapsone, which resulted in prompt resolution of the rash. Only a few cases of drug-induced LAD have been reported, mostly in association with vancomycin. To our knowledge, this is the first reported case precipitated by amlodipine.

Lymphocytic variant of hypereosinophilic syndrome.

Hypereosinophilia may be associated with any of several underlying diseases. Atopy or allergic drug reactions are the most common causes, but infections with bacteria and parasites should also be considered in the differential diagnosis. When thorough evaluation of a patient with chronic hypereosinophilia fails to reveal an underlying disease, the diagnosis of idiopathic hypereosinophilic syndrome (HES) should be considered. We report a patient with unexplained persistent hypereosinophilia associated with a chronic pruritic rash and an underlying diagnosis of HES (lymphocytic variant).