Behavioural changes following gastric surgery for morbid obesity: a prospective, controlled study.

The authors present results of a prospective, controlled longterm follow-up study of patients undergoing a gastric procedure for morbid obesity. Pre-operatively the gastric surgery group (GS) was compared with a group of normal weighted (NC) and obese (OC) individuals participating in self-help weight reduction groups. The GS group was assessed at 3-months, 6-months and one year or more post-operatively. All groups were examined by a structured self-rating schedule reflecting personal characteristics and family history, current attitudes and experiences related to personal weight, and an extensive exploration of eating habits. Moreover, the groups completed the Minnesota Multiphasic Personality Inventory (MMPI), the Katz Adjustment Scale and the Zung Self-rating Depression Scale. The results demonstrated major differences between the GS and the NC and OC groups initially, and at follow-up; the GS demonstrated major weight loss without major psychopathologic reactions. The GS did not show, however, major alterations in eating habits, but clearly showed behavioural change subsequent to weight loss.

Society's reactions to facial disfigurements.

There is a paucity of thorough research on society's reaction to dentofacial anomalies, or to other forms of facial disfigurement. The author reviews the studies of the social effects of dental appearance that do exist, and then reports some results of his own researches into reaction to facial disfigurement. It appears from these studies that facial disfigurement (including dentofacial anomalies) can indeed be a cause of social disadvantage.

A home-based exercise programme improves ankle range of motion in long-term venous ulcer patients.

BACKGROUND AND OBJECTIVES: Decreased ankle mobility is associated with delayed healing of venous ulcers. The aim of this study was to assess the efficacy of a 24-week home-based exercise programme in increasing ankle range of motion and increasing the strength and endurance of the calf muscle. The secondary aim was to see whether subjects with venous ulcers were able to maintain a consistent exercise programme. METHODS: Eleven patients with long-standing venous ulcers were encouraged to undertake a thrice-weekly 5-10 min ankle exercise programme using elastic resistance bands and stretching in a 24-week single-arm pilot study. Ankle range of motion was measured monthly using a bi-plane ankle goniometer. Pain scores and participation levels were also recorded. RESULTS: There were significant improvements in ankle range of motion achieved at 12 and 24 weeks. Median pain scores (scale of 1-10) were reduced from 5.2 at baseline to 2.0 at weeks 12 and 24. CONCLUSION: These results show that a simple, home-based exercise programme is effective in achieving gains in ankle range of motion and may help to reduce pain. Good participation levels show that it is not only effective, but also feasible. A larger randomized controlled study is needed to show whether there is a positive effect on ulcer healing.

Outcome of gastric surgery for morbid obesity: weight changes and personality traits.

This controlled study explores weight change in relation to certain personality and behavioural characteristics in a population of morbidly obese individuals who have undergone a gastric procedure to lose weight. In particular, measures of alexithymia and symbolic function were used, and the results of the study indicate that these concepts are particularly helpful in understanding obese individuals, and aetiology and treatment of their condition.

Erosive pustular dermatosis of the leg.

Two women with a distinctive rash on the legs are reported. The clinical features of erythema, erosions, crusting and pustular lakes, and the failure to respond to any treatment except very potent topical corticosteroids (Dermovate), are very similar to those of erosive pustular dermatosis of the scalp.

Acute lipodermatosclerosis in a pendulous abdomen.

A 54-year-old female developed tender, hot, erythematous skin at the apex of a large pendulous abdomen at the same time as she became symptomatic with congestive cardiac failure secondary to respiratory failure. Clinically and histologically the changes in the abdominal-wall skin resembled lipodermatosclerosis, a condition normally seen in the legs secondary to chronic venous insufficiency.

Intravital video-capillaroscopy for the study of the microcirculation in psoriasis.

Intravital capillaroscopy using a video-microscopy system permits real-time imaging of the skin microvasculature with retrospective analysis of capillary dynamics. The addition of fluorescein angiography improves contrast and detects aspects of blood vessel behaviour, such as perfusion homogeneity and transcapillary solute diffusion, not detectable under native conditions. This study was performed to evaluate whether the method can be applied to the investigation of a skin disease and in particular the understanding of the role of the blood vessel in the pathogenesis of psoriasis. Results demonstrated clear differences between normal and psoriatic skin. More capillaries were red-cell perfused in both plaque and uninvolved skin compared to normal skin (P less than 0.001) and 0.01 less than P less than 0.02, respectively). The capillaries in psoriatic plaque skin were much larger than those in normal skin (P less than 0.001). The density of capillaries was not increased in plaque or uninvolved psoriatic skin, indicating expansion of existing vessels and not new vessel formation. The area of fluorescence seen around each capillary at 60 s was greater in plaque (P less than 0.001) and in uninvolved psoriatic skin (P less than 0.001) than in normal skin, indicating greater vessel transcapillary diffusion. This study confirms the value of video-microscopy as a non-invasive technique for the examination of the cutaneous microcirculation in vivo.

Alexithymia and symbolic function in the obese.

Based on recent literature in which obesity is considered a psychosomatic disease, the authors present results of a study attempting to identify the degree of alexithymia and symbolic function inhibition in two overweight groups (moderately and morbidly obese) and compare the results with a normal-weight control group. The sample was composed of 95 subjects divided into three groups. The results revealed that the two obese groups were generally more alexithymic and had a higher degree of symbolic function inhibition than normal-weight controls. Nevertheless, the two alexithymia measures used in this study disclosed inconsistent results. The data are discussed in terms of etiological, methodological and treatment implications.

Autoimmune blistering diseases associated with HIV infection.

Two cases of autoimmune bullous skin diseases in HIV-positive men are described. One man had bullous pemphigoid limited to his legs and the second man developed pemphigus herpetiformis. The possible association between autoimmune bullous diseases and HIV infection is discussed.

Lymphatic function in the yellow nail syndrome.

Peripheral oedema is commonly seen in the yellow nail syndrome (YNS). Contrast lymphangiography has shown abnormal collecting lymphatics in some patients with YNS. In this study, lymphatic function in the upper and lower limbs of 17 patients with YNS, in normal controls, and in patients with established classical lymphoedema, has been assessed using quantitative lymphoscintigraphy. Nine subjects with YNS had swelling of the legs and two had features typical of lymphoedema. The lymphatic drainage was significantly reduced in the legs of patients with YNS but not to the level seen in lymphoedema. Lymphatic function was also reduced in the arms in patients with YNS. Venous insufficiency did not contribute to the leg oedema. These results suggest that the underlying cause of YNS is not primarily a lymphatic abnormality. The lymphatic impairment associated with YNS appears to be secondary, and predominantly functional in nature, rather than due to structural changes.

Pretibial myxoedema: a manifestation of lymphoedema?

Pretibial myxoedema (PTM) in its most extreme form clinically resembles lymphoedema. Studies with quantitative lymphoscintigraphy and fluorescence microlymphography in two patients with extensive PTM confirmed the presence of both functional and structural changes in the lymphatic system. We suggest that mucin deposition in the dermis causes compression of the dermal lymphatics, which results in dermal oedema and the clinical features of lymphoedema.

Cutaneous manifestations of long-term hydroxyurea therapy.

Skin changes associated with long term hydroxyurea therapy have only rarely been reported and are not widely known. This report concerns a patient in whom extensive and debilitating skin changes developed secondary to hydroxyurea therapy. In addition to previously reported manifestations such as ichthyosis, a dermatomyositis-like eruption on the dorsal hands, facial erythema and accelerated development of premalignant and malignant skin lesions, the patient developed an erosive eruption on the glans penis. He also developed a rapidly enlarging viral wart which clinically resembled a squamous cell carcinoma and histologically showed marked cytological atypia. It is possible that hydroxyurea caused accelerated photoageing and also contributed to the rapid growth of the viral wart and the atypical histological features. The time course of the clinical changes suggests that they result from direct toxicity of hydroxyurea on the basal layer of the epidermis and mucosal surfaces.

Eosinophilic folliculitis: a self-limiting illness in patients being treated for haematological malignancy.

Eosinophilic folliculitis is a recognized skin manifestation of human immunodeficiency virus (HIV) disease. Five cases of eosinophilic folliculitis occurring in HIV-negative patients treated for haematological malignancy are reported. In four cases this self-limiting, pruritic eruption, affecting the head and upper trunk, occurred 3 months after bone marrow transplantation, and the fifth case was a patient undergoing chemotherapy for Waldenström's macroglobulinaemia. This suggests that eosinophilic folliculitis is a consequence of disturbances of immune function, and is not specific for HIV infection.

Lymphatic and venous function in lipoedema.

Lipoedema is a common but infrequently recognized condition causing bilateral enlargement of the legs in women. Although generally considered to be the result of an abnormal deposition of subcutaneous fat with associated oedema, the precise mechanisms responsible for oedema formation have yet to be fully established. In order to evaluate the possible role of lymphatic or venous dysfunction in the pathogenesis of lipoedema, 10 patients were investigated by photoplethysmography (venous function) and quantitative lymphoscintigraphy (lymphatic function). The results were compared with those from patients with primary lymphoedema and those from healthy volunteers. The results demonstrated minor abnormalities of venous function in only two patients. One patient had moderately impaired lymphatic function in both legs and seven patients had a marginal degree of impairment in one or both legs. However, in none of these cases did the impairment attain the low levels seen in true lymphoedema. Lipoedema appears to be a distinct clinical entity best classified as a lipodystrophy rather than a direct consequence of any primary venous or lymphatic insufficiency.

Systemic lupus erythematosus presenting with oral mucosal lesions: easily missed?

Two caucasian patients are described in whom oral mucosal lesions were the first manifestation of systemic lupus erythematosus. In both cases the diagnosis was delayed despite histological examination of oral lesions. Treatment with antimalarials and azathioprine was of significant benefit. In the absence of cutaneous or systemic features, distinguishing oral lupus erythematosus from lichen planus and epidermal dysplasia can be difficult, both clinically and on histology, and requires a high index of suspicion.

Fatal facial ulceration.

A case of an elderly man with a large facial ulcer is reported. The diagnosis of Wegener's granulomatosis was made at post-mortem when evidence of a granulomatous vasculitis was found in both the skin and lungs. This case serves to illustrate the difficulty in making the diagnosis of Wegener's granulomatosis, especially when it presents in its 'limited' form.

Capillary underperfusion in chronic venous insufficiency: a cause for leg ulceration?

Dermal capillaries in the goiter area of the lower leg were examined by video-microscopy before and after the administration of intravenous fluorescein in 13 patients with chronic venous insufficiency (CVI) who were at risk of developing leg ulceration, and in 13 normal controls. The influence of posture on capillary perfusion was determined by viewing the same area of skin with the leg in both the supine and dependent positions. Capillary density was lower in patients than in controls, irrespective of the position of the leg (P < 0.01). Fluorescence angiography studies in normal controls showed a reduction in capillary density with dependency (P < 0.01), but patients with CVI showed no significant change. Fluorescence angiography revealed a greater number of capillaries than seen during native capillaroscopy (P < 0.05). The decreased capillary density, and the loss of the postural vasoconstrictor reflex in patients with chronic venous incompetence may play a role in the pathogenesis of ulceration.