Phototherapy in the elderly.

BACKGROUND: Elderly patients present with a unique spectrum of dermatoses that pose particular management opportunities and challenges, which will be increasingly encountered in dermatological practice. The skin of elderly patients differs from that of younger patients not only in appearance but also in structure, physiology and response to ultraviolet (UV) radiation. However, little is known about the safety and efficacy of phototherapy in elderly patients and how phototherapy is currently being utilized to treat them. AIM: To investigate the safety, efficacy and utilization of phototherapy in elderly patients. METHODS: In January 2014, we analysed all patients recently referred for, currently receiving or recently having completed a course of phototherapy at a university teaching hospital in England (UK). RESULTS: In total, 249 patients were identified; 37 (15%) were over the age of 65 years (the WHO definition of an elderly or older person). The dermatoses being treated were psoriasis (51%), eczema (11%), nodular prurigo (11%), pruritus (11%), Grover disease (5%) and others (11%). One patient with dementia was deemed not safe to embark on phototherapy, and five patients were yet to start. The remaining 31 elderly patients received 739 individual phototherapy treatments: 88% narrowband (NB)-UVB and 12% systemic, bath and hand/foot psoralen UVA (PUVA). The acute adverse event (AE) rate was 1.89%, all occurring in those receiving NB-UVB. No severe acute AEs occurred. Of those who completed their course of phototherapy, 80% achieved a clear/near clear or moderate response, while just two patients (8%) had minimal response and two (8%) had worsening of the disease during treatment. Of those receiving NB-UVB for psoriasis, 91% achieved a clear or near-clear response. CONCLUSIONS: In this small survey, the first of its kind to focus on elderly patients, phototherapy appears to be well-tolerated, safe and efficacious in the short term. Further thought and investigation should be given to delivering phototherapy to an ageing population.

X-linked dyskeratosis congenita presenting in adulthood with photodamaged skin and epiphora.

Dyskeratosis congenita (DC) is a clinically and genetically heterogeneous multisystem bone marrow failure disorder of telomere maintenance, which may present with dermatological features. The main cause of mortality is bone marrow failure, often developing in the second decade of life, although pulmonary disease and malignancies such as squamous cell carcinomas (SCCs) may also prove fatal. We report the case of a 28-year-old man with X-linked DC and confirmed DKC1 gene mutation. In addition to the classic triad of nail dystrophy, hyperpigmentation and oral leucoplakia, the patient had actinic keratosis (AK) and photodamaged skin, hitherto under-recognized features of this condition. Awareness of the clinical presentation of DC is important, as accurate clinical and molecular diagnosis affords patients and their families genetic counselling, cancer prevention and screening measures, and planning for complications such as bone marrow failure.

Measurement accuracy of heart rate and respiratory rate during graded exercise and sustained exercise in the heat using the Zephyr BioHarness.

The Zephyr BioHarness was tested to determine the accuracy of heart rate (HR) and respiratory rate (RR) measurements during 2 exercise protocols in conjunction with either a laboratory metabolic cart (Vmax) or a previously validated portable metabolic system (K4b2). In one protocol, HR and RR were measured using the BioHarness and Vmax during a graded exercise up to V˙O2max (n=12). In another protocol, HR and RR were measured using the BH and K4b2 during sustained exercise (30% and 50% V˙O2max for 20 min each) in a hot environment (30 °C, 50% relative humidity) (n=6). During the graded exercise, HR but not RR, obtained from the BioHarness was higher compared to the Vmax at baseline and 30% V˙O2max (p<0.05), but showed no significant difference at other stages with high correlation coefficients for both HR (r=0.87-0.96) and RR (r=0.90-0.99 above 30% V˙O2max). During the exercise in the heat, there were no significant differences between the BioHarness and K4b2 system. Correlation coefficients between the methods were low for HR but moderately to highly correlated (0.49-0.99) for RR. In conclusion, the BioHarness is comparable to Vmax and K4b2 over a wide range of V˙O2 during graded exercise and sustained exercise in the heat.

Glutathione protects cardiac and skeletal muscle from cyclophosphamide-induced toxicity.

Administration of cyclophosphamide at a dose which is lethal to 10% of control athymic nude mice resulted in sudden death within 3 h in all mice that had been pretreated with the glutathione synthesis inhibitor L-buthionine-SR-sulfoximine. In Fischer 344 rats pretreated with L-buthionine-SR-sulfoximine, the cyclophosphamide dose producing 100% acute toxicity was lowered from 500-150 mg/kg; cardiac monitoring revealed ventricular fibrillation to be the cause of death. These and additional studies reported demonstrate that cytoplasmic glutathione is an important protectant against the cardiac and skeletal muscle toxicity of cyclophosphamide and indicate that such toxicity may be substantially increased by glutathione depletion. Since diet and many drugs (including cyclophosphamide itself) are known to affect glutathione levels, the present studies suggest that cardiac and skeletal muscle glutathione content is likely to be a clinically significant determinant of the frequency and severity of the adverse drug interactions and systemic toxicity sometimes observed during cyclophosphamide therapy.

Cine magnetic resonance imaging and color Doppler flow mapping in infants and children with pulmonary artery bands.

Cine magnetic resonance imaging (MRI) and color Doppler flow mapping were performed in 12 infants and children (aged 3 to 35 months) after pulmonary artery banding to define the anatomy and physiology of the right ventricular outflow tract and evaluate the anatomy. MRI was performed using a 1.5 Tesla magnet in the sagittal, axial and oblique views with all patients studied in the 24 cm head coli following adequate sedation. High-resolution cine MRI was obtained in all patients and the narrowest flow diameter on cine MRI correlated well with the pressure gradient measured across the band in 11 patients at cardiac catheterization or surgery (r = -0.95). Signal loss was always seen distal to the band associated with turbulent flow as seen by color Doppler flow mapping. Signal loss in cine MRI was also seen proximal to the band. The length of this proximal signal void also correlated well with the pressure gradient measured across the band (r = 0.91) and was closely matched by the zone of proximal spatial acceleration defined by digital computer analysis of color Doppler flow map images (r = 0.89), which also demonstrated low grade variance associated with the laminar accelerating flow stream. The position of the band was accurately defined by cine MRI which identified inadequate pulmonary artery banding in 2 patients confirmed subsequently at cardiac catheterization and angiography. Cine MRI and color Doppler flow mapping when used together provide high-resolution detail about the right ventricular outflow tract and pulmonary artery band anatomy and function.(ABSTRACT TRUNCATED AT 250 WORDS)

Nasolacriminal dysfunction.

This investigation describes the normal function of the lacrimal drainage system of the eye. The intent of the presentation is to illustrate by clinical examples and pertinent literature, those alterations of normal function occurring from obstruction, trauma, or neoplasm. Sixty-nine patients with lacrimal dysfunction are included; 19 are offered in detail to illustrate principles of surgical management. It is not within the scope of this discussion to examine any condition which may cause primary hyperlacrimation or hypolacrimation, but to discuss: 1. the role of trauma as a cause of lacrimal drainage dysfunction. 2. the role of surgery in the prevention of lacrimal dysfunction, and 3. the role of surgery in the restoration of function. Among 18 patients with non-traumatic obstruction treated by silicone stenting, previous multiple dilatations treatment was associated with a higher rate of failure than in those patients not previously treated by multiple dilatations. Forty percent of 96 patients with facial fractures of the medial orbit had obstructive nasolacrimal symptoms; 79% of the 96 patients' symptoms cleared spontaneously; 15% required treatment. No incidence of significant iatrogenic trauma (requiring surgical treatment) was found in reviewing 1292 cases of rhinoplasty, rhinoseptoplasty, blepharoplasty, or sinus surgery. Normal function and physiology are reviewed. From the experiences of 69 patients emerge clinically proven methods of surgical management of lacrimal system obstruction. These methods are defined and then compared and contrasted to traditional methods and concepts. When there is disagreement or no consensus, alternate theories are discussed in attempting to explain those clinical conditions which seem to defy accepted principles. This presentation includes cases which have been managed by surgeons other than the author and who have been trained in fields other than otolaryngology. The cases offered in detail have been managed by the author.

Adenoma of the middle ear.

Benign adenoma of the middle ear emerged as a distinct entity following a review of 20 cases as reported from the Armed Forces Institute of Pathology in 1976. We report 4 additional cases and note that the pathologic diagnosis is not so clear cut. Benign primary adenoma may be confused with adenocarcinoma, ceruminoma, and glomus tumor. The otologic surgeon must take a hard look at the clinical signs and symptoms to determine if they are compatible with the diagnosis of primary middle ear adenoma. While middle ear adenoma has recently been implicated as a cause of facial paralysis (including a case herein), bone destruction should never be found in concert with this neoplasm.

Assessment of brain impairment with the Rey Auditory Verbal Learning Test: a comparison with other neuropsychological measures.

In this study the effectiveness of The Rey Auditory Verbal Learning Test (AVLT) at assessing patients with mixed brain impairment was compared with that of a number of other commonly used neuropsychological measures. Subjects were 50 patients with a mixture of medically confirmed neuropathologies, and 50 controls with no evidence of neurological history. Groups were equated for age, education, and sex. The AVLT was administered as pan of a full neuropsychological battery. Results indicated that all seven AVLT recall trials and the total of Trials I-V could significantly differentiate between the two groups (p <.001). The AVLT trial V score performed best (U = 457.5, p <.0001), correctly predicting group membership for 74% of the subjects. This hit-rate was better than any other single test on the Halstead-Reitan or Dodrill batteries, and was surpassed only by the Dodrill Discrimination Index. The potential usefulness of this test as part of a neuropsychological battery is discussed.

Ergonomic comparison of a chem/bio prototype firefighter ensemble and a standard ensemble.

Firefighter turnout gear and equipment protect the wearer against external hazards but, unfortunately, restrict mobility. The aim of this study was to determine the ease of mobility and comfort while wearing a new prototype firefighter ensemble (PE) with additional chemical/biological hazard protection compared to a standard ensemble (SE) by measuring static and dynamic range of motion (ROM), job-related tasks, and comfort. Eight healthy adults (five males, three females), aged 20-40 years, participated in this study. The study consisted of two repeated phases, separated by five uses of the ensembles. Subjects randomly donned either the SE or PE in either dry or wet conditions on separate days. In each phase, five tests were carried out as follows: baseline (non-ensemble), SE-dry, SE-wet, PE-dry, and PE-wet. There was a significant reduction (P < 0.05) of wrist flexion for PE-dry condition compared to the same SE-dry condition. Donning the PE took 80 s longer than the SE in phase 1, this difference disappeared in phase 2. There was a significant decrease (P < 0.05) in post-test comfort wearing the PE compared to the SE. The data collected in this study suggest that, in spite of design features to enhance chemical/biological hazard protection, the PE design does not decrease the wearer's overall functional mobility compared to the SE. However, subjects seem to be more comfortable wearing the SE compared to the PE. These overall findings support the need for a comprehensive ergonomic evaluation of protective clothing systems to ascertain human factors issues.

Quantitation of the nitrosamine 2-ethylhexyl-4-(N-methyl-N-nitrosoamino) benzoate (NPABAO) in sunscreen products.

We have devised a method to quantitate the nitrosamine, 2-ethylhexyl-4-(N-methyl-N-nitrosoamino) benzoate (NPABAO), in commercial products containing the sunscreen ingredient, Padimate O. The method involves a minimum of cleanup steps to afford a nonaqueous extract from product emulsions suitable for analysis by a liquid chromatograph interfaced to a thermal energy analyzer (LC/TEA). The method is applicable to lotions, creams, and gels. Oils are normally soluble in the mobile phase and can be analyzed directly on the LC/TEA without additional cleanup procedures. The method has a minimum detectable limit of about 30 ppb and yields greater than 80% recovery. It is highly reproducible and generates no NPABAO artifactually prior to quantitation on the LC/TEA. Application of the method to 22 different commercial product formulas disclosed that the level of NPABAO in each of the products is below 250 ppb, with 18 of the products containing less than 100 ppb. Of interest was the observation that musk ketone, a common fragrance constituent, produces a false-positive TEA response that can interfere with accurate analysis of NPABAO content in typical commercial products.