[Anti-p200 pemphigoid: a spectacular response to dapsone]

BACKGROUND

Types of subepidermal autoimmune bullous dermatosis (AIBD) are classified by anatomoclinical picture and target antigen. A new entity has recently been identified: anti-p200 pemphigoid.

PATIENTS AND METHODS

An 82-year-old man consulted for a profuse pruritic bullous eruption refractory to the standard treatments for bullous pemphigoid (BP). Direct immunofluorescence examination of a skin biopsy revealed linear deposits of IgG and of C3 at the dermal-epidermal junction, but Elisa screening for circulating anti-BP180 and anti-BP230 antibodies was negative. Indirect immunofluorescence (IIF) testing of cleaved skin revealed a deposit of IgG4 antibodies on the dermal side. Immunoblotting was negative for a dermal extract but showed an antibody directed against a 200-kD epidermal antigen. A diagnosis of anti-p200 pemphigoid was eventually made and the patient was successfully treated with dapsone.

DISCUSSION

The diagnosis of anti-p200 pemphigoid was made in this case in spite of discrepancy between the IIF and immunoblotting results, and despite the fact that the target antigen in this disease is considered as being restricted to dermal sites. Anti-p200 pemphigoid usually begins in the second part of life and differs from standard bullous pemphigoid in terms of more frequent mucous membrane and cephalic involvement, as well as a greater degree of miliary scarring. This disease appears more prominent in males and is associated with psoriasis in around one third of cases. Autoantibodies recognize laminin gamma-1, an extra-desmosomal protein that contributes to dermal-epidermal adhesion.

CONCLUSION

This recently described disease as probably under-diagnosed in France. It should be considered in atypical presentations of bullous disease. Diagnosis is confirmed by immunoblotting detection of autoantibodies directed against a 200-kD antigen normally present in the extract. Dapsone appears to be the most effective treatment.

Financial and social impact of supporting a haematological cancer survivor

Support persons of haematological cancer survivors may be faced with unique challenges due to the course of these diseases and the treatments required. This study aimed to examine the social and financial impacts associated with their role. Eight hundred adult survivors of haematological cancer within 3 years of diagnosis were invited via an Australian state population-based cancer registry to complete a survey. Survivors were mailed two questionnaire packages, one for themselves and one for their primary support person. Non-respondents were mailed reminders via the survivor after 3 weeks. One hundred and eighty-two support persons completed the questionnaire (85% response rate). Of these, 67 (46%) support persons reported having at least one personal expense and 91 (52%) experienced at least one financial impact. Male support persons and support persons of survivors in active treatment reported experiencing more personal expenses than other support persons. Older participants reported fewer financial consequences. A greater number of social impacts were reported by those born outside Australia, those who had to relocate for treatment and support persons of survivors in active treatment. Future research should focus on practical solutions to reducing these impacts on support persons.

Late presentation of HIV infection among adults in New Zealand: 2005-2010

BACKGROUND

Early diagnosis of HIV infection is important for the individual and for disease control. A consensus was recently reached among European countries on definitions of timing of presentation for care: 'Late presentation' refers to entering care with a CD4 count <350 cells/μL or an AIDS-defining event, regardless of the CD4 count. Presentation with 'advanced HIV disease' is a subset having a CD4 count <200 cells/μL and also includes all who have an AIDS-defining event regardless of CD4 count. This study examines timing of presentation in New Zealand from 2005 to 2010.

METHODS

Since 2005, information on the initial CD4 cell count has been requested on all people newly diagnosed with HIV infection through antibody testing in New Zealand. Excluded in this analysis were those previously diagnosed overseas or for an immigration medical.

RESULTS

A CD4 cell count was provided for 606 (80.3%) of the 755 newly diagnosed adults. Overall, 50.0% were 'late presenters' and 32.0% had 'advanced HIV disease'. Compared with men who have sex with men (MSM), people heterosexually infected were more likely to present late. 'Late presentation' and presentation with 'advanced HIV disease' were significantly more common among older MSM. Māori and Pacific MSM were more likely to present with 'advanced HIV disease'. Compared with European MSM, the age-adjusted relative risks for Māori and Pacific MSM were 2.1 [95% confidence interval (CI) 1.4-3.2] and 2.5 (95% CI 1.2-5.0), respectively.

CONCLUSIONS

The high proportion of people presenting late reflects inadequate levels of HIV testing. The lower proportion of late presentations among MSM compared with those heterosexually infected may be explained by a higher proportion of recent locally acquired infections together with different testing patterns.

Are we giving patients enough information on how to use topical treatments? Analysis of 767 prescriptions in psoriasis

BACKGROUND

Unclear instructions probably contribute to the suboptimal efficacy and adherence to topical agents in psoriasis.

OBJECTIVES

To analyse the quality of prescriptions for topical therapy in psoriasis and to determine factors associated with high-quality prescription writing.

METHODS

We made a systematic analysis of 767 topical prescriptions written by dermatologists and general practitioners (GPs). The following parameters were recorded: writing mode (electronic vs. hand written), indication of formulation, frequency of administration, duration of treatment, indication of areas to be treated, and indication of amount of product to be used. We considered prescriptions of high quality to be those including at least four of the five prospectively defined quality parameters.

RESULTS

Only 35·7% of prescriptions fulfilled the definition of a high-quality prescription. Quality of prescription writing was significantly influenced by two factors: electronic writing [odds ratio (OR) 3·04, 95% confidence interval (CI) 2·2-4·21; P < 10(-4) ] and specialty of the prescriber, dermatologists writing higher quality prescriptions compared with GPs (OR 1·61, 95% CI 1·54-2·14; P < 10(-4) ).

CONCLUSIONS

Almost two-thirds of topical prescriptions are not adequately written and do not include the required information to help patients manage their topical treatment in psoriasis correctly. The quality of topical prescriptions could be improved by making the use of electronic prescriptions widespread and by the development of aids for easy evaluation of the right amount of topical treatment to be applied according to body surface area involved.

Comparisons of Visual Rust Assessments and DNA Levels of Phakopsora pachyrhizi in Soybean Genotypes Varying in Rust Resistance

Soybean resistance to Phakopsora pachyrhizi, the cause of soybean rust, has been characterized by the following three infection types: (i) immune response (IM; complete resistance) with no visible lesions, (ii) resistant reaction with reddish brown (RB) lesions (incomplete resistance), and (iii) susceptible reaction with tan-colored (TAN) lesions. Based on visual assessments of these phenotypes, single gene resistance in soybean to P. pachyrhizi has been documented, but colonization within infected tissues based on fungal DNA (FDNA) levels in different soybean genotypes had not been analyzed. The research used a quantitative polymerase chain reaction (Q-PCR) assay to compare visual disease assessment to FDNA in controlled inoculation experiments using two isolates of P. pachyrhizi. The objective of the first experiment was to compare data from digital visual disease assessment to FDNA from Q-PCR assays using digital visual disease assessment using five resistant soybean genotypes (one IM and four RB) and five susceptible genotypes (TAN). The objective of the second experiment was to quantify FDNA using Q-PCR at different time points after inoculation to determine if levels of fungal colonization differed in five soybean genotypes with different levels of resistance (one IM, two RB, and two TAN). For experiment 1, the numbers of uredinia and uredinia per lesion on four of the five resistant soybean genotypes were lower (P < 0.05) than the other six genotypes. Significant differences (P < 0.05) in FDNA concentrations were found among soybean genotypes with TAN lesions and among soybean genotypes with RB lesions. Soybean cultivar UG5 (IM phenotype) had significantly less (P < 0.05) FDNA than all of the other genotypes. Some genotypes that produced TAN lesions had significantly lower (P < 0.05) or non-significantly different FDNA concentrations compared to those genotypes that produced RB lesions. For experiment 2, the regression of FDNA on days after inoculation was significant (P < 0.01) with positive slopes for all genotypes except for UG5, in which FDNA declined over time, indicating a reduction of fungal colonization. The results of this Q-PCR FDNA screening technique demonstrates its use to distinguish different types of resistance, and could be used to facilitate the evaluation of soybean breeding populations, where precise quantification of incomplete and/or partial resistance is needed to identify and map quantitative trait loci.

[Severe airway distress following cervical spine operation: retrospective breakdown of the chain of errors]

A 71-year-old female patient received a prothesis due to a cervical disc prolapsed and bleeding into the collar soft tissues occurred postoperatively. Following a computed tomography examination severe peracute respiratory decompensation occurred while administering topical anesthesia to the pharynx in order to perform fiber optic intubation. Endotracheal intubation using conventional laryngoscopy was unsuccessful and the patient required immediate cricothyroidotomy. As an on-site cricothyrotomy set to establish a secure airway was not available the decision was taken to perform surgical cricothyroidotomy. As a conclusion to this life-threatening event in the case of symptoms, such as dyspnea, dysphonia and dysphagia after operations of the cervical spine the airway has to be secured early and according to the local algorithm.

[Sticking guide wire. Problems with a high-flow catheter]

In the case presented an intravenous line for large volume infusion rates was to be placed in a patient with an aortic aneurysm during clinical preoperative care. After a high-flow catheter had been placed without any problems retraction of the guide wire was found to be impossible. Computer tomography revealed that the reason was a kink in the catheter resulting in the guide wire being nipped off. Fortunately both catheter and guide wire could be removed completely without any further complications.