Development of mycosis fungoides after bone marrow transplantation for chronic myeloid leukaemia: transmission from an allogeneic donor

We report on a patient who developed donor-derived cutaneous T-cell lymphoma (CTCL) 4 years after successful treatment of chronic myeloid leukaemia with an allogeneic bone marrow transplant. The patient developed an eczematous rash unresponsive to topical therapy and immunosuppression. When CTCL was diagnosed in the recipient, his sibling donor had been attending his local dermatology unit with a maculosquamous rash, which proved subsequently to be mycosis fungoides. An identical pattern of donor and recipient clonality assessment and T-cell receptor gene sequencing indicated that the CTCL was probably transmitted in the bone marrow harvest. This suggests that CTCL cells circulate in the marrow at an early subclinical stage in this disease. This is the second case of donor-derived CTCL reported to date.

Infection of the Beard area. Kerion: a review of 2 cases

Folliculitis barbae is a common condition of both infective and non-infectious aetiology. It most frequently presents as a superficial folliculitis, with fine pustules appearing at the opening of hair follicles in the beard area, often associated with shaving; known as Bockhart impetigo and usually due to infection caused by Staphylococcus aureus. If untreated, the infection and inflammation can progress, leading to a more deeply seated infection known as sycosis barbae. Perifollicular nodules, termed furuncles, may appear and when these are multiple and coalesce, a deep-seated, communicating, pustulating plaque called a carbuncle develops, often with associated systemic upset. Such an appearance, which can prompt incision and drainage, should not, however, be assumed to be solely due to staphylococcal infection. Particularly in the context of a history of close animal contact or a lack of response to antibiotic treatment, a diagnosis of tinea barbae should be considered and investigated. Prompt treatment with antifungal agents and often systemic steroids is required once the diagnosis is made. This will help reduce an exacerbation of the pronounced destruction that results from the immune response to the fungal infection, known as a kerion, which would be compounded by surgical intervention. In this article, we review two such cases and review the investigation and management of the disease.

A capabilities approach to population health and public policy-making

BACKGROUND

The objective of this study is to outline a capabilities approach to the social determinants of population health and to compare its explanatory power and implications for public policy-making with psychosocial approaches.

METHODS

A model linking the structures of economic and social relations to health outcomes is developed and logistic methods used to confirm its base validity for a representative sample of 16,488 citizens in 19 developed democracies drawn from the World Values Surveys of 1990 and 2005. Self-reported health is the dependent variable. Age, gender, education, employment status, self-mastery, income, autonomy at work, ties to family and friends, subjective social status, associational memberships and sense of national belonging are considered.

RESULTS

At baseline, risk ratios reflecting movement from the 25th to 75th percentile in the distribution of the variable indicate that increases in income reduce the likelihood of poor health (0.78; 0.73-0.82) as does higher autonomy at work (0.90; 0.85-0.94) but so does access to social resources reflected in ties to family and friends (0.89; 0.86-0.92), associational memberships (0.93; 0.89-0.98), subjective social status (0.77; 0.54-0.90) while the absence of feelings of national belonging increases the likelihood of poor health (1.14; 1.06-1.23).

CONCLUSION

The results suggest that population health is dependent on the distribution of social as well as economic resources along the dimensions predicted by a capabilities model. Governments should be attentive to the impact of policy on the distribution of social, as well as economic, resources.

Cyclin E drives human keratinocyte growth into differentiation

Human epidermis is continuously exposed to environmental mutagenic hazard and is the most frequent target of human cancer. How the epidermis coordinates proliferation with differentiation to maintain homeostasis, even in hyperproliferative conditions, is unclear. For instance, overactivation of the proto-oncogene MYC in keratinocytes stimulates differentiation. Here we explore the cell cycle regulation as proliferating human keratinocytes commit to terminal differentiation upon loss of anchorage or overactivation of MYC. The S-phase of the cell cycle is deregulated as mitotic regulators are inhibited in the onset of differentiation. Experimental inhibition of mitotic kinase cdk1 or kinases of the mitosis spindle checkpoint Aurora B or Polo-like Kinase, triggered keratinocyte terminal differentiation. Furthermore, hyperactivation of the cell cycle by overexpressing the DNA replication regulator Cyclin E induced mitosis failure and differentiation. Inhibition of Cyclin E by shRNAs attenuated the induction of differentiation by MYC. In addition, we present evidence that Cyclin E induces DNA damage and the p53 pathway. The results provide novel clues for the mechanisms committing proliferative keratinocytes to differentiate, with implications for tissue homeostasis maintenance, HPV amplification and tumorigenesis.

Characterizing the biological traits and life history of Acanthopagrus (Sparidae) hybrid complexes: implications for conservation and management

This study examined the spatio-temporal reproductive patterns, population structure, maturity and growth of Acanthopagrus hybrid complexes, which comprise mainly black bream Acanthopagrus butcheri and the hybrids they form with yellowfin bream Acanthopagrus australis, in two Australian estuaries (Coila and Brou Lakes, NSW). There were no differences between pure A. butcheri and hybrids in terms of their population structure, growth and maturity, suggesting that these two breeds have similar life histories and may therefore be managed as single, naturally cohesive units. Sexual variation in size structure was only observed for the complex in Coila Lake. Although there was significant variation in age structure between estuaries, both complexes exhibited dominance of only a few year classes indicating episodic recruitment and high fishing mortality. Acanthopagrus eggs occurred in higher numbers within upstream creek habitats compared to lake habitats, thereby highlighting the need to protect these spawning habitats. Although maturity in the complexes was not influenced by gender or estuary, differences in growth were detected between the genders and estuaries.

Pathobiology of selected tumors of the base of the skull

Skull base surgery is a new subspeciality, and, up to this point, most articles on this subject have focused on innovative operative-reconstructive approaches to tumors in this region. It is now important that we embark on a new era, the era of tumor biology, and concentrate on new ways of evaluating these neoplasms from a pathologic viewpoint. The hematoxylin-cosin section is no longer an end point, but just a beginning. This is the age of molecular biology. It is important that these tumors be evaluated, either prospectively or retrospectively, employing immunohistochemical staining, flow cytometry, oncogene expression, cytogenetics, or other techniques in order to identify important prognostic features. Data from these additional studies may then be used to develop new treatment strategies. Skull base societies should develop protocols for one or more of these tumors to ensure that they are indeed evaluated uniformly. In this article I emphasize the importance of accurate histologic classification or subclassification of these neoplasms and focus on contemporary parameters that may or may not impact on prognosis.

Angiofibroma: a flow cytometric evaluation of 31 cases

Angiofibromas are histologically benign but locally aggressive tumors that often extend beyond the nasopharynx to involve contiguous structures. In addition, attempts to remove the tumors surgically are often frustrated by local recurrences. We studied 31 angiofibromas by flow cytometry to determine if tumor ploidy could be used to identify those tumors that might behave more aggressively. The patients, all males between 5 and 23 years of age, were divided into two groups. The 21 patients with tumors confined to the nasopharynx or paranasal sinuses were regarded as having local disease, the ten with tumors involving the infratemporal fossa, orbit, cheek, or intracranial structures were regarded as having extensive disease. Of the ten with extensive disease, six bad intracranial involvement. All patients were treated with surgery and only one received postoperative irradiation. Follow-up was available in 24, eight of which developed local recurrences (33%). All tumors, including recurrences and those with intracranial extension, were found to be diploid. We therefore conclude that tumor ploidy cannot be used to predict the clinical course of angiofibromas.

'They've got to learn'--a qualitative study exploring the views of patients and staff regarding medical student teaching in a hospice

UK medical school curricula incorporate training in end-of-life care as recommended by Tomorrow's Doctors. Previous research suggests that hospice staff have concerns about the burden on patients when participating in medical student teaching and may gatekeep access to patients. This qualitative study uses semistructured interviews to explore and compare the views of hospice patients and health care staff about patient involvement in medical student teaching. Fifteen patients and 14 staff members were recruited from a single UK hospice involved in teaching third year medical students. Hospice patients, who have been involved in teaching, are strongly positive about meeting medical students and staff carefully select patients based on a number of issues.

Acyclovir and transmission of HIV-1 from persons infected with HIV-1 and HSV-2

BACKGROUND

Most persons who are infected with human immunodeficiency virus type 1 (HIV-1) are also infected with herpes simplex virus type 2 (HSV-2), which is frequently reactivated and is associated with increased plasma and genital levels of HIV-1. Therapy to suppress HSV-2 reduces the frequency of reactivation of HSV-2 as well as HIV-1 levels, suggesting that suppression of HSV-2 may reduce the risk of transmission of HIV-1.

METHODS

We conducted a randomized, placebo-controlled trial of suppressive therapy for HSV-2 (acyclovir at a dose of 400 mg orally twice daily) in couples in which only one of the partners was seropositive for HIV-1 (CD4 count, > or = 250 cells per cubic millimeter) and that partner was also infected with HSV-2 and was not taking antiretroviral therapy at the time of enrollment. The primary end point was transmission of HIV-1 to the partner who was not initially infected with HIV-1; linkage of transmissions was assessed by means of genetic sequencing of viruses.

RESULTS

A total of 3408 couples were enrolled at 14 sites in Africa. Of the partners who were infected with HIV-1, 68% were women, and the baseline median CD4 count was 462 cells per cubic millimeter. Of 132 HIV-1 seroconversions that occurred after randomization (an incidence of 2.7 per 100 person-years), 84 were linked within couples by viral sequencing: 41 in the acyclovir group and 43 in the placebo group (hazard ratio with acyclovir, 0.92, 95% confidence interval [CI], 0.60 to 1.41; P=0.69). Suppression with acyclovir reduced the mean plasma concentration of HIV-1 by 0.25 log(10) copies per milliliter (95% CI, 0.22 to 0.29; P<0.001) and the occurrence of HSV-2-positive genital ulcers by 73% (risk ratio, 0.27; 95% CI, 0.20 to 0.36; P<0.001). A total of 92% of the partners infected with HIV-1 and 84% of the partners not infected with HIV-1 remained in the study for 24 months. The level of adherence to the dispensed study drug was 96%. No serious adverse events related to acyclovir were observed.

CONCLUSIONS

Daily acyclovir therapy did not reduce the risk of transmission of HIV-1, despite a reduction in plasma HIV-1 RNA of 0.25 log(10) copies per milliliter and a 73% reduction in the occurrence of genital ulcers due to HSV-2. (ClinicalTrials.gov number, NCT00194519.)

A new scalp formulation of calcipotriol plus betamethasone dipropionate compared with each of its active ingredients in the same vehicle for the treatment of scalp psoriasis: a randomized, double-blind, controlled trial

BACKGROUND

There is a need for new treatments for scalp psoriasis, as many topical treatments are cosmetically unacceptable and difficult to apply, resulting in poor compliance.

OBJECTIVES

To compare the efficacy and safety of a new, once-daily, two-compound scalp formulation (Xamiol; LEO Pharma A/S, Ballerup, Denmark) containing calcipotriol 50 microg g(-1) plus betamethasone 0.5 mg g(-1) (as dipropionate), with the active ingredients as single compounds in the same vehicle.

METHODS

This 8-week, multicentre, double-blind, parallel-group study, randomized adult patients with scalp psoriasis involving > 10% of the scalp to the two-compound scalp formulation (n = 568), betamethasone dipropionate 0.5 mg g(-1) (n = 563), or calcipotriol 50 microg g(-1) (n = 286). The primary efficacy measure was the proportion of patients with 'absence of disease' or 'very mild disease' according to investigators' assessments at week 8.

RESULTS

The proportion of patients with 'absence of disease' or 'very mild disease' at week 8 was significantly higher in the two-compound group (68.4%) than the betamethasone dipropionate (61.0%, P = 0.0079) or calcipotriol (43.4%, P < 0.0001) groups. The proportion of patients rating their scalp psoriasis as 'clear' or 'almost clear' was significantly higher for the two-compound scalp formulation (69.6%) than for betamethasone dipropionate (59.9%, P = 0.0006) or calcipotriol (44.7%, P < 0.0001). The incidence of lesional/perilesional adverse events was lower in the two-compound and betamethasone dipropionate groups than the calcipotriol group.

CONCLUSIONS

The two-compound scalp formulation was well tolerated and more effective in the treatment of scalp psoriasis than either of its individual components in the same vehicle.

Pyoderma gangrenosum manifesting as a cavitating lung lesion

We present a case of pyoderma gangrenosum (PG) mimicking a lung carcinoma. A 52-year-old woman presented with an unremitting cough. Computed tomography revealed a cavitating lung lesion. Bronchoscopy and biopsy were interpreted as squamous cell carcinoma. Following a staging mediastinoscopy, a sleeve lobectomy and chest-wall resection was performed. The pulmonary histopathological features suggested Wegener's granulomatosis; no malignancy was found. Three months postoperatively, wound breakdown led to dermatological review. A clinical diagnosis of cutaneous PG was made on the basis of the classic appearance of the surgical wounds and an ulcer on the upper back that had been present before surgery. The patient has been consistently negative for cytoplasmic-staining antineutrophil cytoplasmic antibodies, which supports the diagnosis of PG with cutaneous and pulmonary involvement. Lung manifestations of PG are rare. PG is amenable to systemic therapy. Pulmonary PG is a rare but important differential diagnosis that is not familiar to many physicians and surgeons in this type of presentation.

Dermatitis herpetiformis: no evidence of bone disease despite evidence of enteropathy

The majority of patients with dermatitis herpetiformis (DH) have small intestinal enteropathy that may result in bone loss. The objective of this study was to evaluate bone mineral density (BMD) in DH and to examine whether dietary treatment or degree of the small intestinal lesion correlate with BMD. Twenty-five patients with DH (18 men) were investigated. Detailed dietary assessment and duodenal biopsies were performed on all patients before entry into the study. BMD at lumbar spine and femur was determined by DXA scan. Bone biomarkers, vitamin D, and parathyroid status were assessed. Twenty patients had enteropathy. None of the patients had hypovitaminosis D or secondary hyperparathyroidism. Resorption and formation markers were within normal limits. BMD Z-scores were not significantly different from expected (-0.38; CI, -0.84 to 0.07) and femur (0.46; CI, -0.06 to 0.97). There was no relationship between BMD Z-scores and the severity of the degree of enteropathy. We conclude that enteropathy of differing severity is present in 80% of patients with DH, but this is not associated with bone disease.

Efficacy results of a 52-week, randomised, double-blind, safety study of a calcipotriol/betamethasone dipropionate two-compound product (Daivobet/Dovobet/Taclonex) in the treatment of psoriasis vulgaris

BACKGROUND

The calcipotriol/betamethasone dipropionate two-compound product is safe and effective in the short-term treatment of psoriasis.

OBJECTIVE

The primary objective was to investigate the safety of two treatment regimens involving use of the two-compound product over 52 weeks. The efficacy results are presented here.

METHODS

Six hundred and thirty-four patients were randomised double-blind to treatment (once daily, when required) with either: 52 weeks of two-compound product (two-compound group), 52 weeks of alternating 4-week periods of two-compound product and calcipotriol (alternating group), or 4 weeks of two-compound product followed by 48 weeks of calcipotriol (calcipotriol group).

RESULTS

There was a trend towards a difference between treatments from the overall treatment effect for the percentage of satisfactory responses for each patient during the study (p = 0.071). This appeared to be due to the comparison of the two-compound and calcipotriol groups (p = 0.025).

CONCLUSION

There was a trend towards the efficacy of the two-compound product used for up to 52 weeks being better than that of 4 weeks of the two-compound product followed by 48 weeks of calcipotriol.

The management of basal cell carcinomas

The mortality and morbidity associated with basal cell carcinoma (BCC) is low. However, BCCs represent a significant burden to the health service due to their high and increasing incidence. This audit was designed to examine the management of BCCs by a dermatology department and to highlight deficiencies in the service offered to patients. The mean intervals between the first dermatology clinic visit and definitive treatment by the dermatology and the plastic surgery departments were 62 and 129 days respectively. Factors contributing to the delay included the frequent use of diagnostic incisional biopsies and the high referral rate from dermatology to the department of plastic and reconstructive surgery. In 90% of cases the dermatologist made an accurate clinical diagnosis. Despite this, diagnostic biopsies were performed in 72% of cases, often necessitating additional hospital visits. Forty three percent of cases were treated definitively by dermatology, whereas over 50% were referred to the department of plastic surgery. A number of changes are planned or are in process as a consequence of the audit.

A 52-week randomized safety study of a calcipotriol/betamethasone dipropionate two-compound product (Dovobet® /Daivobet® /Taclonex® ) in the treatment of psoriasis vulgaris

BACKGROUND

The calcipotriol/betamethasone dipropionate two-compound product Dovobet/Daivobet/Taclonex(LEO Pharma A/S, Ballerup, Denmark) has been shown to be safe and effective in the treatment of psoriasis for up to 8 weeks. As psoriasis is a chronic disease, long-term treatment may be required, so there is a need to investigate the safety of its use over a longer period of time.

OBJECTIVES

To investigate the safety of two treatment regimens involving use of the two-compound product over 52 weeks in the treatment of patients with psoriasis.

METHODS

Patients (n = 634) were randomized double-blind to treatment with: (i) 52 weeks of the two-compound product (two-compound group); (ii) 52 weeks of alternating 4-week periods of the two-compound product and calcipotriol (alternating group); or (iii) 4 weeks of the two-compound product followed by 48 weeks of calcipotriol (calcipotriol group). Treatments in all groups were used once daily when required.

RESULTS

Adverse drug reactions (ADRs) occurred in 45 (21.7%) patients in the two-compound group, 63 (29.6%) in the alternating group and 78 (37.9%) in the calcipotriol group. The odds ratio for an ADR in the two-compound group relative to the calcipotriol group was 0.46 (95% confidence interval 0.30-0.70; P < 0.001). ADRs of concern associated with long-term topical corticosteroid use occurred in 10 (4.8%) patients in the two-compound group, six (2.8%) in the alternating group and six (2.9%) in the calcipotriol group; those with the highest incidence were skin atrophy, occurring in four (1.9%), one (0.5%) and two (1.0%) patients, respectively, and folliculitis, in three (1.4%), one (0.5%) and no patients, respectively.

CONCLUSIONS

Treatment with the two-compound product for up to 52 weeks appears to be safe and well tolerated whether used on its own or alternating every 4 weeks with calcipotriol treatment.

Could your case of necrotising fascitis be Pyoderma gangrenosum?

Necrotising fascitis is a fulminant infective process which can result in significant morbidity and can indeed be life threatening. It needs to be recognised early and managed aggressively with extensive surgical debridement followed by appropriate antibiotics. On the other hand, Pyoderma gangrenosum is a disease process that needs to be managed non-surgically. We present one such case, the diagnosis of which had treaded along the thin line between the two.

First Report of Oleander Leaf Scorch Caused by Xylella fastidiosa in Texas

Bacterial leaf scorch caused by Xylella fastidiosa has been reported on oleander in California (3) and Florida (4). In June 2002, leaf scorch symptoms including chlorotic mottling of leaves, necrosis on leaf tips or whole leaves, defoliation, and shortened internodes were observed in oleander plants at various locations in Texas, including Galveston, Harlingen, Austin, San Antonio, and El Campo. The symptomatic varieties Calypso, Commandant Barthelemy, Lane Taylor Sealy, Little Red, Mrs. George Roeding, Mrs. Runge, Scarlet Beauty, and Petite Salmon, as well as symptomless varieties, Turner's Shari D and Sugarland from Moody Gardens in Galveston, Texas were sampled. All samples were tested for the presence of X. fastidiosa using enzyme-linked immunosorbent assay (ELISA) and bacterial isolation according to the methods of Huang and Sherald (2). All symptomatic varieties reacted positively in ELISA, and colonies characteristic of X. fastidiosa were isolated from all eight symptomatic varieties 10 to 15 days after incubation at 28°C. The colonies were confirmed to be X. fastidiosa using polymerase chain reaction (PCR) (2). ELISA tests and bacterial isolations from the symptomless Shari D and Sugarland varieties were negative. Membrane entrapment immunofluorescence (MEIF) (1) using the antibody CREC 26 to X. fastidiosa was also done on three of the symptomatic varieties and one asymptomatic variety obtained from Moody Gardens, and fluorescing bacteria were found only in the three symptomatic varieties. Symptomatic samples of Petite Salmon, one pink variety and one red variety obtained from a residential area west of Galveston, and a red oleander in Harlingen, TX, also tested positive with MEIF. Other ELISA-positive samples were obtained from symptomatic oleanders from Austin, San Antonio, and El Campo, TX. The X. fastidiosa bacteria isolated from the variety Lane Taylor Sealy were used to inoculate three red oleander plants by making an 8-cm-long vertical cut into the stem and then in 15 locations injecting approximately 15 μl of a X. fastidiosa suspension (10^8-9 cells per ml). The cut area was wrapped with Parafilm after inoculation, and the plants were kept at 29°C in a greenhouse. Three healthy red oleanders were inoculated with periwinkle wilt liquid medium for controls. Approximately 3 months after inoculation, chlorotic mottling along the edges of leaves was observed in the oleanders inoculated with X. fastidiosa, and the bacterium was reisolated from symptomatic leaves as described above. No symptoms were observed on the control plants, and bacterial isolation from the control plants was also negative. To our knowledge, this is the first report to show the causal role of X. fastidiosa in oleander leaf scorch and the presence of the disease in different locations in Texas, extending the geographic range of this important bacterial disease. References: (1) R. H. Brlansky et al. Plant Dis. 74:863, 1990. (2) Q. Huang and J. L. Sherald. Curr. Microbiol. 48:73, 2004. (3) A. H. Purcell et al. Phytopathology 89:53, 1999. (4) R. L. Wichman and D. L. Hopkins. Plant Dis. 84:198, 2000.

Availability of acupuncture in the hospitals of a major academic medical center: a pilot study

BACKGROUND

Acupuncture is widely used by the American public, but little is known about its availability and use in academic medical settings. We performed a pilot study to compare acupuncture services provided by hospitals affiliated with a major academic teaching institution, and a parallel survey of services provided through an acupuncture school in one city in New England.

METHODS

Between December 2000 and July 2001, a telephone survey was conducted of the 13 hospitals affiliated with Harvard Medical School, and the clinics affiliated with the New England School of Acupuncture.

RESULTS

Acupuncture was available in 8 of the 13 hospitals. Acupuncture was provided in ambulatory clinics in all eight hospitals, but was available to inpatients in only one hospital. Six hospitals delivered acupuncture through an outpatient pain treatment service, one through a women's health center, one through an HIV clinic, and one hospital delivered acupuncture through two services; a program in the anesthesia department and a multi-disciplinary holistic program in a primary care department. In contrast, the acupuncture school clinics provided services through an on-site clinic at the school, through acupuncture departments at two community-based hospitals, and through a network of 12 satellite acupuncture-dedicated clinics operating throughout the state.

CONCLUSION

Acupuncture is available on a limited basis in a majority of the teaching hospitals in this city. At the acupuncture school clinics, there are few barriers to care. Future health care studies will need to examine the role of acupuncture in diverse geographic settings and to examine its impact on quality of care, teaching and its role in research in academic centers.