A single-centre experience rolling out an antibiotic stewardship intervention prior to and during the SARS-CoV-2 pandemic 2019-2022

Background

Antibiotics are prescribed to nearly one-half of patients with viral respiratory tract infections (RTI) in outpatient settings. This use is ineffective and may cause undue harm and excess cost from unnecessary antibiotic exposure. We implemented a multifaceted intervention to address inappropriate antibiotic prescribing for viral RTI. Here, we discuss the impact over 4 years, before and during the SARS-CoV-2 pandemic.

Methods

This observational study describes the implementation and initial impact of a multimodal stewardship intervention on inappropriate antibiotic prescribing for viral RTIs in outpatient care settings at a single centre. We tracked the rate of visits for viral RTI as well as antibiotic prescribing for viral RTIs in urgent care, primary care and the emergency department between January 2018 and March 2022. Data were collected 1 year prior to implementation and 3 years after implementation. The primary outcome - the rate of inappropriate antibiotics prescribed for viral RTIs - was described by calendar year (CY) to review changes after the stewardship intervention.

Results

In CY2018, the year prior to implementation of targeted RTI antimicrobial stewardship, the rate of inappropriate RTI antibiotics prescribed was 10% in urgent care, 11% in primary care and 18% in the emergency department (ED). During the first CY of the intervention, rates were 8% in urgent care, 10% in primary care and 16% in the ED. In CY2020, the second year of the intervention, inappropriate RTI antibiotics were prescribed in 5% of urgent care and 3% primary care RTI visits and 15% of ED RTI visits. These rates were similar in CY2021 and the first 3 months of CY2022. Over 30,000 visits for RTIs were seen annually in CY2018 and CY2019. Annual RTI visits dropped to 20,222 in CY2020 and 14,172 in CY2021.

Conclusion

Although total visits for non-COVID RTIs decreased by approximately 50% during the first 2 years of the SARS-CoV-2 pandemic, an antimicrobial stewardship intervention was associated with decreases in inappropriate antibiotic prescribing for RTIs. This was maintained throughout 2 years of the pandemic.This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.

Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

193. Adding Insalt to Injury: Evaluating the Consequences of Sepsis Protocols on Patients with Heart Failure

Background

Inpatients with acute decompensated heart failure (ADHF) frequently meet sepsis criteria defined by the systemic inflammatory response syndrome (SIRS). To meet CMS guidelines, they receive a fluid bolus and broad-spectrum antibiotics, like piperacillin/tazobactam (pip/tazo), within 3 hours of presentation. A daily regimen of pip/tazo can contain as much as 1040 mg, or half the recommended dietary intake, of sodium. The objective of this investigation was to evaluate volume overloading and clinical consequences of sepsis protocols in patients with ADHF.

Methods

We reviewed inpatients ≥18 years old with ADHF per ICD-10 codes and an IV loop diuretic order who were initiated on a sepsis bundle, identified by IV fluid bolus and IV antibiotic orders. Patients who received ≥16 g of pip/tazo consecutively were compared to those who received other antibiotics. Outcomes included change in fluid homeostasis defined by increase in diuretic dose or frequency, or a weight increase ≥1 kg within a calendar day after receiving antibiotics; discharge disposition, length of stay (LOS), and 30-day readmission.

Results

We identified 95 patients admitted from 2/1/19 – 8/1/19. Thirty-four received pip/tazo, 61 received other antibiotics. Average age was 75, and 70% of patients had an infectious diseases diagnosis on discharge. Fluid homeostasis was poorer in the pip/tazo group compared to the other antibiotics group, demonstrated by weight increase ≥ 1kg (42% vs. 38%) and/or increase in diuretic intensity (65% vs. 51%). 30-day readmission rate was 2.9% in the pip/tazo group and 4.9% in the other antibiotics group. Median LOS was 11.5 vs. 7 days for the pip/tazo group and other antibiotics group, respectively. Rate of mortality was 32.6% during this encounter.

Conclusion

Early initiation of fluids and antibiotics may be detrimental in those without an infectious syndrome based on disrupted fluid homeostasis. Given lower sodium burden associated with other antibiotic selections, this has implications for antimicrobial stewardship.

Disclosures

All Authors: No reported disclosures

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Management of lateral abdominal hernias

PURPOSE

Lateral abdominal wall hernias are rare defects but, due to their location, repair is difficult, and recurrence is common. Few studies exist to support a standard protocol for repair of these lateral hernias. We hypothesized that anchoring our repair to fixed bony structures would reduce recurrence rates.

METHODS

A retrospective review of all patients who underwent lateral hernia repair at our institution was performed.

RESULTS

Eight cases (seven flank and one thoracoabdominal) were reviewed. The median defect size was 105 cm² (range 36-625 cm²). The median operative time was 185 min (range 133-282 min). There were no major complications. One patient who was repaired without mesh attachment to bony landmarks developed a recurrence at ten months and subsequently underwent reoperation. Patients with mesh secured to bony landmarks were recurrence free at a median follow-up of 171 days.

CONCLUSIONS

Lateral hernias present a greater challenge due to their anatomic location. An open technique with mesh fixation to bony structures is a promising solution to this complex problem.

1673 Accuracy and prognostic value of physiologist-led stress echocardiography for coronary disease

Funding Acknowledgements

No funding sources

Background

Cardiac physiologist-led stress echocardiography (PLSE) services provide potential for expansion of SE services and increased productivity for cardiologists. There is no published data on the accuracy or prognostic value of PLSE.

Purpose

To assess and compare the accuracy and prognostic value of PLSE and cardiologist-led stress echocardiography (CLSE) for CAD assessment

Methods

Retrospective study of 898 subjects undergoing PLSE (n = 393) or CLSE (n = 505) for CAD assessment using exercise or dobutamine. For accuracy assessment, the primary outcome was the ability of stress echocardiography to identify significant CAD on invasive angiography (ICA). Incidence of 24-month non-fatal myocardial infarction (MI), total and cardiac mortality, revascularisation and combined major adverse cardiac events (MACE) were assessed.

Results

Demographics, comorbidities, CAD predictors and cardiac medications were matched between the PLSE and CLSE groups. PLSE had high sensitivity, specificity, positive and negative predictive value and accuracy (85%, 74%, 69%, 88%, 78% respectively). PLSE accuracy measures were similar and non-inferior to CLSE. There was a similar incidence of individual and combined outcomes in PLSE and CLSE subjects. Negative stress echocardiography conferred a low incidence of non-fatal MI (PLSE 1.4% vs. CLSE 0.9%, p = 0.464), cardiac mortality (0.6% vs. 0.0%, p = 0.277) and MACE (6.8% vs. 3.1%, p = 0.404).

Conclusion

This is the largest study of PLSE accuracy and first study of the prognostic value of PLSE. PLSE demonstrates high and non-inferior accuracy compared with CLSE for CAD assessment. Negative PLSE and CLSE confer a similarly very low incidence of cardiac outcomes, confirming for the first time the important prognostic value of PLSE.

Accuracy of PLSE and CLSE for CAD Marker of diagnostic test Total (n = 72) PLSE (n = 32) CLSE (n = 40) p Significant CAD present (n, %) 20 (27.8%) 12 (37.5%) 8 (20.0%) 0.167 * Single-vessel CAD 12 (60.0%) 7 (58.3%) 5 (62.5%) 0.325 * Multi-vessel CAD 8 (40.0%) 5 (41.7%) 3 (37.5%) 0.325 Sensitivity 76% (66-76%) 85% (73-97%) 63% (48-78%) Non-significant Specificity 73% (63-73%) 74% (59-89%) 72% (58-86%) Non-significant Positive predictive value (PPV) 53% (42-64%) 69% (53-85%) 29% (15-43%) Significant Negative predictive value (NPV) 88% (80-96%) 88% (77-99%) 88% (78-98%) Non-significant Overall accuracy 74% (64-84%) 78% (64-92%) 70% (56-84%) Non-significant Accuracy data expressed as value (95% confidence interval). CAD= coronary artery disease. Differences in values between PLSE and CLSE considered statistically significant if no crossover in 95% confidence intervals

Abstract 1673 Figure. Predicted coronary artery lesion from SE

Salivary pH and flow rate in menopausal women

OBJECTIVE

This study aims at determining pH and Flow Rate (FR) of Unstimulated Whole Saliva (UWS) in a sample of 120 ♀ (60 menopausal women and 60 healthy fertile women with similar mean age); detecting the DMFT index (Decayed, Missing, Filled Teeth index) and evaluating any correlations between pH, FR, age and DMFT.

PATIENTS AND METHODS

Concerning the day before sample collection, patients were advised to keep a relaxed attitude and not to practice sports. They were also told to not eat or drink during the hour preceding sampling procedures. Saliva was collected via "spitting" method. Each sampling session started at 11:00 a.m., lasted for 5 minutes and used a pre-weighed, dry, deionized and sterile test tube. The procedure took place under controlled environmental temperature and humidity conditions (means 23.27°C; 60.08%). FR was evaluated via weighing technique and pH was measured with a portable pH-meter.

RESULTS

There was a minimal but significant pH difference (0.11; p<0.05) between menopausal women (6.75 ± 0.34) and fertile women (6.86 ± 0.24); and a FR difference (0.19; p<0.0001) between menopausal women (0.29 ± 0.17 mL/min) and fertile women (0.48 ± 0.19 mL/min). Correlation (R2) between pH and age was 0.0135 for fertile women and 0.0055 for menopausal women; while the correlation between FR and age was 0.0673 for fertile women and 0.139 for menopausal women. Mean DMFT was 11.93 ± 7.14 in menopausal women and 12.23 ± 6.37 in fertile women.

CONCLUSIONS

We observed a minimal decrease in pH and a decrease in FR in menopausal women. Further studies will be needed to investigate the possible role of other environmental and individual variables in the determination of such values.

Evaluation of Long-pulsed 1064 nm Nd:YAG Laser-assisted Hair Removal vs Multiple Treatment Sessions and Different Hair Types in Indian Patients

Background:

Longer wavelength lasers such as Nd: YAG are considered to be the best for darker skin phototypes.

Objectives:

The aim of this study was to investigate the safety and efficacy of long-pulsed, 1064 nm Nd:YAG laser-assisted hair removal in relation to multiple treatment sessions and different hair types in Indian patients.

Method:

Fifty-nine adult women with skin phototypes IV and V were treated with a long-pulsed Nd: YAG laser (1064 nm, 10 mm spot size, fluence of 30–50 J/cm², pulse duration 15–30 ms). Six consecutive treatment sessions were given at 4–6 week intervals. The modified Ferriman Gallway system of scoring was used to grade the hairs before each treatment session and six weeks after the last therapy. Based on this grading, three main hair types were recognised: thin vellus (Grade 1), intermediate (Grade 2), and terminal hair (Grades 3 and 4). Patients were divided into three groups: achievers who converted to thin vellus hair (Grade I), responders who shifted to a lower grade but were short of reaching grade 1, and failures who did not show any change throughout the six laser sessions.

Results:

Six weeks after six laser treatment sessions, the achievers totaled 56%, responders 23%, and failures 20% of the patient population. At the end of the 3^rd, 4^th, 5^th, and 6^th sessions, achievers were 5, 15, 25, and 56% respectively of all the patients (P < 0.001, which was statistically significant). Achievers for terminal hair were 57.5% while it was 53.8% for intermediate hair (P = 0.9, nonsignificant). There were no permanent side effects. There were no failures in the terminal group while nearly 50% of the patients were failures in the intermediate group.

Conclusion:

Six multiple laser treatment sessions with a long-pulsed, 1064 nm Nd: YAG laser with contact cooling were found to be safe and effective for hair reduction in Indian patients with both terminal and intermediate hair. The success rate was found to improve with successive sessions. However, terminal hairs responded better than intermediate hairs.

Reduced-intensity hematopoietic cell transplantation in older patients with AML/MDS: umbilical cord blood is a feasible option for patients without HLA-matched sibling donors

Umbilical cord blood (UCB) has increased access to hematopoietic cell transplantation (HCT) for patients without HLA-matched sibling donors (MSD). We compared outcomes of HCT using MSD (N=38) or UCB (N=60) among older patients (age ≥ 55 years) with AML or myelodysplastic syndromes (MDS). All patients received a reduced intensity regimen consisting of CY, fludarabine and 200 cGy TBI. Median age at HCT was 63 years for MSD and 61 years for UCB recipients. Among UCB recipients, 95% received two UCB units and 88% received 1-2 locus HLA-mismatched units to optimize cell dose. OS at 3-years was 37% for MSD and 31% for UCB recipients (P=0.21). On multivariate analysis, donor source (MSD vs UCB) did not impact risks of OS, leukemia-free survival and relapse or treatment-related mortality. UCB is feasible as an alternative donor source for reduced-intensity conditioning HCT among older patients with AML and MDS who do not have a suitable MSD.

Potassium iodide remains the most effective therapy for cutaneous sporotrichosis

Sporotrichosis is a subcutaneous fungal infection caused by the dimorphic fungus Sporothrix schenckii. Itraconazole has largely replaced older therapies, but we present a case of lymphocutaneous sporotrichosis that failed to respond to an adequate course of itraconazole yet responded dramatically to treatment with saturated solution of potassium iodide (SSKI).

Treatment of angiolymphoid hyperplasia with eosinophilia with the carbon dioxide laser

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon, idiopathic condition that presents with isolated or grouped plaques or nodules in the periauricular region, forehead, or scalp. ALHE is marked by a proliferation of blood vessels with distinctive large endothelial cells accompanied by a characteristic inflammatory infiltrate that includes eosinophils. The lesion is benign but may be persistent and difficult to eradicate. Various therapeutic modalities that have been tried for its treatment include intralesional and oral corticosteroids, cryotherapy, oral retinoids, vinblastine, surgical excision, laser therapy, and INFalpha2a. We report two cases with this rare condition: one patient, treated with cryotherapy, did not improve, while the second patient was successfully treated with the CO(2) laser.

Awareness during anaesthesia

SUMMARY

Awareness is the postoperative recall of sensory perception during general anaesthesia. The incidence is quoted at 1-2 per every 1000 patients. This rare but serious adverse event can be extremely distressing for both the patient as well as the anaesthesiologist. Awareness during anaesthesia may occur despite apparently sound anaesthetic management and is usually not associated with pain. However, a few cases may experience excruciating pain and have long term neuropsychiatric sequelae like post-traumatic stress disorder. This adverse event can also have serious medicolegal implications. This article addresses the various contributory factors that may predispose to intra-operative awareness. Preventive measures in the preinduction period as well as intraoperatively are discussed, including the use of depth of anaesthesia monitors. Remedial steps to be taken when such an event occurs are also discussed.

Anhidrotic ectodermal dysplasia with palmoplantar keratoderma: an unusual presentation

Anhidrotic ectodermal dysplasia (AED), or Christ-Siemens-Touraine syndrome, was first described in 1848 by Thurnam. It is characterized by a partial or complete absence of sweat glands, hypotrichosis and hypodontia. The mode of inheritance is predominantly X-linked but an autosomal recessive pattern has also been observed.(2) Palmoplantar keratoderma is classically a component of hidrotic ectodermal dysplasia; however, we report herein two brothers who had classical manifestations of AED along with palmoplantar keratoderma.

Pilot trial: Pioglitazone versus placebo in patients with plaque psoriasis (the P6)

BACKGROUND

Disordered differentiation and hyperproliferation of keratinocytes with inflammation are the hallmarks of psoriasis. Ligand activation of peroxisome proliferator receptor-gamma (a class of nuclear receptors) by thiazolidinediones can normalize the histologic features of psoriasis.

METHOD

In a 10-week, double-blind, randomized, placebo-controlled, parallel-group study, 70 patients with moderate to severe psoriasis received one of the following treatments: pioglitazone 15 mg, pioglitazone 30 mg or placebo. Efficacy was evaluated by observing the change in the psoriasis area and severity index (PASI) after 10 weeks of treatment.

RESULTS

There was a dose-dependent improvement in psoriasis. Median PASI scores at the end of 10 weeks were significantly reduced in the pioglitazone treatment groups as compared to the placebo-treated group. The psoriasis lesions cleared in more than 40% of patients treated with pioglitazone as compared to 12.5% of those with placebo. The percentage reduction in mean PASI scores was 21.6%, 41.1% and 47.5% in the placebo, pioglitazone 15 mg, and 30 mg groups, respectively. No serious adverse events were detected.

CONCLUSION

This is the first report from a controlled trial demonstrating that pioglitazone could be considered as an efficacious and safe agent for the treatment of plaque psoriasis. The optimum dose and duration of pioglitazone therapy remain to be determined.

Angioma serpiginosum: report of two unusual cases

Angioma serpiginosum (AS) is a rare vascular naevoid disorder due to ectatic dilation of capillaries in the papillary dermis. The condition is found almost exclusively in females who have grouped erythematous punctate lesions usually on the lower limbs or buttocks. We report two rare cases of AS, each representing a different and unusual clinical feature of AS: one with familial involvement and the other with an extensive distribution of lesions.

The utility of three different methods for measuring urinary 18-hydroxycortisol in the differential diagnosis of suspected primary hyperaldosteronism

OBJECTIVE

Urine 18-hydroxycortisol (18-OHF) measurements are claimed to discriminate between primary hyperaldosteronism due to Conn's syndrome/adrenal adenoma or idiopathic bilateral adrenal hyperplasia (BAH), and also to identify cases of glucocorticoid-suppressible hyperaldosteronism (GSH). We have evaluated three urine 18-OHF methods using a panel of urine samples from patients with hypertension.

DESIGN

Clinical methods comparative study.

METHODS

Urine samples from patients with primary hyperaldosteronism due to either adenoma (n = 6), BAH (n = 6), GSH (n = 9), or essential hypertension (n = 38) were analysed without knowledge of the diagnosis using three different methods in different laboratories. These included 'in-house' radioimmunoassay (RIA), 'in-house' time-resolved fluorometric assay (DELFIA), and gas chromatography mass spectrometry (GC-MS).

RESULTS

The three assays showed good correlation, but there were large bias differences: RIA bias was greater than DELFIA which was greater than GC-MS. Discrimination between adenoma and BAH patients was best for the DELFIA method, with no overlap between results for these two groups. All three methods gave significantly elevated results for the GSH group compared with the BAH and essential hypertension groups. No assay distinguished BAH from essential hypertension.

CONCLUSION

Measurement of urine 18-OHF may be a useful additional test in the differential diagnosis of primary hyperaldosteronism. The clinical diagnostic value of urinary 18-OHF measurements is method-dependent with the DELFIA assay having the best discriminatory value.

Erythema nodosum and antitubercular therapy

OBJECTIVE

To establish the efficacy of antitubercular therapy in patients with erythema nodosum with a highly positive Mantoux test.

METHODS

A retrospective analysis of all patients diagnosed with idiopathic erythema nodosum with a highly positive Mantoux reaction between 1988 and 2001 was undertaken. In the absence of any other clinical or investigative evidence of active tuberculosis they were treated with antitubercular therapy.

RESULTS

Out of a total of 52 patients diagnosed with idiopathic erythema nodosum with a strongly positive Mantoux test (average of 19 mm), data could be analyzed in only 47 patients. After treatment with antitubercular drugs, new lesions stopped appearing in 45 patients within 6-8 weeks and subsided in two. The therapy was well tolerated except for jaundice in one patient and transient urticarial lesions in another.

CONCLUSIONS

Antitubercular therapy definitely has a role in the management of patients with erythema nodosum, even in the absence of a detectable focus of tubercular infection, especially in regions where tuberculosis is endemic.

Dowling-Degos disease with dyschromatosis universalis hereditaria-like pigmentation in a family

Dowling-Degos disease is a rare autosomal dominant inherited pigmentary disorder characterized by reticulate pigmentation of the flexures, prominent comedone like lesions and pitted scars. Dyschromatosis universalis hereditaria is characterized by the presence of hypopigmented as well as hyperpigmented macules. We report a family showing features of both these diseases.

Topical 0.25% methotrexate gel in a hydrogel base for palmoplantar psoriasis

Palmoplantar psoriasis (PPP) is a chronic, disfiguring condition, and its management is difficult. The systemic side effects of methotrexate can be avoided if it is effective topically. We studied the efficacy and safety of a recently marketed topical methotrexate (0.25%) preparation in a hydrogel base in patients with palmoplantar lesions. A total of 14 adult patients diagnosed clinically as plaque type of palmoplantar psoriasis (>30% of the palm and/or sole areas involved) were included in the study. Topical methotrexate 0.25% in a hydroxygel base was applied twice daily to the lesions for twelve weeks. The lesions were assessed for degree of erythema, scaling, induration and fissuring (ESIF) and were scored on a severity score of 0-3 (0--clear, 1--mild, 2--moderate, 3--severe) every two weeks. The most severe condition was given 12 points; 0 denoted no disease. The response at the end of the study was graded as minimal if there was up to 25% reduction in the EISF score, mild as 26-50% reduction, moderate improvement as 51-75% reduction in score, and marked improvement as >75% reduction in score. The average age of the 11 male and female patients was 41.5 years (18-57 years) with the duration of the disease varying from 2 months to 15 years. Ten patients had both palmar and plantar lesions; two each had only palmar lesions or plantar lesions. The ESI score at baseline was 5.8 +/- 0.9 for the palms and 6.8 +/- 0.5 for the soles. The scores at the end of the study were 3.5 +/- 0.7 for palms and 4.8 +/- 0.2 for the soles. The average time taken for improvement was at least six weeks. None of the patients had complete clearance of lesions. The drug was well tolerated by all patients. Methotrexate 0.25% in a hydrophilic gel is well tolerated but is not very effective in controlling the lesions of psoriasis on the palms and soles. A higher concentration in a different base with better penetration could possibly provide better results.

Effect of diclofenac pretreatment on pain during propofol injection

In a randomized, double-blind, controlled trial, 120 ASA 1 or 2 patients were allocated to receive diclofenac or normal saline as pretreatment to assess their effect on incidence and severity of pain during propofol injection. Diclofenac in two different doses, i.e. 25 mg and 15 mg, was tried for this purpose. The overall incidence of pain did not significantly differ among the groups, but the incidence of moderate to severe pain following propofol injection was significantly less in patients who received diclofenac 25 mg (P = 0.0017) or 15 mg (P = 0.0363) than in those who received saline. However, the diclofenac itself was associated with mild pain in some patients.

Generalized bullous impetigo in a neonate

Generalized bullous impetigo is uncommon in healthy and term neonates. It must be differentiated from staphylococcal scalded skin syndrome and other commonly encountered vesiculopustular lesions. We report generalized bullous impetigo in an otherwise healthy neonate.

Clostridium difficile toxin assay in psoriatic patients

Chemotherapy-induced pseudomembranous colitis is most commonly associated with methotrexate and 5-fluorouracil. Methotrexate and mesalazine have also been used for the treatment of psoriasis but the effect of these therapies on the Clostridium difficile carriage in the stool of psoriatic patients has not been studied. Our aim was to detect the presence of C. difficile toxin in patients with psoriasis hospitalized for systemic therapy and in those receiving methotrexate and mesalazine. A total of 58 patients with psoriasis were divided into three groups: group A comprised 30 patients admitted with psoriasis involving >30% body surface area, group B1 comprised 15, psoriatic patients receiving methotrexate (0.3-0.4 mg/kg/week), group B2 included 6 patients receiving mesalazine (50-60 mg/kg/day) while group C comprised of 7 patients (5 on methotrexate, 2 on mesalazine) in whom stool samples were taken twice. Among patients in groups B1 and B2, stool samples were taken after at least 4 weeks of therapy. Detection of C. difficile toxin in stool samples was done using the latex agglutination method. Out of the 58 patients 47 were males and 11 were females. The mean age of the patients was 45+/-2.5 years and the duration of the disease was 3+/-0.9 years. Positive C. difficile toxin was found in a total of 19 patients in all three groups (5 patients in group A, 9 in group B1, 2 in group B2 and 3 in group C). Three patients complained of slight abdominal discomfort and increased frequency of stool, of whom 2 had toxin positive in low titres. The rest of the 17 patients who were positive for C. difficile toxin were asymptomatic. There is a obvious rise in the rate of GIT carriage of C. difficile to a variable degree in patients on methotrexate and mesalazine. However, no clear correlation of the gastrointestinal symptoms with either the presence of toxin or its titre could be established.

Variegate porphyria

Variegate porphyria is a rare, hereditary form of hepatic porphyria characterized by acute systemic symptoms as in acute intermittent porphyria in addition to cutaneous symptoms simulating porphyria cutanea tarda. We describe a 22-year-old female from India who first presented to the emergency department with acute symptoms and was later confirmed to have variegate porphyria.

Granuloma multiforme

CASE 1: A 51-year-old woman presented with skin-colored annular lesions on the upper chest, neck, and dorsa of the hands of 1-year duration. The lesions initially started as small papular lesions, which gradually evolved to form large annular and polycyclic lesions. Initially, the lesions were associated with a burning sensation and pruritus. She had no other systemic complaints. Examination revealed 5-6 annular, polycyclic lesions distributed over the upper chest, neck, and dorsa of both hands, varying in size from 1 to 5 cm. All the lesions had a prominent erythematous to skin-colored, irregular, papular border which was firm in consistency (Figs 1 and 2). Central clearing and minimal atrophy were evident in larger lesions. There was no sensory loss or peripheral nerve thickening. Clinical possibilities entertained were granuloma annulare, granuloma multiforme, and annular sarcoid. Routine investigations, including hemogram, renal and liver functions, blood sugar levels, chest X-ray, and urine examination, were within normal limits. A skin biopsy taken from the edge of a lesion revealed foci of collagen degeneration surrounded by an inflammatory infiltrate composed of many histiocytes and multinucleated giant cells. In addition, there were perivascular and periadnexal lymphocytic aggregates. No acid-fast bacilli (AFB) were detected. These findings were consistent with a diagnosis of granuloma multiforme (Fig. 3). CASE 2: A 47-year-old man presented with annular skin-colored lesions associated with a mild burning sensation of 8 months' duration. On examination, 2-3 annular, arciform lesions were distributed over the upper chest and neck. The lesions ranged in size from 2 to 7 cm in diameter, were irregular in shape, and were rimmed by a well-defined raised papular border. Again, there was no sensory loss or peripheral nerve thickening. Histopathology of the skin from the edge of the lesion showed multiple areas of histiocytic granulomas with focal necrobiosis and prominent multinucleated giant cells, findings consistent with granuloma multiforme.

Melanocyte transfer via epidermal grafts for vitiligo of labial mucosa

BACKGROUND

Physiologic pigmentation of labial mucosa is seen regularly in dark-skinned races. Vitiligo of nonkeratinized labial mucosa is often visible while talking and is a cosmetic problem. Medical therapies are not effective, and surgical therapies have not been tried for this site.

OBJECTIVE

To study the efficacy of melanocyte transfer through contact of intact epidermal grafts with abraded labial mucosa.

METHODS

Seven patients (five females and two males, age range from 17 to 29) with vitiligo of labial mucosa with or without involvement of vermilion were included in the study. Affected labial mucosa was dermabraded, and suction blister grafts were transferred over these areas. After 7 days, both dressing and grafts were removed, and photochemotherapy was started.

RESULTS

Excellent color match and repigmentation were seen in all patients after 4 to 6 weeks.

CONCLUSIONS

The proposed modification in a well-established procedure of epidermal grafting is safe and effective. It is less time consuming and simpler than melanocyte culture, although the results are equivalent. There is no actual trans-plantation of keratinized skin, as it was removed.

Unilateral linear psoriasis with palmoplantar, nail, and scalp involvement

Linear psoriasis is a rare entity. It is commonly confused clinically and histopathologically with verrucous epidermal nevus. We report a child who had linear psoriasis in a unilateral distribution with palmoplantar, nail, and scalp involvement.

Subdural hygroma in a patient with Parry-Romberg syndrome

Parry-Romberg syndrome (PRS) is a poorly understood disorder characterized by progressive hemifacial atrophy. A number of neurologic associations have been reported. We describe a rare association of seizures, PRS, and subdural hygroma. To the best of our knowledge, this association has not been reported in the literature.