Digestive Decolonization of Colorectal Carriage of Vancomycin-resistant Enterococcus faecium in a Japanese Adult

Patients with vancomycin-resistant Enterococcus (VRE) colonization should be managed in an isolation room with contact precautions. We herein report a patient whose colorectal carriage of VRE was successfully decolonized using concomitant bowel irrigation with polyethylene glycol, probiotics, and oral antimicrobials, linezolid and orally-administered daptomycin, for release from isolation and contact precautions. We therefore would like to suggest a potential strategy for managing patients with VRE colonization.

Dermoscopy in Basal Cell Carcinoma: An Updated Review

Dermoscopy is a noninvasive technique that has been demonstrated to improve diagnostic accuracy in basal cell carcinoma (BCC). The first dermoscopic model for the diagnosis of BCC, based mainly on the identification of pigmented structures, was described by Menzies et al., and since then dermoscopy has generated an abundance of literature useful to routine clinical practice. From a practical perspective, dermoscopic structures associated with BCC can be classified as pigmented, vascular, or nonpigmented/nonvascular. One of the most recent applications of dermoscopy in BCC is as an aid to predicting histologic subtype and essentially differentiating between superficial and nonsuperficial BCC. It can also, however, help raise suspicion of more aggressive variants with a higher risk of recurrence. A thorough dermoscopic examination during follow-up of patients with actinic damage or a history of multiple BCCs can facilitate the detection of very incipient lesions and significantly impact treatment and prognosis.

The Use of Apremilast in Psoriasis: A Delphi Study

BACKGROUND

Experience in the use of apremilast in clinical practice complements the information available from pivotal clinical trials.

MATERIAL AND METHOD

Following a review of the literature, a panel of dermatologists with expertise in the management of psoriasis considered 5 scenarios in which the evidence supporting the use of apremilast to treat moderate psoriasis is insufficient or controversial. These scenarios were then assessed using a Delphi questionnaire.

RESULTS

Consensus was reached on 96 (67%) of the 143 items (positive in 85 and negative in 11). The therapeutic goal for apremilast should be based on 4 outcomes: clinical response, symptoms, quality of life, and patient satisfaction. The scenario in which the use of apremilast was considered to have the greatest possibility of success was in patients with stable moderate psoriasis. Most of the clinicians considered apremilast to be an appropriate treatment when conventional therapies fail or are contraindicated, preferably before the prescription of biologic therapy. Consensus was reached that apremilast is an appropriate treatment for psoriasis in difficult locations, such as the scalp or the palms and soles. It was also agreed that apremilast requires less prescreening and monitoring than other conventional and biologic systemic therapies.

CONCLUSIONS

Apremilast could be a treatment option for patients with a different profile to that of clinical trial participants. The limitations of this proposal are the absence of consensus on the definition of moderate psoriasis, the lack of real-world evidence on the use of apremilast, and certain aspects related to tolerability.

Blood microvessel density, lymphatic microvessel density and lymphatic invasion in predicting melanoma metastases: systematic review and meta-analysis

In malignant melanoma (MM) there is an urgent need to identify new markers with predictive value superior to the traditional clinical and histological parameters. Angiogenesis and lymphangiogenesis have been recognized as critical processes in tumour growth and metastasis development, and numerous studies have evaluated the significance of these parameters in predicting the prognosis in solid tumours, including MM. We set out to determine whether angiogenesis, lymphangiogenesis and lymphatic invasion (LI) are valuable prognostic markers in MM. We systematically reviewed the available literature and subsequently performed a meta-analysis on the compiled data. To be eligible for the systematic review, a study had to provide the microvessel density (MVD), the lymphatic vessel density (LVD) or information about LI, assessed by immunohistochemistry on the primary site in patients with MM. To be evaluable for the meta-analysis, a study also had to provide information on clinical outcome. We approached selected studies with the Reporting recommendations for tumour marker (REMARK) criteria, verifying whether they had followed the recommendations. In total, nine angiogenesis, seven lymphangiogenesis and 10 LI studies were included in our meta-analysis, representing 419, 474 and 802 patients, respectively. Using meta-analysis, we showed that peritumoral LVD and the presence of LI have prognostic value for patients with MM. In contrast, MVD and intratumoral LVD did not have prognostic value in these patients. LVD and LI seem to have prognostic value for patients with MM.

Methicillin-resistant Staphylococcus aureus (MRSA) ST398 in a farmer with skin lesions and in pigs of his farm: clonal relationship and detection of lnu(A) gene

Skin infection associated with methicillin-resistant Staphylococcus aureus (MRSA)-ST398 was detected in a pig-farmer, and MRSA-ST398 isolates were also detected in nasal samples of the patient and of 11/12 pigs on his farm. Twelve MRSA isolates were obtained from skin lesions (n = 6) and nasal samples (n = 6) of the patient in two sampling moments and 11 MRSA isolates from nasal samples of pigs. They were typed as t011-SCCmecIVa-agrI and t108-SCCmecV-agrI (patient and pigs) and t588-SCCmecV-agrI (patient). The following resistance genes were detected (number isolates): tet(K) (1), tet(L) (23), tet(M) (13), erm(A) (13), erm(C) (13), msr(A) (11), lnu(A) (21), aph(2'')-acc(6') (3), ant(4') (13), aph(3') (12), dfrS1 (15) and dfrK (22). Seventeen human and animal MRSA-ST398 isolates showed indistinguishable PFGE patterns (A1-spa-t011 or B2-spa-t108) and similar phenotypic-genotypic characteristics, including the presence of the lnu(A) gene, associated with lincomycin resistance. Potential pig-to-human transference of ST398 is suggested in this study. The first detection of the lnu(A) gene in MRSA-ST398 is reported.

[Treatment of moderate-to-severe psoriasis in clinical practice: a survey of Spanish dermatologists]

BACKGROUND AND OBJECTIVES

Various treatment options are available for use in moderate-to-severe psoriasis and election is dependent upon the clinical criteria applied by the attending physician. We undertook a survey among dermatologists to assess the treatment of moderate-to-severe psoriasis currently used in clinical practice in Spain.

METHODS

A cross-sectional study was performed by sending a questionnaire to dermatologists in Spain who treat patients with moderate-to-severe psoriasis. The questionnaire comprised 33 items distributed in 6 sections: profile of the dermatologist, case load, patient profile, follow-up and management of the disease, treatment regimens, and assessment of pharmacological treatments.

RESULTS

According to the responses of the 164 dermatologists surveyed, 6.8% of patients seen in their clinics have moderate-to-severe psoriasis; of those, 45.8% receive systemic treatment and 22.9% are treated with biologic drugs. In many of those patients (50.2%), the dermatologist felt that a change in treatment was necessary; in 51.1% of cases, this change would be from systemic therapy to a biologic drug. The principal reason for the change (50.8%) would be lack of efficacy or the appearance of adverse effects. Efficacy and safety were considered essential criteria in the choice of an appropriate treatment (82.9% and 28.0% of dermatologists, respectively). Patient quality of life was also considered an essential consideration in choice of treatment by 28.0% of dermatologists.

CONCLUSIONS

Optimal treatment for moderate-to-severe psoriasis should be effective and safe, and improve patient quality of life. This makes it essential to use drugs with an excellent efficacy and safety profile.

[Diagnostic agreement between primary care physicians and dermatologists in the health area of a referral hospital]

INTRODUCTION

Skin diseases account for a high proportion of presenting complaints in primary health care. In Spain, the growing demand for consultations and the resulting longer waiting lists make it necessary to establish criteria for appropriate referrals to a specialist. This study aimed to investigate the characteristics of referrals from primary care centers to dermatology specialists as well as the correlation between the presenting complaint and the final dermatologic diagnosis.

PATIENTS AND METHODS

We collected data from 3164 patients seen for the first time by dermatologists in our specialist service during 1998. Patients were stratified according to the referring primary health care center and the reason for referral. The agreement between the presenting complaint and the final dermatologic diagnosis was studied. For each dermatologic condition, the positive predictive value, diagnostic sensitivity, and k statistic were calculated.

RESULTS

The overall diagnostic agreement was 65.52 %. Primary care physicians were found to over diagnose diseases caused by papillomavirus and the diagnostic sensitivity was very low for diseases such as basal cell carcinoma and seborrheic keratosis.

CONCLUSIONS

It is necessary to insist on training primary care physicians, ensuring appropriate referral from primary health care clinics, and promoting an effective dialogue with the specialist.

[Analysis of the demand for dermatological care in the immigrant population served by hospital Miguel Servet in Saragossa, Spain]

INTRODUCTION

In recent years there has been an increase in the size of the immigrant population consulting dermatology services in Spain. The aim of this study was to describe the epidemiological characteristics of this sector of the population in the health care area served by Miguel Servet Hospital in Saragossa, Spain.

MATERIAL AND METHODS

Data were collected on immigrant patients seen in the dermatology department of our hospital during 2004. Dermatological diagnoses were classified according to the International Classification of Diseases, Ninth Revision, Clinical Modification. Statistical analysis was undertaken using the SPSS statistical package, Access database management software, and Excel spreadsheets.

RESULTS

A total of 706 patients were seen, corresponding to approximately 4 % of all first appointments, and more women were seen than men, a difference that was statistically significant. The mean age of the patients was 31 years and there were no statistically significant differences in age between the sexes. In order of frequency, the most common countries of origin of the patients were Ecuador, Colombia, Romania, Morocco, Gambia, Guinea, and Senegal. The most common skin diseases in this population group were infectious diseases, in particular mycoses, followed by viral diseases and pyodermatitis, as well as sexually transmitted diseases. In all cases, the incidence of the disease was higher than in the Spanish population.

CONCLUSIONS

An appropriate knowledge of dermatological diseases in this population group is necessary both to obtain correct diagnosis and to develop preventative measures for imported diseases.

Dermoscopic findings of haemosiderotic and aneurysmal dermatofibroma: report of six patients

BACKGROUND

The clinical diagnosis of dermatofibroma is commonly easy. However, the differentiation of dermatofibroma from other cutaneous tumours is difficult in some instances, primarily in atypical cases and rare variants. Haemosiderotic dermatofibroma is a variant composed of numerous small vessels, extravasated erythrocytes and intra- and extracellular haemosiderin deposits. Aneurysmal dermatofibroma is a variant composed of large, blood-filled spaces without endothelial lining. Some authors consider that haemosiderotic dermatofibroma is an early stage in the development of aneurysmal dermatofibroma. The clinical differential diagnosis of haemosiderotic or aneurysmal dermatofibroma must include melanoma and other melanocytic tumours, vascular neoplasms, adnexal tumours and nonspecific cysts. Dermoscopy improves the diagnostic accuracy in pigmented and nonpigmented skin lesions.

OBJECTIVES

To evaluate specific dermoscopic criteria.

METHODS

Dermoscopic examination (using the DermLite Foto; 3Gen, LLC, Dana Point, CA, U.S.A.) of six patients with haemosiderotic or aneurysmal dermatofibromas was performed to evaluate specific dermoscopic criteria.

RESULTS

A multicomponent pattern with a central bluish or reddish homogeneous area in combination with white structures and a peripheral delicate pigment network along with vascular structures was noted in five of six lesions.

CONCLUSIONS

This dermoscopic pattern yielded the diagnosis of haemosiderotic or aneurysmal dermatofibroma in most cases. However, this multicomponent pattern may present in some melanomas and although it is useful in determining a clinical diagnosis of aneurysmal dermatofibroma, it may not be specific to this entity.

Recurrent lentigo maligna as amelanotic lentigo maligna melanoma

Amelanotic lentigo maligna and lentigo maligna melanoma are extremely rare tumours. Even rarer is a recurrent amelanotic lentigo maligna or amelanotic lentigo maligna melanoma at the site of a previously removed pigmented lentigo maligna. We describe two cases of recurrent amelanotic lentigo maligna melanoma manifesting as erythematous plaques evolved from previously excised pigmented lentigo maligna.

Effect of blending calcium compounds on hydrolytic degradation of poly(DL-lactic acid-co-glycolic acid)

To clarify the effect of blending calcium compounds with different acidity or basicity on the degradation of poly(DL-lactic acid-co-glycolic acid) (PLGA). composite materials composed of PLGA incorporated with 30 mass% of calcium dihydrogenphosphate (CDHP), calcium hydrogenphosphate, calcium phosphate, and calcium carbonate (CC) were prepared by mixing in dioxane followed by freeze-drying. The porous composite materials were then compressed to yield nonporous films with 0.5 mm thickness. The blend films and the unfilled films as a control were immersed in phosphate-buffered saline (pH 7.4) at 37 degrees C. Specimens were removed at 1, 2, 3, 4, 6, and 8 weeks and subjected to measuring of water absorption, mass loss, thickness change, and molecular weight. The temporal changes in appearance and measurements for the five materials differed from each other; especially, the CC blend differed from the other four materials. The degradation of PLGA decreased with increasing basicity of the calcium compounds blended. The most basic CC was most effective to delay the degradation, while the most acidic CDHP was least effective. However, even CDHP had appreciable degradation-delaying effects compared with unfilled PLGA. Thus, the findings of the present study suggest that degradation of PLGA can be varied by blending inorganic compounds with different basicity.

Age-related hypermethylation of the hMLH1 promoter in gastric cancers

To determine whether methylation of the hMLH1 promoter is related to increasing age and gastric carcinogenesis, we examined hMLH1 methylation and expression in 100 gastric cancers. hMLH1 methylation and aberrant protein expression were observed in 9 and 13 cancers, respectively. Normal and intestinal metaplastic tissues adjacent to cancers with hypermethylation did not exhibit any hMLH1 methylation, indicating that it may be specific to gastric cancers. The frequency of hMLH1 methylation significantly increased with age. These results suggest that hMLH1 methylation plays an important role in gastric carcinogenesis in old people.

Primary tuberculous chancre caused by Mycobacterium bovis after goring with a bull's horn

A 14-year-old boy was gored by a bull during festival celebrations. The horn of the bull caused a wound on his left hand and after 3 months it was a accompanied by an ulcerated nodule on the left upper arm and an axillary adenopathy. The tuberculin test was positive and a culture of the aspiration biopsy specimen of the axillary lymph node yielded Mycombacterium bovis.

Visceral leishmaniasis with cutaneous lesions in a patient infected with human immunodeficiency virus

We report a case of visceral leishmaniasis (VL) with cutaneous lesions in a patient infected with human immunodeficiency virus (HIV). The cutaneous lesions consisted of erythematous papules on the legs. Biopsy of one lesion showed abundant Leishmania amastigotes within epithelial cells of an eccrine sweat gland in the dermis. Leishmania organisms were also found in a blood smear. Rapid and complete clearance of the cutaneous lesions was achieved after antimony therapy. Cutaneous lesions in VL are being reported increasingly frequently in patients with HIV infection and their significance remains in discussion.

[Regional intravenous anesthesia (RIA): a simple method not used frequently]

We studied 20 outpatients undergoing surgery of the extremities with regional intravenous anesthesia (RIA). In our study RIA vas performed with the help of a double tourniquet in order to prevent adverse reactions; the drug of choice was lidocaine, because we considered it more suitable for this kind of procedure. The technique was of simple execution and well tolerated by the patient. This technique maker it possible to perform surgery of forearm and foot with a small amount of anesthetic even in outpatients.

A thrombin ointment that achieves rapid haemostasis of split thickness donor wounds, particularly on the scalp

A procedure is described to achieve rapid haemostasis of split thickness donor wounds by using an ointment containing thrombin (10,000 units mixed in 10 g of petroleum jelly-based gentamicin ointment). The ointment, prepared just before the removal of the skin graft, is immediately spread over the wound after the graft has been taken. With this technique, a steady haemostasis is promptly and simply achieved without the recurrence of bleeding compared to the technique using only a thrombin solution (bleeding time: a mean of 11.5 s for the thrombin ointment and 25.5 s for the thrombin solution, P less than 0.01). Thus, particularly when many skin grafts are needed, further skin grafts from adjacent areas can be readily taken without interference by bleeding. This procedure has proved to be extremely useful in achieving rapid haemostasis of split thickness skin donor wounds, especially when taking skin grafts from the scalp.

Experiences using silicone gel tie-over dressings following skin grafting

Twenty-six patients with 27 skin grafts treated with tie-over dressings using silicone gel sheets containing 0.02 per cent Ofloxacin are described. This method ensured direct in-progress inspection of healing of the grafted skin. Although the silicone gel tie-over procedure without any additional pressure resulted in haematoma and congestion in four out of 12 grafts (33.3 per cent), in the group with additional pressure (approximately 20-30 mmHg) limited to the early period after surgery there was no haematoma and congestion of the grafts in 15 grafts (P less than 0.05, Chi-square test). It is surmised that adequate pressure applied to the graft for a few days after surgery would be beneficial in preventing haematoma formation.

Treatment of dermal depth burn wounds with an antimicrobial agent-releasing silicone gel sheet

Silicone gel sheets containing 0.02 per cent Ofloxacin were used in the treatment of 24 patients with a total of 27 dermal depth burn wounds. The gel provided a continuing drug delivery system from the dressing to the wound. Clinically the silicone gel sheets did not adhere to the wound and could be removed easily without pain. No infection developed in any of the dermal depth burn wounds treated with the gel sheets. The silicone gel sheets were found to promote prompt epithelialization in 16 burn wounds of superficial dermal depth (mean 8.4 days) compared with ointment-impregnated gauze dressings (mean 14 days, P less than 0.01). There was less pain and discharge by macroscopic observation of the absorbent materials from both dressings. In nine wounds of mixed superficial and deep dermal burn, the silicone gel also provided prompt epithelialization (mean 12 days) compared to the control wounds (mean 22 days, P less than 0.01).

Expanding oral angle plasty using a subcutaneous pedicle flap to correct severe microstomia after extensive facial burns

Expanding oral angle plasty using a subcutaneous pedicle flap to correct severe microstomia due to extensive facial scar contractures is described. This technique is especially suited for the elderly, who are unable to tolerate large skin grafting of the face, and for patients with insufficient normal donor skin to undertake extensive correction of scar contractures.

Refinement of the scrap technique of skin grafting

A technique to obtain a sheet of meshed skin by assembling many small skin grafts is described. The merits of this technique are that a meshed skin graft of desired size and shape is obtained using many small pieces of skin, and moreover, these pieces of skin do not break down when meshed or when applied to the recipient bed, since the graft is reinforced by a plastic film. Graft survivals and epithelialization of the wound are excellent. This technique is especially useful in extensively burned patients with a limited and scattered donor area, and also for patients who require stamp grafts but are not cooperative enough to keep still for prolonged periods after surgery.

Bilateral vermilion flap

A bilateral tissue expanding flap is described for the reconstruction of the mid-vermilion border. With this technique, a defect of about one-half of the vermilion border can be reconstructed with little discomfort to the patient. Because of the high degree of tissue extensibility, this procedure appears to be a versatile one especially in elderly people.

[Concentrations of cefuroxime in the skin]

Concentrations of cefuroxime (CXM) in the skin and the serum of 24 patients were examined. CXM (0.75 g, 1.5 g) was administered to these patients intravenously in one shot. The skin and the serum were collected at 30 and 60 minutes after the injection. Concentrations of CXM in the skin were following: 0.75 g, 30 min.; 11.4 +/- 5.3 micrograms/g 60 min.; 9.5 +/- 4.7 micrograms/g 1.5 g, 30 min.; 17.1 +/- 6.8 micrograms/g 60 min.; 15.7 +/- 13.2 micrograms/g Concentration ratios (skin/serum) at 60 minutes after the injection were from 72.5% to 79.2%. The binding ratio of CXM to serum protein was 41%, which was lower than most other antibiotics. High concentration levels of CXM were maintained in the skin for a long time. Based on this study, we consider that CXM is effective in the skin surgery.

Presence of eosinophilia in progressive systemic sclerosis and localized scleroderma

Recent studies on eosinophilic fasciitis have lead to this investigation of eosinophilia in progressive systemic sclerosis and localized scleroderma. Eosinophilia (eosinophilic count greater than 300/cmm) was found in ten of 63 progressive systemic sclerosis patients (15.8%) and in two of nine localized scleroderma cases (22.2%). In patients with progressive systemic sclerosis eosinophilia was found occasionally in six cases; it was transitory, but frequent in three cases; it was constant and very high in one case. In patients with localized scleroderma eosinophilia was found occasionally in one case and frequent, but not constant, in the other one. The possible influence of drugs could be excluded in five cases: three progressive systemic sclerosis cases and two affected with localized scleroderma. Therefore, it is possible to confirm that eosinophilia is not a distinctive sign of eosinophilic fasciitis in patients suffering from scleroderma-like syndromes. While eosinophilia is related to inflammation in eosinophilic faciitis, eosinophilia and disease activity could not be correlated in our patients with PSS. Recently, it has been suggested that eosinophilia might be an unfavorable prognostic criterion in progressive systemic sclerosis. Our data does not allow confirmation of this assumption.