Photopatch testing of 1155 patients: results of the U.K. multicentre photopatch study group

BACKGROUND

Photoallergic contact dermatitis can be difficult to diagnose if not appropriately investigated. Currently, the most common U.K. photoallergens appear to be sunscreen chemicals. The investigation of choice is photopatch testing (PPT), which is probably underused. In part, this is due to differences in methodology and results interpretation.

OBJECTIVES

To conduct PPT using a group of sunscreen chemicals, defined indications and a standardized methodology including interpretation and relevance of reactions in patients attending for investigation at 17 centres across the U.K., Ireland and the Netherlands.

METHODS

Patients (n = 1155) who fulfilled the inclusion criteria were investigated with PPT using sunscreen chemicals in addition to suspected topical products. Readings were taken at 24, 48 and 72 h following standardized ultraviolet A irradiation (5 J cm(-2)). The clinical relevance of any reaction was recorded.

RESULTS

Of the 1155, 130 had allergic reactions (11.3%). Of these, 51 had photoallergy (PA) (4.4%), 64 had contact allergy (CA) (5.5%), and 15 patients had combined PA and CA (1.3%). Multiple PA was seen in some. The most common photoallergen was benzophenone-3 (27 reactions; 21%). Most reactions (60%) were clinically relevant. The most common indication for testing in patients found to have PA was a history of reacting to a sunscreen (41%). The other 59% had an exposed-site dermatitis/skin problem or a photodermatosis. Some centres (n = 8) performed readings after the standard 48-h reading, and an extra 32 PA and 22 CA reactions were detected, which were not evident at 48 h. A new photoallergen (octyl triazone) was detected in two patients.

CONCLUSIONS

Sunscreen PA and CA are probably equally uncommon. Most reactions, of both reaction types, were relevant clinically. A large proportion of patients (59%) found to have PA was unaware of reacting to a sunscreen chemical, suggesting that PA should be considered as an explanation in any exposed-site dermatitis. Although this study focused on reactions at 48 h postirradiation, readings performed up to 96 h, while inconvenient, add value by detecting additional relevant responses. A previously unknown photoallergen was found, highlighting the need for awareness of novel photoallergens in the marketplace. A standardized PPT method not only encourages more use of this investigation, but also facilitates comparison of results between centres and so will improve our understanding of PA.

A pilot study of treatment of lentigo maligna with 5% imiquimod cream

BACKGROUND

Lentigo maligna (LM) is an in situ form of malignant melanoma, and surgical excision is often unsatisfactory. Imiquimod cream is an immune response modifier and induces a predominantly T-helper 1 type response.

OBJECTIVES

Assessment of histological and clinical response of surgically resectable LM after treatment with 5% imiquimod cream.

METHODS

Six patients with LM were treated with 5% imiquimod cream daily for 6 weeks. The whole site of the original lesion was then excised. Clinical and histological and appearances were measured using clinical response and histological grading scores.

RESULTS

Complete or almost complete clearance of pigmentation with minimal residual histological evidence of LM was observed in four patients, one patient showed no clinical or histological improvement, and the remaining patient had almost no residual pigmentation clinically after treatment yet histopathological changes remained as severe as before treatment.

CONCLUSIONS

Topical imiquimod cream merits further investigation as a new therapy for LM.

Perceived outcomes and utilization of upper extremity surgical reconstruction in individuals with tetraplegia at model spinal cord injury systems

STUDY DESIGN

Survey.

OBJECTIVE

To measure the utilization of upper extremity reconstructive surgery and the clinicians' perceptions of the outcomes provided for persons with tetraplegia across the Model Spinal Cord (SCI) Injury Systems.

SETTING

Model SCI Systems.

METHODS

PARTICIPANTS

A clinician from each of the Model Centers.

MAIN OUTCOME MEASURE

A mailed survey eliciting responses with respect to: (1) utilization of upper extremity reconstructive procedures and (2) the clinicians' perceived outcomes of these procedures.

RESULTS

In all, 76% responded positively about the availability and appropriateness of upper extremity surgical reconstruction at their center. Of the respondents, 75% felt that surgery recipients were generally satisfied with their surgeries, 80% felt that the surgery made a positive impact on recipients' lives, 81% felt that recipients showed increased independence, and 70% reported a positive impact on recipients' occupation. In all, 93% felt insurance companies should pay for the procedures. Compared to the satisfaction of surgery recipients using a similar instrument, clinicians anticipated slightly greater improvements in all areas except occupation.

CONCLUSIONS

There is a positive perception of the benefits of reconstructive surgery for tetraplegia; however, procedures are not routinely offered at all centers. The primary reasons reported for this include the misconception that insurance does not remit payment, that a surgeon is not available, and that surgical candidates are referred to another center.

A neuroprosthesis for high tetraplegia

BACKGROUND

This case report describes a neuroprosthesis that restored shoulder and elbow function in a 23-year-old man with chronic C3 complete tetraplegia. Before implementation of the neuroprosthesis, electrodiagnostic testing revealed denervation from C5 to T1, with the greatest degree of denervation in the C8 and T1 myotomes. Thirteen percutaneous intramuscular electrodes were implanted into muscles acting on the shoulder and elbow of one upper limb. Before functional testing, the subject underwent a conditioning regimen to maximize the strength and endurance of the implanted muscles.

RESULTS

After completion of the 8-week exercise regimen, stimulated active range of motion against gravity included 60 degrees of shoulder abduction, 45 degrees of shoulder flexion, 10 degrees of shoulder external rotation with the shoulder passively abducted to 90 degrees, and 110 degrees of elbow flexion. Stimulated elbow extension lacked 20 degrees of full extension with gravity eliminated. After system setup, the subject was able to pick up mashed potatoes on a plate with a utensil and bring them to his mouth using the neuroprosthesis and a balanced forearm orthosis. A switch mounted on the headrest of the subject's wheelchair and a position sensor mounted on the contralateral shoulder allowed the subject to control movement of his upper limb.

Electrically stimulated elbow extension in persons with C5/C6 tetraplegia: a functional and physiological evaluation

OBJECTIVE

To measure the effect of electrically stimulated triceps on elbow extension strength, range of motion, and the performance of overhead reaching tasks.

SETTING

Clinical research laboratory.

PARTICIPANTS

Four individuals with spinal cord injuries at the C5 or C6 motor level.

INTERVENTIONS

The participants, who already had an implanted upper extremity neuroprosthesis, were provided with elbow extension through functional electrical stimulation (FES) of the triceps brachii.

MAIN OUTCOME MEASURES

Comparisons of stimulated elbow extension to voluntary elbow extension: (1) evaluations of impairment such as range of motion and strength; (2) performance of a set of functional overhead reaching tasks that required elbow extension; (3) a usage survey (conducted by telephone) to examine use of triceps stimulation in the home and community.

RESULTS

All participants achieved greater range of motion and strength of elbow extension with stimulated triceps versus without. Overall functional task performance improved in 100% of the tasks tested for all but one participant, who showed improvement in 60% of the tasks. Participants reported using the triceps in at least one activity for at least 90% of the days the neuroprosthesis was donned.

Satisfaction with and usage of a hand neuroprosthesis

OBJECTIVE

To measure the satisfaction with, clinical impact of, and use of an implantable hand neuroprosthesis.

SETTING

Eight different medical centers.

PARTICIPANTS

Thirty-four individuals with spinal cord injuries at the C5 or C6 motor level.

INTERVENTIONS

Participants were implemented with a hand neuroprosthesis that provides grasp and release. The neuroprosthesis includes a surgically implanted stimulator, implanted electrodes sutured to the hand and forearm muscles, and an externally mounted controller.

MAIN OUTCOME MEASURE

A survey was mailed to study participants, who were asked to respond to statements such as "If I had it to do over, I would have the hand system implanted again," using a 5-level Likert scale ("strongly agree" to "strongly disagree").

RESULTS

Eighty-seven percent of participants were very satisfied with the neuroprosthesis, 88% reported a positive impact on their life, 87% reported improvements in activities of daily living, and 81% reported improved independence. Participants reported using the neuroprosthesis a median of 5.5 days per week; 15 participants used the neuroprosthesis 7 days per week, and 5 participants reported not using the device.

CONCLUSIONS

The neuroprosthesis was used by most participants. The neuroprosthesis performed satisfactorily, increased users' ability to perform activities of daily living and independence, and improved their quality of life.

An implanted upper-extremity neuroprosthesis. Follow-up of five patients

An implanted neuroprosthesis supplying functional neuromuscular stimulation was used to provide grasp and release to tetraplegic individuals. This article describes the results, at a minimum of three years, for the first five patients to have operative implantation of an eight-channel stimulator-receiver. All of the patients had a clinically complete spinal cord injury with motor function remaining at the level of the fifth or sixth cervical nerve root. In addition to implantation of the stimulator system, each patient had augmentative operations on the hand to improve function. The procedures included tendon transfers, side-to-side tendon anastomoses, arthrodesis of the interphalangeal joint of the thumb, and rotational osteotomy of the radius. The neuroprosthesis provides two grasp patterns controlled by voluntary motion of the shoulder or wrist. Functional evaluations included measurement of pinch force, a grasp-release test, evaluation of the level of functional independence, and usage surveys. Pinch force ranged from eight to twenty-five newtons. All five patients demonstrated functional grasp patterns, had increased independence, and were able to use the neuroprosthesis at home on a regular basis. The implanted stimulator has proved to be safe and reliable, with seven years as the longest time in situ at the time of writing.