Severe recalcitrant pyoderma gangrenosum responding to a combination of mycophenolate mofetil with cyclosporin and complicated by a mononeuritis.

We describe a 17-year-old boy with severe recalcitrant pyoderma gangrenosum. Healing was achieved with a combination of mycophenolate mofetil and cyclosporin, negative pressure dressings and split-skin grafts. His recovery was complicated by a sciatic nerve palsy, which we believe was caused by direct involvement of the nerve at the level of the sciatic notch.

Availability of condoms in urban and rural areas of KwaZulu-Natal, South Africa.

BACKGROUND: Promoting condom use to prevent HIV transmission is futile if condoms are not readily available. GOAL: This study assessed condom availability in clinics, shops, and other outlets in urban and rural South Africa. STUDY DESIGN: Snowball sampling was used to select 70 private-sector and public-sector outlets. One male and one female black fieldworker were posed as clients seeking condoms to assess condom availability and provider attitudes. RESULTS: Condoms were available in nine (100%) public clinics, in five of nine (55%) private doctor's rooms, and in only 5 of 52 (10%) nonhealth outlets. Access was limited in the public sector by clinic opening times, inadequate clinic signs and markings, and by some providers' attitudes. CONCLUSION: A major opportunity to make condoms available in nonhealth outlets in rural areas and urban townships is being missed in South Africa. Above all, the high level of condom awareness is not being matched by easy availability.

Figurate erythema with bullous pemphigoid: a true paraneoplastic phenomenon?

There has been controversy about the possible link between bullous pemphigoid and underlying malignancy. We report a case of bullous pemphigoid with marked figurate erythema which arose shortly before the clinical presentation of colonic carcinoma and cleared completely 1 week after its resection. We review the literature and conclude that patients who present with clinically atypical bullous pemphigoid may warrant investigation for underlying neoplasia.

Digital teledermatology for skin tumours: a preliminary assessment using a receiver operating characteristics (ROC) analysis.

A low-cost store-and-forward teledermatology system using digital images for the remote diagnosis and management of skin tumours was evaluated. Two hospitals participated in the trial. Patients were seen face to face at one hospital, and had their images and clinical history viewed remotely by a different dermatologist at a second hospital. A preliminary receiver operating characteristics (ROC) analysis revealed clinical agreement between the teledermatologist and face-to-face dermatologist in 93% of cases in terms of their assessment of the benign/malignant nature of the lesions. Sensitivity of the judgements was 88% and specificity was 80%. These preliminary findings indicate the potential for remote management of skin tumours using a low-cost system in the National Health Service.

Comparison of teleconsultations and face-to-face consultations: preliminary results of a United Kingdom multicentre teledermatology study.

The objective of this multicentre study was to undertake a systematic comparison of face-to-face consultations and teleconsultations performed using low-cost videoconferencing equipment. One hundred and twenty-six patients were enrolled by their general practitioners across three sites. Each patient underwent a teleconsultation with a distant dermatologist followed by a traditional face-to-face consultation with a dermatologist. The main outcome measures were diagnostic concordance rates, management plans and patient and doctor satisfaction. One hundred and fifty-five diagnoses were identified by the face-to-face consultations from the sample of 126 patients. Identical diagnoses were recorded from both types of consultation in 59% of cases. Teledermatology consultations missed a secondary diagnosis in 6% of cases and were unable to make a useful diagnosis in 11% of cases. Wrong diagnoses were made by the teledermatologist in 4% of cases. Dermatologists were able to make a definitive diagnosis by face-to-face consultations in significantly more cases than by teleconsultations (P = 0.001). Where both types of consultation resulted in a single diagnosis there was a high level of agreement (kappa = 0.96, lower 95% confidence limit 0.91-1.00). Overall follow-up rates from both types of consultation were almost identical. Fifty per cent of patients seen could have been managed using a single videoconferenced teleconsultation without any requirement for further specialist intervention. Patients reported high levels of satisfaction with the teleconsultations. General practitioners reported that 75% of the teleconsultations were of educational benefit. This study illustrates the potential of telemedicine to diagnose and manage dermatology cases referred from primary care. Once the problem of image quality has been addressed, further studies will be required to investigate the cost-effectiveness of a teledermatology service and the potential consequences for the provision of dermatological services in the U.K.

Measuring cervical ectopy: direct visual assessment versus computerized planimetry.

OBJECTIVE: Cervical ectopy has been identified as a possible risk factor for heterosexual transmission of human immunodeficiency virus. To accurately assess the importance of cervical ectopy, methods for measuring ectopy with precision need to be developed. The objective of this study was to evaluate the reliability of two methods of measuring cervical ectopy: direct visual assessment and computerized planimetry. STUDY DESIGN: Cervical photographs of 85 women without cervical disease were assessed for cervical ectopy by three raters using direct visual assessment and a computer planimetry method. Agreement between the two methods, among the three raters, and among measurements by each rater over time was calculated with use of intraclass correlation coefficients, where 1.0 represents perfect agreement and 0 represents no agreement except by chance. RESULTS: The intraclass correlation coefficient among the three raters (interrater agreement) was 0.58 for direct visual assessment without application of acetic acid to the cervix compared with 0.72 for direct visual assessment with acetic acid and 0.82 for computerized planimetry with acetic acid. The intraclass correlation coefficient among measurements by each rater over time (intrarater agreement) was 0.66 for direct visual assessment without acetic acid compared with 0.77 for direct visual assessment and 0.83 for computerized planimetry after application of acetic acid. When acetic acid was used, the intraclass correlation coefficient between the two methods was 0.69. CONCLUSIONS: Computerized planimetry of cervical photographs may provide the most consistent estimate of the percent of ectopy. However, if time and resources make the use of computer planimetry difficult, direct visual assessment after application of 5% acetic acid appears to provide comparable estimates.

Nonoxyl-9 and women's struggle against HIV.

PIP: Most people worldwide contract HIV through unprotected heterosexual intercourse. There is strong evidence that women are biologically at greater risk of heterosexual transmission than men. The presence of easily traumatized columnar cells on the vaginal portion of the uterine cervix of young women and girls makes these women even more vulnerable to infection. Women need effective, available, and appropriate ways to protect themselves against HIV infection, preferably methods which are invisible to their male sex partners. Many women lack the necessary social and economic power to force men to practice safer sex. Vaginal microbicides may be just what women need. Nonoxynol-9, a nonionic detergent which disrupts cell membranes, has been in use as a spermicide for more than 30 years. Its efficacy as a microbicide, however, is unclear. A protective effect has been shown against bacterial sexually transmitted diseases (STD), but questions remain about its effectiveness against HIV. New formulations of low-dose nonoxynol-9 have recently been tested in healthy volunteers. These trials have thus far shown limited toxicity, even with multiple administration. The long-term safety of these low-dose formulations and their efficacy against male-to-female HIV transmission need to be assessed. Both female condoms and vaginal microbicides are being tested in KwaZulu-Natal.^ieng

The correction of acidosis does not increase dietary protein intake in chronic renal failure patients.

In normal humans and in patients with chronic renal failure (CRF), acidosis increases whole-body protein degradation. Correction of acidosis reduces protein degradation. The mechanisms underlying these changes in protein metabolism are unclear. However, one possibility is that dietary protein intake is reduced in acidosis and that this causes increased protein degradation. This possibility has not been tested. In this study the effects of acidosis on protein intake in patients with CRF have been assessed using 7-day weighed dietary inventories in the acidotic state (venous bicarbonate 15.6 +/- 1.0 mmol/L) and following treatment with oral sodium bicarbonate (venous bicarbonate 21.0 +/- 1.4 mmol/L). Protein intake was also derived from urinary nitrogen excretion. There was no significant difference in protein intake calculated from dietary records (1.0 +/- 0.09 g/kg/d v 1.06 +/- 0.1 g/ kg/d) or calculated from urinary nitrogen (1.13 +/- 0.07 g/kg/d v 1.06 +/- 0.06 g/kg/d) between the untreated and bicarbonate-treated states in eight patients with CRF. We conclude that acidosis in CRF patients does not affect dietary protein intake and that dietary changes therefore do not contribute significantly to the changes in protein metabolism seen in acidosis.

Correction of acidosis in CAPD decreases whole body protein degradation.

Correction of acidosis in CAPD decreases protein degradation and synthesis but has no effect on leucine oxidation. The effect of the correction of metabolic acidosis in CRF patients treated with CAPD was determined from the kinetics of infused L-[1-13C]leucine. Seven CAPD patients were studied before (acid) and after correction of acidosis (bicarbonate) (pH:acid 7.39 +/- 0.01, bicarbonate 7.41 +/- 0.01, P = 0.005). Leucine appearance from body protein (PD) [corrected] and leucine disappearance into body protein (PS) [corrected] decreased significantly with correction of acidosis. (PS: acid 211.7 +/- 9.8, bicarbonate 142.3 +/- 4.2 micromol x kg-1 x hr-1, P < 0.001; PD: acid 200.6 +/- 8.5, bicarbonate 132.4 +/- 3.7 micromol x kg-1 x hr-1, P < 0.001). There was no significant change in leucine oxidation or plasma amino acid concentrations. These results demonstrate that optimal correction of acidosis in CAPD is beneficial in terms of protein turnover.

Drug-induced Sweet's syndrome (acute febrile neutrophilic dermatosis) associated with hydralazine.

We report a case of Sweet's syndrome associated with hydralazine. The association of Sweet's syndrome with hydralazine, and with the oral contraceptive, minocycline, and trimethoprim/sulphamethoxazole, has been reported previously. We suggest that a drug aetiology should be sought in cases of Sweet's syndrome.

A pilot study to determine the cost efficiency of a standard parenteral feeding regimen.

This pilot study was initiated to investigate methods designed to reduce the cost of a total parenteral nutrition (TPN) regimen. Seven patients at the Western General Hospital Edinburgh (WGH) were placed on a standard modified TPN regimen where the total fat, nitrogen and energy content of the regimen was reduced. The nutritional status of each patient was monitored prior to and on completion of TPN. Five out of seven patients lost weight. All of the patients exhibited a rise in plasma alkaline phosphate levels demonstrating possible fatty infiltration of the liver. It is concluded that further research is required to test if there is an ideal 'standard' regimen. It may be that such an entity does not exist and a compromise of two regimens may be necessary.