Breaking through the steroid stigma: a single-centre study on topical corticosteroid perception and adherence in dermatology patients and caregivers.

INTRODUCTION: Topical corticosteroid phobia is a common phenomenon that can result in poor treatment adherence and therapeutic failure. OBJECTIVES: This study aims to evaluate the prevalence and degree of topical corticosteroid phobia and its impact on treatment adherence in various dermatological conditions. Additionally, we explored the sources of information regarding topical corticosteroids. MATERIALS AND METHODS: A cross-sectional study was conducted among 300 participants with topical corticosteroid usage experience. Topical corticosteroid phobia was assessed with the topical corticosteroid phobia (TOPICOP) scale, and treatment adherence was measured with the Elaboration d'un outil d'evaluation de l'observance des traitements medicamenteux (ECOB) score. Information sources regarding topical corticosteroids were identified, and their level of trust was assessed. The data were collected via questionnaires in three languages, namely English, Malay and Mandarin. RESULTS: The study found that topical corticosteroid phobia was prevalent, with 98% of participants expressing a certain degree of phobia. The mean global TOPICOP score was 32.7 ± 6.7%. The mean score of each domain was 27.1 ± 17.2% for knowledge and belief, 35.7 ± 23.8% for fears and 40.8 ± 25.8% for behaviour. Patients/caregivers who have eczema, highly educated, severe disease, low tolerability to symptoms, previous adverse effects with topical corticosteroids and tend to traditional/non-steroidal alternative therapy usage had a significant association with topical corticosteroid phobia (p<0.05). Dermatologists were the most common and trusted source of information on topical corticosteroids. CONCLUSIONS: This study highlights the widespread topical corticosteroid phobia in dermatological practice. Dermatologists should take the lead in combating steroid phobia and provide patients with public awareness regarding topical corticosteroids to improve treatment adherence and therapeutic outcomes.

Percutaneous sclerotherapy of foot venous malformations: evaluation of clinical response.

AIM: To evaluate a single institutional experience with percutaneous sclerotherapy of venous malformations (VM) of the foot. MATERIALS AND METHODS: Sixteen patients (mean age 14.6 years; range 6-27.3 years), who underwent 34 sclerotherapy procedures were retrospectively analysed. Technical success, Puig classification, VM size reduction, and the complication rate were evaluated. In procedures in which C-arm computed tomography (CT) was performed, the VM-to-skin surface distance was measured. Additionally, an e-mail-based questionnaire to evaluate the response to sclerotherapy was answered by the patients. RESULTS: Technical success was 97%. The mean number of procedures per patient was 2.1 (range 1-5). In all procedures, sodium tetradecyl sulphate foam was used. Appropriate follow-up was available for 29/33 procedures (88%). Post-procedural complications occurred after 6/29 procedures (21%), all of which were self-limited skin complications. C-arm CT was performed in 19/33 procedures (58%). The lesion-to-skin surface distance was significantly shorter in patients with skin post-procedural complications (p < 0.001). The e-mail-based questionnaire was completed by 13/16 patients (81%). Decrease in swelling, improvement of foot function and a significant decrease in pain (p = 0.003) was reported. No patient reported dis-improvement after sclerotherapy. CONCLUSION: Percutaneous sclerotherapy is an effective option for treating foot VMs. Skin complication rates are higher with shorter VM-to-skin surface distance.

Rising from the dead!

A report of a patient with Lazarus phenomenon (the return of spontaneous circulation after cardiopulmonary resuscitation) following cardiac arrest (myocardium ischemia) is presented. A 65 year patient was found unconscious at home. He taken to the emergency department On arrival he was unconscious, his pupils fixed and dilated bilaterally. Resuscitation proceeded for 55 minutes. He was then pronounced dead. Forty minutes later spontaneous breathing was noted and his blood pressure was 110/48 and heart rate 90bpm. He survived a further 13 days in the coronary care unit. The implications for management of cardiac arrest in the emergency and medical department are discussed.

Total synthesis of cytochrome b562 by native chemical ligation using a removable auxiliary.

We have completed the total chemical synthesis of cytochrome b562 and an axial ligand analogue, [SeMet(7)]cyt b562, by thioester-mediated chemical ligation of unprotected peptide segments. A novel auxiliary-mediated native chemical ligation that enables peptide ligation to be applied to protein sequences lacking cysteine was used. A cleavable thiol-containing auxiliary group, 1-phenyl-2-mercaptoethyl, was added to the alpha-amino group of one peptide segment to facilitate amide bond-forming ligation. The amine-linked 1-phenyl-2-mercaptoethyl auxiliary was stable to anhydrous hydrogen fluoride used to cleave and deprotect peptides after solid-phase peptide synthesis. Following native chemical ligation with a thioester-containing segment, the auxiliary group was cleanly removed from the newly formed amide bond by treatment with anhydrous hydrogen fluoride, yielding a full-length unmodified polypeptide product. The resulting polypeptide was reconstituted with heme and folded to form the functional protein molecule. Synthetic wild-type cyt b562 exhibited spectroscopic and electrochemical properties identical to the recombinant protein, whereas the engineered [SeMet(7)]cyt b562 analogue protein was spectroscopically and functionally distinct, with a reduction potential shifted by approximately 45 mV. The use of the 1-phenyl-2-mercaptoethyl removable auxiliary reported here will greatly expand the applicability of total protein synthesis by native chemical ligation of unprotected peptide segments.

Subcutaneous phaeohyphomycotic cysts caused by Exophiala jeanselmei in a lung transplant patient.

BACKGROUND: Phaeohyphomycosis is a skin fungal infection caused by dematiaceous fungi that often affects immunocompromised patients. Local recurrence after medication or surgical treatment is common in these patients. We present a case in which a 42-year-old woman status post-bilateral lung transplant developed phaeohyphomycotic cysts with local recurrence and then was successfully treated by local excision with pre- and postsurgery oral itraconazole treatment. OBJECTIVE: To demonstrate the utility of pre- and postsurgery oral itraconazole in immunocompromised patients with recurrent phaeohyphomycosis. METHODS: Local excision with pre- and postsurgery oral itraconazole treatment. RESULTS: Simple excision or excision with postsurgery oral itraconazole resulted in local recurrence in this patient. Local excision with pre- and postsurgery oral itraconazole was effective in preventing the local recurrence. CONCLUSION: Phaeohyphomycosis can run a prolonged course in immunocompromised patients with multiple recurrences. Local excision with pre- and postsurgery oral itraconazole can be used to treat these patients with recurrent phaeohyphomycosis.

Forehead lipoblastoma mimicking a hemangioma.

A case of forehead lipoblastoma simulating a hemangioma in a male infant is reported, to alert pediatricians to this rare tumor and to increase the index of suspicion in atypical hemangiomas. A 2-month-old male infant developed a protruding forehead mass with increased vascularity. It demonstrated progressive and accelerated growth over the subsequent 6 months, unresponsive to steroid therapy. A magnetic resonance imaging scan supported the diagnosis of hemangioma because of the hypervascular nature of the lesion. Surgical excision was performed because of visual obstruction. Pathologic examination of the specimen was consistent with a very primitive lipoblastoma. This tumor is a rare, benign lesion of immature fat cells that is found almost exclusively in the pediatric population. Lipoblastomas are more common in males than females and frequently present as asymptomatic, rapidly enlarging, soft lobular masses on the extremities. Complete surgical excision is the definitive treatment. In the vast majority of reported cases, however, the preoperative diagnosis was incorrect, underscoring the diagnostic dilemma presented by these rare tumors.

Treatment of pyogenic granuloma by shave excision and laser photocoagulation.

We present herein our technique for the management of pyogenic granulomas. Twenty such lesions were treated in 13 patients by shave excision followed by laser photocoagulation of the base. Recurrence was noted in just one case and was successfully treated by repeated laser treatment. The cosmetic results have been uniformly excellent. Shave excision followed by laser photocoagulation is an effective therapeutic alternative to excision and linear closure for the treatment of pyogenic granuloma, one that minimizes scar formation while preserving the ability to confirm the diagnosis.

Management of sternal and abdominal wounds in a pediatric heart transplant patient.

A 14-year-old girl with congenital heart disease underwent ventricular assist device placement before cardiac transplantation. The inability to close her abdominal fascia necessitated the placement of Prolene mesh, which subsequently became exposed and contaminated when her incision dehisced. Stable closure was obtained with Vicryl mesh and a rectus abdominis turnover flap. Her posttransplant course was notable for compression of the donor heart, necessitating prolonged open sternotomy. She failed an attempt at delayed sternal closure due to compression of the right ventricle by the sternum. In addition to standard pectoralis advancement flaps, a pedicled osseous sternal flap based on her left internal mammary artery was developed to avoid ventricular compression yet still provide some protection to the mediastinum. Alternative uses of this vascularized bone flap to assist with chest wall reconstruction are discussed.

Bigger is not always better: body image dissatisfaction in breast reduction and breast augmentation patients.

This study investigated body image dissatisfaction in breast reduction and breast augmentation patients. Thirty breast reduction and 30 breast augmentation patients completed two body image measures preoperatively. Breast reduction patients reported greater dissatisfaction with their overall body image as compared with breast augmentation patients, part of which can be understood as a function of their increased body weight. When asked specifically about their breasts, reduction patients displayed increased body image dysphoria and maladaptive behavioral change, including embarrassment about their breasts in public areas and social settings and avoidance of physical activity. Results are discussed in the context of ideal body weight cutoffs by third-party payers for reimbursement for breast reduction. Recommendations for reimbursement criteria that de-emphasize the role of body weight are made.

Histidine-tailed microperoxidase-10: a pH-dependent ligand switch.

The electronic absorption and magnetic circular dichroism (MCD) spectra of ferric histidine-tailed microperoxidase-10 (His-MP10) change dramatically as the pH is raised from 1.8 to 11.8. Two distinct species are observed (pKa = 4.4). The spectra of acidic ferric His-MP10 nearly match those of ferric mesoporphyrin-reconstituted myoglobin and so the axial ligands are assigned to be histidine and water. The retention of histidine ligation below pH 4 contrasts to the behavior of myoglobin and horseradish peroxidase which convert to five-coordinate water ligated and then lose the heme prosthetic group at even lower pH. Neutral and alkaline ferric His-MP10 have spectra that are very similar to those of the imidazole complex of ferric mesoporphyrin-reconstituted myoglobin. Thus, we conclude that it is bis-histidine ligated with the C-terminal histidine bound as the sixth ligand. Thus, ferric His-MP10 exhibits a pH-dependent ligand switch with a change in axial ligation from water and histidine at low pH to bis-histidine at neutral and alkaline pH.

Serratus anterior free-tissue transfer: harvest-related morbidity in 34 consecutive cases and a review of the literature.

Donor-site morbidity in serratus anterior free-tissue transfers is investigated in 34 consecutive cases. Nineteen lower-extremity reconstructions and 15 facial reconstructions were retrospectively analyzed. office and hospital charts were reviewed, and patients were given a follow-up questionnaire. The mean operative time was 6.3 hr and the mean estimated blood loss was 441 cc. Transfusion was required in 24 percent of cases. The early complication rate was 21 percent consisting of 6 percent hematomas and 15 percent seromas. Scar appearance, pain, numbness, and shoulder strength and mobility were acceptable. Scapular winging was detectable in 3/9 patients examined, but symptomatic in only one. The number of muscle slips harvested or whether the graft was innervated did not significantly affect this rate. Half of the patients had returned to work or school. None attributed any work disability to their donor sites. They participated in many athletic activities, including those requiring upper extremity strength and dexterity. Previously reported series are discussed, and the morbidity of this donor site is compared with reported series of other free muscle flaps. The authors find this flap useful for facial reanimation and for soft-tissue coverage with minimal bulk. Low rates of operative, perioperative, and long-term morbidity are definite advantages.

Laser treatment of facial venous vascular malformations.

Facial venous vascular malformation (VVMs) can be cosmetically and functionally disabling. Few studies separate the treatment of these lesions from other vascular birthmarks, despite their unique physiology and natural history. This study retrospectively evaluates the treatment of 34 patients with facial VVMs treated with laser photocoagulation in 63 consecutive procedures. Twenty-two procedures used an argon laser, 12 used a yellow dye laser, and 32 used a yttrium aluminum garnet/potassium titanyl phosphate (YAG/KTP) laser. In 11 procedures the fiberoptic wand of the KTP laser was passed percutaneously for deep photocoagulation. Office charts and operative reports were reviewed, and patients were given a follow-up questionnaire. Bulkiness and discoloration usually improved in the early postoperative period. Partial or complete recurrence was common, most frequently noted at 2 to 6 months. Healing usually occurred within 1 to 4 weeks. Postoperative pain was minimal in most patients, although severe pain occurred in a small number. The complication rate was 5%, including an oral commissure scar contracture following treatment by KTP laser, a small cutaneous burn following deep fiberoptic photocoagulation, and a herpes flare-up following argon laser treatment. Satisfaction was high, and all but 2 patients would have laser treatment again. Laser photocoagulation provides palliation for facial venous malformations with minimal scarring and morbidity, but recurrence and the need for repeated treatments is common.

Successful revascularization of a toe-avulsion injury in a three-year-old child, using a digital artery transfer.

The partially avulsed second toe of a 3-year-old girl was successfully revascularized using a digital artery transfer from the adjacent third toe. The technique is explained and discussed.

Hemangiomas and vascular malformations.

The biological classification system provides a useful clinical distinction between proliferative and biologically stable vascular anomalies. Hemangiomas demonstrate the ability to proliferate, then involute, and the majority still are followed conservatively. Intervention usually is reserved for life- or vision-threatening lesions. Surgical reconstruction may be indicated for the 10% to 30% of hemangiomas that do not regress adequately. The use of lasers to treat early hemangiomas is controversial but may gain greater clinical application as favorable data accumulate. In the future, biological suppression with antiangiogenic agents may become the preferred mode of therapy. Vascular malformations represent developmental errors in embryogenesis. They are present at birth, do not proliferate, and do not regress spontaneously. Lasers, interventional radiology, and surgical therapy may offer significant palliation and possible cures. It is important that the physician understand the difference between these two groups to better provide appropriate prognostic and therapeutic advice to the parents of children with these anomalies.

Effects of chlorhexidine spray on plaque and gingival health in institutionalized persons with mental retardation.

In this study, eight institutionalized males received a 0.12% chlorhexidine gluconate spray twice daily. A second group of eight males received a placebo spray in the same manner. The results indicated that pump-administered chlorhexidine spray can effectively reduce plaque and gingivitis in patients with mental retardation who are unable to brush their own teeth.

A survey of the availability of dental services to developmentally disabled persons residing in the community.

Public Law 88-164, enacted in 1963, has led to extensive deinstitutionalization of persons with mental retardation from a peak census of 194,650 in 1967 to 91,440 by 1988. This population now depends on the community-based health care system for medical and dental care. A survey conducted to determine the availability of dental care to the developmentally disabled residing in group homes located in north central Florida indicated that 40% of caretakers experienced difficulty in locating dentists willing to provide comprehensive dental services for residents. According to the caretakers, although 75% of the residents were cooperative dental patients, dentists were reluctant to provide services for a variety of reasons, including financial disincentives, inadequate knowledge and preparation, and a lack of proper equipment necessary to treat this group of special patients.

Soft-tissue injuries of the hand and wrist in racquet sports.

Participants in racquet sports are prone to a host of soft-tissue injuries to their hands and wrists owing to the direct impact of the handle as well as the repetitive stretching that occurs as the wrist is forcefully whipped into extremes of position. Tendinitis can occur in all tendons but is most common in the first dorsal compartment, flexor carpi ulnaris, flexor carpi radialis, and extensor carpi ulnaris. Ligamentous tears can produce instability patterns that, if unrecognized, can become chronic disabilities. Vessels and nerves can be compromised by repetitive blunt trauma to the structures themselves or by entrapment by surrounding structures. Prompt diagnosis will allow for the appropriate treatment and eliminate the need for vague terms such as "wrist sprain." The goal of early recognition and treatment is to allow the player to get back to the court and prevent the development of chronic discomfort or permanent impairment.

Differential hemispheric activation during complex visuomotor performance: alpha trends and theta.

Two experiments were done to study asymmetry in left and right cerebral hemispheres while subjects performed in verbal and nonverbal tasks, including a complex visuomotor T.V. tennis game (Pong). Previous analyses demonstrated asymmetries of alpha activity during these tasks, and in this paper we describe sequential changes of alpha asymmetry associated with playing Pong. Alpha power was stable in the left hemisphere but decreased in the right hemisphere during each rally, returning to symmetry during inter-rally intervals. Theta activity increased bilaterally in most of the tasks and differed from the alpha patterns in several respects. The second experiment demonstrated the usefulness of video games for assessing sex and age differences in visuospatial capacities'--male performance was better than female and performance was inversely related to age.