Leg ulceration due to cutaneous melioidosis in a returning traveller.

A 26-year-old man, returned to the UK having travelled extensively in Asia. He was referred with a 3-month history of distal leg ulceration following an insect bite while in Thailand. Despite multiple courses of oral antibiotics, he developed two adjacent ulcers. A wound swab isolated an organism identified as Burkholderia thailandensis The histology of the skin biopsy was non-specific. A diagnosis of cutaneous melioidosis was made, based on clinical and microbiological grounds. The ulcers re-epithelialised on completion of intravenous ceftazidime followed by 3 months of high dose co-trimoxazole and wound care. Many clinical microbiology laboratories have limited diagnostics for security-related organisms, with the result that B. pseudomallei, the causative bacterium of melioidosis, may be misidentified. This case highlights the importance of maintaining high levels of clinical suspicion and close microbiological liaison in individuals returning from South-East Asia and northern Australia with such symptoms.

PEACE in the midst of an emergency: a rash not to miss.

We present the case of a 29-year-old woman who initially presented to her GP with a short history of non-pruritic annular skin lesions with central clearing. A month later, she developed signs and symptoms of bone marrow failure with bruising, epistaxis and fatigue. After urgent review of a blood film, she was diagnosed with acute promyelocytic leukaemia (APML), which is a haematological emergency. Treatment with all-trans retinoic acid (ATRA) was commenced immediately and she was subsequently treated with arsenic trioxide (ATO). The annular rash was subsequently diagnosed as paraneoplastic erythema annulare centrifugum (PEACE), which resolved with treatment. This case demonstrates the importance of the urgent diagnosis of APML and highlights PEACE as a rash that clinicians should be aware of, as it can be the initial manifestation of a number of both haematological and non-haematological malignancies.

Modifiable Lifestyle Factors Associated With Response to Treatment in Early Rheumatoid Arthritis.

OBJECTIVE: We aimed to evaluate the associations between response to algorithm-directed treat-to-target conventional synthetic disease-modifying antirheumatic drug therapy and potentially modifiable lifestyle factors, including dietary fish oil supplementation, body mass index (BMI), and smoking history in a rheumatoid arthritis (RA) inception cohort. METHODS: Patients with RA with a duration of less than 12 months were reviewed every 3 to 6 weeks to adjust therapy according to disease response. All patients received advice to take fish oil supplements, and omega-3 status was measured as plasma levels of eicosapentaenoic acid (EPA). Lifestyle factors and other variables potentially prognostic for 28-joint Disease Activity Score (DAS28) remission and DAS28 low disease activity (LDA) at the 12-month visit were included in multivariable logistic regression models. RESULTS: Of 300 participants, 57.7% reached DAS28 LDA, and 43.7% were in DAS28 remission at 1 year. Increase in plasma EPA was associated with an increase in the odds of being in LDA (adjusted odds ratio [OR] = 1.27; P < 0.0001) and remission (adjusted OR = 1.21; P < 0.001). There was some evidence that the effect of BMI on LDA might be modified by smoking history. An increase in BMI was associated with a decrease in the odds of being in LDA in current and former smokers but had no impact on LDA in patients who had never smoked. There were no meaningful associations between BMI or smoking history and remission. CONCLUSION: Omega-3 status, BMI, and smoking history are potential predictors of outcome in early RA. The possibility of an effect modification by smoking on the predictive value of BMI merits further investigation.

A cohort investigation of anaemia, treatment and the use of allogeneic blood transfusion in colorectal cancer surgery.

INTRODUCTION: Preoperative identification and treatment of anaemia is advocated as part of Patient Blood Management due to the association of adverse outcome with the perioperative use of blood transfusion. This study aimed to establish the rate of anaemia identification, treatment and implications of this preoperative anaemia on ARBT use. METHODS: All patients who underwent elective surgery for colorectal cancer over 18 months at a single Tertiary Centre were reviewed. Electronic databases and patient casenotes were reviewed to yield required data. RESULTS: Complete data was available on 201 patients. 67% (n = 135) had haemoglobin tested at presentation. There was an inverse correlation between tumour size and initial haemoglobin (P < 0.01, Rs = -0.3). Initial haemoglobin levels were significantly lower in patients with right colonic tumours (P < 0.01). Patients who were anaemic preoperatively received a mean 0.91 units (95%CI 0-0.7) per patient which was significantly higher than non-anaemic patients (0.3 units [95%CI 0-1.3], P < 0.01). For every 1 g/dl preoperative haemoglobin increase, the likelihood of transfusion was reduced by approximately 40% (OR 0.57 [95%CI 0.458-0.708], P < 0.01). Laparoscopic surgery was associated with fewer anaemic patients transfused (P < 0.01). CONCLUSION: Haemoglobin levels should be routinely checked at diagnosis of colorectal cancer, particularly those with large or right sided lesions. Early identification of anaemia allows initiation of treatment which may reduce transfusion risk even with modest haemoglobin rises. The correct treatment of this anaemia needs to be established.

An observational study investigating the effect of platelet function on outcome after colorectal surgery.

INTRODUCTION: Previous studies have assumed patients have uniform responses to aspirin, yet significant numbers are occult hypo- or hyper-responders. A new validated test of platelet function measures platelet P-selectin expression, which rises with increased platelet activity. This study investigated the measured perioperative changes in platelet function in response to aspirin, and subsequently whether quantitative variations in platelet activity affected perioperative complication severity and frequency. METHODS: 107 patients undergoing major colorectal surgery were recruited and assigned to either control (no antiplatelet therapy) or aspirin groups. P-selectin was measured following platelet stimulation at recruitment prior to cessation of medication, and at surgery before intervention. Perioperative complications, hemoglobin changes and blood transfusions were also recorded. RESULTS: Platelet function was higher in control (n = 87) than aspirin group (n = 20) at recruitment (median 1303u [IQR 1102-1499] vs 77u [IQR 63.5-113.5],P < 0.01) and surgery (median 1224u [IQR 944-1496] vs 281.5u [IQR 106.8-943], P < 0.01). There was a positive correlation between length of aspirin cessation and platelet function at surgery (R(S) = 0.66, P < 0.01). Complication rates and hemorrhagic complication rates (P < 0.05) were higher with aspirin than control, although complication severity was not increased. Platelet function of the entire cohort at surgery was not associated with complication rate, severity or transfusion use. DISCUSSION: Although complication rates were higher in aspirin group, impaired platelet function within ranges seen with aspirin continuation did not affect complication severity or rate or blood transfusion use. Consequently, aspirin continuation may not affect clinical outcome in patients undergoing major colorectal surgery and requires further investigation with a large randomized trial.