An unusual complication after percutaneous drainage of a pancreatic pseudocyst into the stomach.

In the period between September 1995 and June 1999, we performed percutaneous drainage into the stomach in 12 patients. There were no complications or pseudocyst recurrences on insertion or after endoscopic removal of the catheter, which was left in site for 1 year on average. After endoscopic removal of the drainage catheter, one of the patients presented with a cystic formation in the stomach wall, which caused stomach emptying disorder. Therefore, the patient had to be reoperated. The cyst wall was incised and a part of the cystic wall sampled for histological examination. The cyst was then drained into the isolated Roux loop of the jejunum. Histological findings of the cystic wall specimen showed the presence of granulation tissue and smooth muscle layers with ganglia cells of myenteric nerve plexus. Despite this complication, we believe that percutaneous endoscopically and ultrasonographically guided drainage of pancreatic pseudocyst into the stomach by means of a double pigtail catheter is a good method that yields encouraging results in sonographically selected cases. The position of the drainage catheter needs to be checked endoscopically, and the catheter should be removed only after 1 year.

Assessment of the ability of the topical skin protectant (TSP) to protect against contact dermatitis to urushiol (Rhus) antigen.

BACKGROUND: Military personnel have a need for effective protection against cutaneous exposure to chemical warfare agents (CWA). Topical Skin Protectant (TSP) is being developed to supplement chemical warfare protective garments. TSP protects against CWA exposure in animals, but does it work for humans? Because humans should not be tested with live CWA, urushiol (poison ivy) extract was used as a surrogate substance in place of CWA for human efficacy testing of TSP. OBJECTIVE: Determine whether TSP protects human skin against experimentally-induced urushiol dermatitis. METHODS: Open urushiol patch testing of 50 rhus-sensitive subjects comparing the 96-hour dermatitis severity scores between TSP protected and TSP unprotected sites. There were 4 paired sites (i.e., protected versus unprotected) per subject. Test sites were scored using a 9-point dermatitis scale of 0.0 to 4.0 (using 0.5 increments). RESULTS: Analysis of variance of the dermatitis scores from 192 paired sites on 48 evaluable subjects showed that TSP protected sites had mean dermatitis scores about 2 points lower than TSP unprotected sites (P <.001). CONCLUSION: Although this study does not provide direct scientific evidence that TSP protects humans against the percutaneous absorption of CWA, it does provide circumstantial evidence that this is the case. The fact that TSP is so highly effective against a lipophilic substance like urushiol and that most common vesicant CWAs are lipophilic and are weaponized in oleaginous vehicles, makes the effectiveness of TSP in preventing absorption and dermatitis from CWA seem likely.

The history of teledermatology in the Department of Defense.

The Department of Defense (DoD) healthcare system supports the medical needs of service members while engaged in a variety of missions frequently in isolated, remote, and austere locations. As a result, the DoD has been a leader in the development of telemedicine, including teledermatology as a way to provide "good medicine in bad places." A brief technical history of teledermatology, representative DoD experiences including military unique concerns, and a novel approach to increase the access of DoD teledermatology consultation are presented in this article.

The effect of decreasing digital image resolution on teledermatology diagnosis.

OBJECTIVE: To determine the effect of degraded digital image resolution (as viewed on a monitor) on the accuracy and confidence of dermatologic interpretation. MATERIALS AND METHODS: Eight dermatologists interpreted 180 clinical cases divided into three Logical Competitor Sets (LCS) (pigmented lesions, non-pigmented lesions, and inflammatory dermatoses). Each case was digitized at three different resolutions. The images were randomized and divided into (9) 60-image sessions. The physicians were completely blinded concerning the image resolution. After 60 seconds per image, the viewer recorded a diagnosis and level of confidence. The resultant ROC curves compared the effect of LCS, level of clinical difficulty, and resolution of the digital image. One-way analysis of variance (ANOVA) compared the curves. RESULTS: The areas beneath the ROC curves did not demonstrate any consistently significant difference between the digital image resolutions for all LCS and levels of difficulty. The only significant effect observed was amongst pigmented lesions (LCS-A) where the ROC curve area was significantly smaller in the easy images at high resolution compared to low and medium resolutions. For all other ROC curve comparisons within LCS-A, at all other levels of difficulty, as well as within the other LCS at all levels of difficulty, none of the differences was significant. CONCLUSION: A 720 x 500 pixel image can be considered equivalent to a 1490 x 1000 pixel image for most store-and-forward teledermatology consultations.

Percutaneous drainage of pancreatic pseudocyst into the stomach.

BACKGROUND: We present our experience with percutaneous ultrasonographically guided internal cystogastric drainage of pancreatic pseudocysts using a double pigtail catheter. METHODS: In nine patients, the pancreatic pseudocysts following acute pancreatitis were drained percutaneously into the stomach with the double pigtail catheter under ultrasonographical (US) control. The needle insertion through both gastric walls and the final position of the proximal curve of the catheter were monitored with a gastroscope. The position of the distal curve of the catheter was checked by US. There were no procedure-related complications. The patients were followed up monthly by clinical and US examination. RESULTS: At first follow-up 1 month after the intervention, none of the patients had evidence of the pseudocyst. The patients were not aware of the catheter and functioned normally throughout the procedure and catheter removal. The catheter was removed endoscopically after 5-8 months. CONCLUSIONS: The method is minimally invasive and also feasible in high-risk surgical patients. It requires a team consisting of an interventional radiologist, an ultrasonographer, and an endoscopist. In properly selected patients, the results are excellent.

Plea for standardization in teledermatology: a worm's eye view.

Like any clinical interaction, teledermatology requires accurate, timely, and relevant information. The need to provide reliable, representative, diagnostic-quality images to the consultant is obvious. Predetermined patient views for a given clinical presentation and optimal hands on techniques to acquire them are not standardized. As a result, the training provided to those who take the images is inconsistent. Anecdotal evidence from the author's telemedicine practice is employed to support this contention. A formal collaboration between the telemedicine and medical photography communities is proposed to generate such standards and a relevant curriculum.

The epidemiology of dermatologic and venereologic disease in a deployed operational setting.

We studied the epidemiology, morbidity, and etiology of dermatologic and non-human immunodeficiency virus venereologic disease (Derm/STD) aboard a deployed aircraft carrier to revise Derm/STD training objectives for shipboard primary care providers. Onboard supplies for treatment of Derm/STD were also evaluated. Over 3 months, 929 Derm/STD patients were treated for 1,320 diagnoses generating 2,011 visits. Derm/STD caused 22% of the total morbidity. Pyoderma alone accounted for nearly one-half of that morbidity and involved many work-center groups. Air wing, aircraft maintenance, and engineering work-center groups had lower burdens of pyoderma. Bacterial cultures were performed on 248 exudative dermatoses. Staphylococcus aureus was the dominant pathogen and was overwhelmingly sensitive in vitro to common, inexpensive antibiotics. Strategies to encourage prevention, earlier diagnosis, and rapid treatment of Derm/STD by deployed primary care providers are discussed.

An atypical piloleiomyoma presenting as a nonhealing ulcerated nodule.

Piloleiomyomas are benign smooth muscle tumors arising from the arrectores pilorum muscles in the skin. They vary in size and number, and are often spontaneously painful or sensitive to touch and cold. An unusual case of an ulcerated and painless piloleiomyoma is presented.

Postoperative alopecia: a case report and literature review.

Postoperative alopecia is the temporary or permanent loss of hair that occurs following prolonged immobilization during general anesthesia and intubation. The clinical and histopathologic aspects of a typical case are described and the literature reviewed. Localized pressure-induced ischemia is the likely cause. Patients at highest risk for permanent hair loss include those subject to cardiac or gynecologic surgical procedures where the combined intraoperative and postoperative intubation time exceeds twenty-four hours. Frequent intraoperative and postoperative head repositioning provides excellent prophylaxis.

Extensive dermal metastases from primary signet-ring carcinoma of the urinary bladder.

Dermal metastasis from internal carcinoma occurs infrequently. Bladder carcinoma is a rare source of skin metastasis. This report details the case of a twenty-five-year-old man with a fatal primary signet-ring adenocarcinoma of the bladder who experienced unique, extensive, infiltrative, cutaneous metastases within a few weeks of his initial presentation with an occultly carcinomatous ruptured spleen. The literature on cutaneous metastasis from carcinoma of the bladder is reviewed.

Tuberculoid leprosy: a case report.

A case of tuberculoid leprosy, undiagnosed and consequently untreated for four years, is presented. This case report is presented in an attempt to alert the clinician to the occurrence of leprosy in American population and to raise the index of suspicion in the proper clinical setting.

The uncombable hair syndrome.

The uncombable hair syndrome was first described by Dupre as "cheveux incoiffables." Since that time more than fifty cases have been reported. We wish to present three more cases, review the salient features of the syndrome, and describe some new observations.

Porokeratotic eccrine ostial and dermal duct nevus: a case of systematized involvement.

We describe a case of porokeratotic eccrine ostial and dermal duct nevus presenting as widespread, symmetrical lesions. To our knowledge, this represents the most extensive case of this entity reported to date. Both the localized and systematized variants of this nevoid condition are discussed.