Management of snakebites by the staff of a rural clinic: the impact of providing free antivenom in a nurse-led clinic in Meserani, Tanzania.

In Tanzania, the impact, on clinical outcomes and treatment-seeking behaviour, of a rural, nurse-led clinic that provides free, antivenom-based treatment of snakebite envenomation was recently assessed. Data on all 85 patients who, between April 2007 and the end of 2009, received treatment for snakebite envenomation at the Snake Park clinic in Meserani, Tanzania, were collected prospectively. Although only four cases of snakebite envenomation were treated in the last 9 months of 2007, 34 such cases were treated in 2008 and 47 in 2009. The 85 snakebite cases had a mean age of 23 years and a male:female ratio of 1.4. Most of the bites occurred in the evening or at night and most also occurred during the rainy season. In some cases, the seeking of treatment from traditional healers delayed treatment at the clinic. After being bitten, the snakebite cases travelled a mean of 82 km (range=2-550 km) to reach the clinic. Thirty-two (37%) of the cases were each unable to identify the snake that had bit them. Of the bites in which the snake was identified, the puff adder (Bitis arietans) caused more (24) than any other snake. Forty-two of the snakebite cases received antivenom. Only one patient (1%), a 12-year-old girl, was believed to have died as the result of a snakebite but another six (7%) each required a skin graft or the amputation of a limb or digit. Establishment of the Snake Park clinic appears to have improved access to snakebite treatment, with cases of snakebite travelling long distances to reach the clinic (because of the lack of any other source of antivenom in Tanzania). Although the clinic is nurse-led, treatment outcomes among the snakebite victims who attend the clinic appear to be good.

Photodynamic therapy for superficial basal cell carcinoma and Bowen's disease.

Photodynamic therapy (PDT) is an effective treatment for superficial basal cell carcinoma (BCCs) and Bowen's disease. Several studies have reported complete response rates of 80-95% and an excellent cosmetic outcome. Bowen's disease and superficial basal cell carcinomas characteristically affect older patients who may also have associated difficulties with mobility. Using a portable PDT light source we were able to deliver PDT in a community setting with the aim of providing a more convenient service for patients. This randomised study confirmed that community delivered PDT is a viable treatment option and can be administered safely in the community by a trained dermatology nurse. The results from patient questionnaires suggest that community delivered PDT is more convenient to the patient, and also cost effective.

Tissue-engineered dermal skin grafting in the treatment of ulcerated necrobiosis lipoidica.

Necrobiosis lipoidica is a well recognized but comparatively rare cutaneous complication of diabetes mellitus. The aetiology is probably multifactorial with microangiopathy, immune complex formation, abnormal collagen synthesis and breakdown, and altered haemostasis all thought to play a part. Necrobiosis lipoidica often proves very resistant to treatment. We report a case of a 44-year-old woman with ulcerated necrobiosis lipoidica that healed following grafting with a tissue-engineered living dermal tissue.

Effect of abciximab on cardiac enzyme elevation after transluminal extraction atherectomy (TEC) in high-risk saphenous vein graft lesions: comparison with a historical control group.

Saphenous vein graft (SVG) intervention has been associated with an increased incidence of distal embolization. Long lesions and lesions associated with thrombus are particularly at increased risk. This study was performed to determine whether abciximab may decrease this risk in high risk SVG angioplasty. From June 1994 to June 1998, 84 patients with at least one high risk factor, i.e., lesion length >20 mm or angiographic evidence of thrombus, underwent Transluminal extraction atherectomy (TEC) procedure followed by balloon dilatation or stenting. Of these 84 patients, 37 who had procedure after September 1995 underwent TEC with abciximab (Abciximab Group) and 47 who had their procedure before that date had TEC without abciximab thereby serving as historic control (Non-Abciximab Group). All patients had normal pre-procedure CK and CK-MB. Total creatine kinase (CK) and CK-MB were measured every 8 hr post-procedure for 24 hr. Baseline demographics, angiographic characteristics, incidence of LV dysfunction and triple vessel disease were similar between the two groups. Graft age was similar between two groups (122 +/- 70 vs. 117 +/- 54 months). Graft diameter, pre and post-procedure percent stenoses were not different between the two groups. Stents were used in 65% in the Abciximab group and 45% in Non-Abciximab group (P = 0. 14). There was no in-hospital repeat PTCA, urgent bypass surgery, or cardiac death. There was no difference between the two groups in regards to the incidence of any elevation of total CK (27% vs. 21. 3%) or CK-MB (54% vs. 51%). When used in conjunction with TEC in treating high risk vein graft lesions, abciximab did not reduce post procedure CK-MB elevation in this patient population.

Two cases of primary hyperparathyroidism associated with primary cutaneous lymphoma.

Primary hyperparathyroidism has been described previously in association with malignancy, but to our knowledge has not been reported in association with primary cutaneous lymphoma. We report two cases of parathyroid adenoma with primary cutaneous lymphoma, the first in a 42-year-old woman with CD30-negative cutaneous large cell lymphoma, and the second in a 67-year-old man with mycosis fungoides and CD30-positive anaplastic large cell lymphoma.

Extracranial vertebral artery stent placement: in-hospital and follow-up results.

OBJECT: The authors summarize their experience with stent deployment in the treatment of vertebrobasilar artery (VBA) insufficiency. This is an underdiagnosed condition, and the incidence of significant vertebral artery (VA) stenosis has been underappreciated. Medical therapy has been the mainstay of treatment because of the high rate of morbidity associated with surgical correction of VA stenosis. Recently, some authors have reported acceptable results with the use of percutaneous transluminal angioplasty, but this technique has significant weaknesses such as elastic recoil and problems in achieving safe treatment of dissections. METHODS: The authors investigated the feasibility, safety, and outcome of VA stent placement in 50 patients in whom 55 vessels were treated using stents. Technical success was achieved in 54 (98%) of 55 vessels, with no procedure-related complications. However, one patient (2%) died of nonneurological causes, and one (2%) suffered a stroke that occurred within the 30-day postprocedural period and was related to a complicated coronary intervention. Clinical follow-up review performed at a mean of 25 +/- 10 months revealed two patients (4%) with recurrence of VBA symptoms. Six-month angiographic follow up was completed in 90% of eligible patients, with a 10% incidence of restenosis as defined by greater than 50% luminal narrowing. CONCLUSIONS: Vertebral artery stent placement is feasible in patients who have significant VA stenosis, with predictably good angiographically demonstrated and clinical results. The 6-month angiographically confirmed restenosis rate appears to be low, as does the clinical recurrence rate. This technique solves the problems of elastic recoil and the treatment of angioplasty-induced dissections. Further prospective comparison with medical preventive strategies is warranted.

Unusual skin ulceration in an HIV-positive patient who had cutaneous syphilis and neurosyphilis.

We present a case of a patient coinfected with syphilis and the human immunodeficiency virus (HIV) who had unusual and severe cutaneous ulceration. The profound immune defects associated with HIV may lead to an altered clinical presentation and a more aggressive course in patients infected with Treponema pallidum. Despite non-confirmatory histological findings, we feel our patient's cutaneous ulcers probably represent superficial gummata, which have failed to resolve completely following currently accepted high-dose antisyphilis chemotherapy.

Cutaneous tuberculosis in Blackburn district (U.K.): a 15-year prospective series, 1981-95.

Data collected prospectively on all 1065 cases of tuberculosis occurring in the Blackburn district, U.K. (population 265,000), over a 15-year period have been analysed, and from these 47 cases of cutaneous tuberculosis have been identified. The most common form was scrofuloderma, skin involvement with adjacent structural disease, of which there were 26 cases (55.3%). There was no ethnic bias in this group. The eight white patients with scrofuloderma were of average age 66 years, and are thought to represent reactivation disease. Six patients (12.8%) had lupus vulgaris, four (8.5%) had metastatic tuberculosis and 10 (21.3%) were diagnosed as having one of the tuberculides, of which Bazin's disease (erythema induratum) was the most common. In addition, one patient (2.2%) had orificial tuberculosis. In contrast to scrofuloderma, all other forms of cutaneous tuberculosis occurred almost exclusively in patients from the Indian Subcontinent (ISC). The high incidence of tuberculosis in Blackburn is mainly linked to its significant proportion of residents of ISC ethnic origin. There were no cases of HIV infection coexisting with either cutaneous or other forms of tuberculosis. Recommendations for the treatment of cutaneous tuberculosis are made.

Factitious purpura.

Factitious purpura may present as a perplexing problem for the dermatologist and can mimic serious disease. This form of mechanical purpura, often caused by suction may be deliberately or unknowingly induced by the patient. Some cases may go unrecognized for a considerable length of time and undergo unnecessary investigation before the diagnosis is realized. Three cases of purpura are reported in which the causative agents were very different.

Harvest mites--a present from the Lake District.

A case of harvest-mite infestation acquired in the South Lakeland area is described in a 7-year-old boy and his immediate family. The characteristic papular urticarial lesions produced are extremely florid and may cause diagnostic problems when patients present in areas where the mite is uncommon. The life cycle of the harvest mite is discussed and recommendations for treatment given.

Detection of antibody to avian viruses in human populations.

The ability of three avian viruses to elicit antibody response in humans was surveyed for the purpose of identifying zoonotic diseases. Antibody levels in people associated with poultry were compared to those in people having limited poultry association. Antibody levels to three avian viruses: infectious bursal disease virus, a birnavirus; Newcastle disease virus, a paramyxovirus; and avian infectious bronchitis virus, a coronavirus were determined by enzyme-linked immunosorbent assays (ELISA). Differences between the two study groups were evident: people having a known association with poultry showed significantly higher levels of antibodies to Newcastle disease and avian infectious bronchitis virus. Antibodies detected may be due to virus exposure rather than zoonoses.