Long-standing dermatitis treated with dupilumab with subsequent progression to cutaneous T-cell lymphoma.

This case series discusses 3 patients with long-standing eczematous or psoriasiform dermatitis, demonstrated by multiple biopsies. Following off-label treatment with dupilumab, all 3 patients had clinical expansion of disease, with histopathologic features consistent with cutaneous T-cell lymphoma (CTCL) on subsequent biopsy. We postulate that this expansion likely was secondary to an exacerbation of extant CTCL following exposure to dupilumab. A proposed mechanism of promotion of CTCL is based on the functional increase in IL-13 available for binding at the upregulated IL-13 receptor (IL-13R) α2 site on cells, following blockade of the α1 receptor with dupilumab. This progression merits further investigation.

The value of full-body skin examination: Poland syndrome diagnosed as an incidental finding.

Poland syndrome is a rare congenital disorder characterized by agenesis of the pectoralis major muscle. It is generally unilateral, right-sided, and can be associated with a myriad of thoracic and upper limb defects. Knowledge of this disorder can lead the astute clinician to prompt diagnosis and referral to surgical specialists for further workup. Surgery is often performed for either esthetic or functional concerns.

The shoulder: taking the strain during restraint.

The decision to use or utilize physical intervention techniques is a contentious one. There has been much discussion on the complex legal and ethical dimensions framing the use of force. The risk of injury has also been considered in detail, but almost all of the published work has focused on restraint asphyxia, the prone restraint hold and the use of particular pain compliance techniques such as the wrist flexion hold. This paper focuses on the structure and function of the shoulder and examines how physical interventions and a variety of risk factors can threaten its physical integrity. This paper is for practitioners such as training commissioners, trainers, frontline staff and investigators or regulators who have to make considered determinations on the potential immediate physical impact of a variety of holds and escape manoeuvres. Sound risk assessment must be premised on a sound understanding of anatomy and physiology.

Managing the risks of physical intervention: developing a more inclusive approach.

Since psychiatry evolved as a professional discipline, mental healthcare professionals have had to, as a last resort, physically intervene to manage physically aggressive patients. In the United Kingdom, physical intervention techniques migrated from the prison service in the mid 1980s where there was extensive use of two particularly controversial practices; 'pain compliance' and the 'prone restraint position'. This paper examines how the classification of the 'prone restraint position' has led to a narrowed focus on one technique and a resultant misunderstanding around the wider risks associated with the applying force and managing restraints. The paper goes on to propose the 'transitional stabilizing position' (TSP) as an alternative concept and puts forward a dynamic risk assessment model. It explores how a shift in staff training away from developing pure competence in the performance of tightly specified techniques to managing the patient in TSPs could conceivably reduce the relatively low risk of death or serious injury associated with the application of restraint techniques to an even lower level.

Proposing a common sense approach to assessing the risks posed by physical intervention techniques.

Irrespective of whether they are universally accepted or approved, physical intervention techniques are being applied, in a variety of health and care settings, on a daily basis. Every time a technique is applied there is a risk of injury. Therefore, there is an imperative to develop an effective way in which such techniques can be effectively risk assessed. The development of a process that is robust enough to evaluate all types of techniques, and is simple and concise enough to engender widespread and regular use could eliminate the use of unnecessary and inappropriate techniques. This paper discusses how the five-step model proposed in the UK by the Health & Safety Executive as well as a common sense approach to completing assessments could be used to simplify the process.

Can peer educators influence healthy eating in people with diabetes? Results of a randomized controlled trial.

AIMS: To assess whether the Expert Patient Programme (EPP), adapted for people with Type 2 diabetes, can be used to promote healthy eating to improve glycaemic control. METHODS: Adults with Type 2 diabetes (n = 317) were randomized to receive either a diabetes-specific EPP (n = 162) or individual one-off appointments with a dietitian (control group) (n = 155). The diabetes-specific EPP followed the standard National Health Service programme although all participants in the group had diabetes only, rather than a mix of chronic conditions. Participants attended a group session for 2 h once per week for 6 weeks. In addition, a final seventh-week 2-h session was included that was specific to issues concerning diabetes. Outcomes were assessed at baseline, 6 and 12 months. RESULTS: There were no statistically significant differences between the control and the intervention group in any of the clinical outcomes measured. There was no significant difference between the groups in any dietary outcome. There was a higher starch intake in the EPP group, although this did not reach statistical significance (effect size for starch adjusted for baseline values 8.8 g; 95% CI -1.3 to 18.9). There was some loss of participants between baseline measurement and randomization, although this did not appear to have had an important impact on baseline balance. CONCLUSIONS: In this study of people with Type 2 diabetes, the EPP approach was not effective in changing measures of diabetes control or diet.

Physical intervention trainers: the case for greater accountability.

Physical intervention training courses are commonplace events in psychiatric and mental healthcare settings across the UK. While there is still debate as to what techniques should be taught on such courses, there is good evidence as to the mechanisms whereby pain, injury and even death can be inflicted. There is also a wealth of literature identifying how organizational culture can influence the quality of service delivery and standards of client care. It is well documented that the dignity, well-being and physical integrity of service users can be compromised by staff acts and omissions stemming from corrupted cultures. What has not been explored in detail to date is the role of physical intervention trainer, specifically the values they model and how these may influence the readiness with which staff resort to physical restraint strategies. It is possible that even approved physical techniques can become compromised through poor training technique and expose end recipients to needless humiliation and potential harm. This paper discusses this area of practice, offers insight on how the learning process is compromised by trainers and suggests areas for future research.

Risk factors for suicide attempts among African American women.

The aim of this study was to examine psychological and interpersonal risk factors for suicidal behavior in low income, African American women; 285 African American women who reported being in a relationship with a partner in the past year were studied, 148 presented to the hospital following a suicide attempt, and 137 presented for general medical care. Cases were compared to controls with respect to psychological symptoms, alcohol and drug abuse, family violence (intimate partner abuse, childhood trauma), relationship discord, and social support. Psychological risk factors for suicide attempts at the univariate level included psychological distress [Crude Odds Ratio (COR) = 6.5], post traumatic stress disorder (PTSD) symptoms (COR = 3.8), hopelessness (COR = 7.7), and drug abuse (COR = 4.2). Interpersonal risk factors at the univariate level included relationship discord (COR = 4.0), physical partner abuse (COR = 2.5), nonphysical partner abuse (COR = 2.8), childhood maltreatment (COR = 3.2), and low levels of social support (COR = 2.6). A multivariate logistic regression model identified four variables that were strongly and independently associated with an increased risk for suicide attempts: psychological distress, hopelessness, drug abuse, and relationship discord. The model predicted suicide attempt status correctly 77% of the time. The results reveal that African American women who report high levels of psychological distress, hopelessness, drug use, and relationship discord should be assessed carefully for suicidal ideation and referred for appropriate mental health care.

The epidemiology of syphilis in the waning years of an epidemic: Houston, Texas, 1991-1997.

BACKGROUND: National and local syphilis rates have fallen since 1990. Accurate epidemiologic information about the distribution of syphilis during the waning years of an epidemic are important to health care organizations so that they can specifically target screening and intervention programs. GOALS: To describe the epidemiology of syphilis in Houston, Texas, from 1991 through 1997. STUDY DESIGN: Descriptive evaluation of morbidity surveillance data from the Houston Department of Health and Human Services. RESULTS: Between 1991 and 1997, rates for syphilis fell 61%. Rates for primary and secondary syphilis fell 90% among men and women in all race/ethnicity groups; early latent rates fell 81% among blacks, 57% among Hispanics, and 50% among whites. Late latent rates were stable among blacks and whites and increased among Hispanics. The proportion of total cases identified as late latent disease increased from 16% in 1991 to 63% in 1997. Congenital syphilis rates have remained at approximately 2 per 1,000 live births since 1993. CONCLUSION: Syphilis continues to be a problem in Houston. The medical community and HIV/STD prevention programs need to be vigilant in actively screening high-risk individuals to identify syphilis at earlier stages of the disease and to prevent congenital syphilis.

Factors that mediate and moderate the link between partner abuse and suicidal behavior in African American women.

Findings from a study comparing partner abuse in African American women suicide attempters (n = 148) and nonattempters (n = 137) revealed higher rates of physical and nonphysical partner abuse among attempters than their demographically similar nonsuicidal counterparts. The partner abuse--suicidal behavior link was mediated by psychological distress, hopelessness, and drug use and moderated by social support. Results also revealed that nonphysical partner abuse accounted for unique variance in the prediction of suicide attempt status beyond that attributable to childhood maltreatment. Implications of the findings for assessing both suicidal and abused women are discussed, and recommendations for preventive interventions for women at risk for suicidal behavior are provided.

The epidemiology of early syphilis in Houston, Texas, 1994-1995.

BACKGROUND AND OBJECTIVES: Since 1990, rates of syphilis in the United States have steadily declined. However, the South still records disproportionately high rates of syphilis infection. GOAL: The objective of this study is to describe the epidemiology of early syphilis in Houston, TX, the largest urban center in the South, in 1994 and 1995. STUDY DESIGN: The study is cross-sectional and descriptive, and uses data collected by Disease Intervention Specialists on the Interview Form 73.54 from interviews with men and women diagnosed with early syphilis. RESULTS: Early syphilis in Houston is highly concentrated in a "belt" that extends north to south in a line just east of the city center. Although sex-specific rates of early syphilis are roughly equal, men are 3.5 times more likely than women to be diagnosed with primary syphilis, whereas women are nearly 2 times more likely than men to be diagnosed with secondary syphilis and 1.5 times more likely to be diagnosed with early latent syphilis. CONCLUSION: Routine surveillance data indicate that young, African-American men and women in Houston's inner-city neighborhoods are disproportionately affected by syphilis. Particular efforts must be made to reach women, who are detected and treated at later stages of the disease than men.

Empirically validated family interventions for pediatric psychology: sickle cell disease as an exemplar.

Prompted by the growth of managed care and the American Psychological Association's recent guidelines for treatment efficacy studies, we have struggled with the challenges associated with devising and implementing manualized family intervention programs for pediatric patients. This manuscript outlines the strengths and challenges of controlled manual-based family interventions for medically ill children, using pediatric sickle cell disease (SCD) as an example. A culturally and developmentally sensitive intervention program, designed for the researcher's subject population (African American, low SES, inner city) is discussed. Possible solutions to the challenges of conducting family-oriented intervention efficacy studies with pediatric populations are presented.