An Unexpected Post-Egg-Free Influenza Vaccine Granulomatous Reaction.

ABSTRACT: A 53-year-old woman presented with a pruritic plaque on the left upper arm that appeared following an egg-free flu vaccine due to a history of reaction to the standard vaccine. The affected area enlarged over a several month period immediately following vaccine administration. Physical examination revealed an 8 × 4 cm coalescent pink plaque on the left upper arm. A shave biopsy of the lesion showed dermal "naked" granulomas, or granulomas with sparse lymphocytic infiltrate at the margins, as typically seen in sarcoidosis. No foreign material was seen in the granulomatous reaction, including with polarization. Special stains, including acid fast bacilli, Grocott methenamine silver, periodic acid-Schiff, and Gram, were negative for organisms. The diagnosis of granulomatous dermatitis was made. Subsequent imaging demonstrated no findings suggestive of sarcoidosis. While vaccine-associated hypersensitivity reactions occur frequently, these reactions are typically due to individual vaccine components, such as egg protein, and do not normally result in the formulation of granulomas. Vaccination-induced granulomas are more often associated with the use of aluminum as an adjuvant; however, this is not present in the egg-free influenza vaccine. Thus, a granulomatous reaction to the egg-free influenza vaccine is very unusual and, to our knowledge, not previously reported.

Non-psoriatic uses of calcipotriol: a concise updated review.

Calcipotriol (calcipotriene) is a synthetic vitamin D3 derivative that is a standard treatment option for psoriasis. It is generally well tolerated with minimal side effects. Due to its ability to reduce keratinocyte proliferation and induce keratinocyte differentiation as well as its immunomodulatory effects, calcipotriol has been used to treat a variety of skin disorders such as atopic dermatitis, actinic keratoses, lichen planus, seborrheic keratoses, and vitiligo [1]. We surveyed the literature examining the use of calcipotriol for non-psoriatic dermatologic disease.

Pseudolymphoma to Lymphoma: A Case of Chronic Reactive Lymphoid Hyperplasia Transforming to Primary Cutaneous Marginal Zone Lymphoma.

ABSTRACT: Primary cutaneous marginal zone lymphoma (PCMZL) is a low-grade malignant B-cell lymphoma that originates from the skin. It often presents as erythematous solitary or multiple papules, nodules, and/or plaques. It is one of the 3 main subtypes of primary cutaneous B-cell lymphomas. PCMZLs are believed to develop from chronic antigenic stimulation such as from tick-borne bacteria, vaccines, tattoo pigment, or other foreign body. In addition, cutaneous lymphoid hyperplasia, a documented precursor to malignant PCMZL, often presents in response to areas of chronic inflammation. Cutaneous lymphoid hyperplasia and PCMZL share several clinical and histological similarities that require clinicopathologic suspicion, immunohistochemical ancillary studies, and histopathologic analysis to accurately differentiate the 2 entities. Although gene rearrangement studies have historically been of limited value in the diagnosis of PCMZL, recent studies investigating molecular markers have identified the presence of multiple genetic abnormalities that have helped to better characterize the disease and aid in diagnosis. In addition, newer studies have found associations between PCMZL and gastrointestinal disorders, including Helicobacter pylori and inflammatory bowel disorders. In this article, we describe a case of a 56-year-old patient with a history of ulcerative colitis presenting with chronic reactive lymphoid hyperplasia that transformed to primary cutaneous marginal zone lymphoma.

Interstitial Mycosis Fungoides: An Unusual Mimic of Interstitial Granuloma Annulare Not to Miss.

Interstitial mycosis fungoides is a rare histopathologic variant of mycosis fungoides that may resemble interstitial granuloma annulare, inflammatory morphea, and interstitial granulomatous dermatitis. Reported is a case of a 62-year-old African American female who presented with an asymptomatic, progressive rash of the left underarm and abdomen with histologic features suggestive of granuloma annulare. Biopsies revealed an interstitial pattern of cells in the dermis with prominent small aggregates of atypical lymphocytes, a few atypical lymphocytes in the lower epidermis, and a mild increase in dermal mucin. Immunohistochemistry staining revealed the atypical lymphocytes to be positive for CD3 and CD8 and negative for CD4 and CD7, an aberrant immunoprofile. Mixed in the dermis with the atypical lymphoid cells were a few CD68 positive histiocytes and S100 protein positive dermal dendritic cells. T-cell receptor beta gene rearrangement studies showed nearly the same clonal peaks for TCRB rearrangement in two biopsy specimens from separate sites, all supporting a diagnosis of interstitial mycosis fungoides. The patient is undergoing treatment with full body narrowband UVB (nbUVB) phototherapy with notable improvement in skin discoloration and resolution of several abdominal lesions. A diagnosis of interstitial mycosis fungoides is challenging to make based on clinical features alone and is often clinically misdiagnosed. Awareness of histopathologic features is critical to make an accurate diagnosis and thus patient management.

Holistic processing of gaze cues during interocular suppression.

Direct eye contact is preferentially processed over averted gaze and has been shown to gain privileged access to conscious awareness during interocular suppression. This advantage might be driven by local features associated with direct gaze, such as the amount of visible sclera. Alternatively, a holistic representation of gaze direction, which depends on the integration of head and eye information, might drive the effects. Resolving this question is interesting because it speaks to whether the processing of higher-level social information in the visual system, such as facial characteristics that rely on holistic processing, is dependent on conscious awareness. The Wollaston Illusion is a visual illusion that allows researchers to manipulate perceived gaze direction while keeping local eye features constant. Here we used this illusion to elucidate the driving factor facilitating the direct gaze advantage during interocular suppression. Using continuous flash suppression, we rendered Wollaston faces with direct and averted gaze (initially) invisible. These faces conveyed different gaze directions but contained identical eye regions. Our results showed clear evidence for a direct gaze advantage with Wollaston faces, indicating that holistic representations of gaze direction may drive the direct gaze advantage during interocular suppression.

Treating linear porokeratosis with topical lovastatin/cholesterol cream.

Linear porokeratosis is a rare variant of porokeratosis that is characterized by unilateral lesions along the lines of Blaschko. Like all variants of porokeratosis, linear porokeratosis is characterized by the histopathologic finding of cornoid lamellae bracketing the lesion. The underlying pathophysiology involves a two-hit post-zygotic knockdown of genes involved in mevalonate biosynthesis in embryonic keratinocytes. Although there is currently no standard or effective treatment, therapies targeted to rescue this pathway and restore keratinocyte cholesterol availability are promising. Presented here is a patient with a rare, extensive case of linear porokeratosis treated with compounded 2% lovastatin/2% cholesterol cream leading to partial resolution of the plaques.

Autologous hematopoietic stem cell transplants that utilize total body irradiation can safely be carried out entirely on an outpatient basis.

Outpatient hematopoietic stem cell transplants (HSCT) are usually performed in patients receiving minimally mucotoxic preparative regimens; total body irradiation (TBI)-based regimens typically are excluded. To improve resource utilization and patient satisfaction, we developed a totally outpatient HSCT program for TBI regimens and compared outcomes for our first 100 such transplants to 32 performed as in-patients during the same interval, for caregiver or financial reasons. Symptoms were managed predominately with oral agents; pain management consisted of transdermal fentanyl and oral morphine solution. Except for more unmarried in-patients, the two groups were matched. Time to engraftment, severity of mucositis and transplant duration were identical for the two groups. Twenty-seven of the outpatients were admitted (median-6 days), primarily for progressing infection. Thus 92% of all transplant days were outpatient. There were no septic episodes or hospital admissions for pain management. There were no deaths to day 30 in either group and 100-day survival was identical. There was a mean cost savings of Dollars 16,000 per outpatient transplant and outpatient patient/caregiver quality of life was similar to that reported for in-patients. Patients undergoing severely mucotoxic regimens can be safely transplanted in an outpatient setting with a significant cost saving, with no increase in morbidity or mortality.

Patients' understanding of disease status and treatment plan at initial hematopoietic stem cell transplantation consultation.

Patients referred for hematopoietic stem cell transplantation (HSCT) often have knowledge deficits about their disease and overestimate their prognosis making it difficult initially to discuss potentially life-threatening transplant options. To determine patients' understanding of their disease and the adequacy of a 3-h consultation at our center, we developed a survey that measured perceived knowledge deficits of disease, prognosis, and emotional status before and after their initial consultation. Ninety nine consecutive eligible patients completed the survey. Although 76.7% claimed adequate information about their disease pre-HCST visit, 51.5 and 41.4% respectively lacked knowledge about their 1-year prognosis with and without any therapy. After the visit, 66.7% of the patients had obtained enough information to make an informed decision regarding HSCT versus 23.2% pre-visit, and a significant reduction in the need for further information was reported by 53.5% of patients (P<0.001). Patients were not overwhelmed or confused by the visit and there was a small but significant decrease in negative affect. Measures to increase patients understanding of their disease and its prognosis pre-HSCT consultation visit are warranted; however, a 3-h consultation visit provides the majority of patients with sufficient information to make an informed decision about the risk/benefit ratio of HSCT.

Double-blind comparative trial of oral ondansetron versus oral granisetron versus IV ondansetron in the prevention of nausea and vomiting associated with highly emetogenic preparative regimens prior to stem cell transplantation.

The optimal management of transplantation preparative regimen-induced nausea and vomiting remains unknown. We conducted a Phase III double-blind study to determine the efficacy and costs of oral ondansetron versus oral granisetron versus IV ondansetron and PRN rescue antiemetics for the prevention/control of nausea and vomiting associated with high-dose chemotherapy or chemoradiotherapy prior to stem cell transplantation. One hundred two patients were randomized to receive either 8 mg PO ondansetron every 8 hours, 1 mg PO granisetron every 12 hours, or 32 mg IV ondansetron every 24 hours plus 10 mg IV dexamethasone daily during and 1 day after the various preparative regimens. Study arms were compared in terms of emetic episodes, subjective nausea, amount and cost of rescue antiemetics used, and total costs. Response was defined as complete response (CR), no emesis with no or mild nausea and no rescue antiemetics; major response (MR), 1 episode of emesis or moderate nausea with or without rescue antiemetics; and major efficacy (ME), CR + MR. Subjective nausea was assessed using a 100-mm visual analog scale (VAS) with 0 = no nausea. Ninety-six patients completed the study; the trial was analyzed according to intention-to-treat. Overall CR rates were: 48% for oral ondansetron, 47% for oral granisetron, and 49% for IV ondansetron. Overall ME rates were 82% for oral ondansetron, 84% for oral granisetron, and 81% for IV ondansetron. Mean VAS scores were 32 for oral ondansetron, 32 for oral granisetron, and 27 for IV ondansetron. None of the differences were statistically significant. A cost analysis revealed significant differences among all arms (P = .0001, all comparisons). All 3 regimens had similar efficacy in this BMT population; oral ondansetron was the most cost-effective.

Standard obstetric record charting system: evaluation of a new electronic medical record.

OBJECTIVE: To develop, implement, and evaluate an electronic record that tracks antepartum, intrapartum, and postpartum care. METHODS: The Standard Obstetric Record Charting system (STORC) was created by a group of programmers and clinicians who developed screen designs, reports, pick lists, and standard notes, and ensured a flexible, yet standard system. To evaluate data within the system, ORYX (Joint Commission) performance measures were collected retrospectively and compared with STORC data. RESULTS: The STORC, officially implemented as our complete inpatient and outpatient obstetric record in March 1998, provided seamless integration of antepartum, intrapartum, and postpartum care records, standard forms, and standard and ad hoc reports. Data for customizable case and procedure lists are generated easily. Unplanned and total cesarean deliveries were identified retrospectively in 0% (0 of 18) of charts reviewed for ORYX; however, STORC identified the actual rates of each as 8.3% (23 of 276) and 12.3% (34 of 276), respectively. Other critical ORYX measures not identified by retrospective data collection, but accurately provided by STORC, included rates of third and fourth degree lacerations, postpartum hemorrhage, low and extremely low birth weights, and macrosomia. CONCLUSION: After implementation in a large referral center, completeness and accuracy of charting and rapid access to obstetric outcome data were improved. Provider acceptance of the system also was dramatic and improved over time as a result of direct development oversight by obstetric health care providers, local control of system changes, and immediate access to outcome data. (Obstet Gynecol 2000;96:1003-8.)

Malignant melanoma and adjuvant alpha interferon-2b for patients at high risk of relapse.

Malignant melanoma, the least common but most serious form of skin cancer, is increasing at a faster rate than any other form of cancer. Early diagnosis can lead to cures through surgery alone. Patients with deeper primary lesions (greater than 4 mm) or regional lymph node involvement have a high risk of relapse. High-dose alpha interferon-2b is the first agent to significantly affect the relapse-free survival of high-risk patients with melanoma in a large randomized, controlled trial. Knowledge of the stages of malignant melanoma, its treatments, the mechanism of action of interferon, and commonly experienced adverse events will contribute to the nurse's ability to manage the clinical problems patients with melanoma face.

Nursing management of patients with malignant melanoma receiving adjuvant alpha interferon-2b.

As the incidence of melanoma continues to increase, oncology nurses will be caring for more patients receiving adjuvant alpha interferon-2b. Managing the side effects from this therapy requires expert nursing care. The nurse's role throughout the year-long therapy is critical to ensure the patient's continued adherence to the treatment schedule.

Parent participation.

Ultimate care of the critically ill child is contingent on a parent-professional partnership that acknowledges both the needs and the strengths of families. In providing pediatric care, parent participation maintains and empowers parents to care for their child. Models of care must include programs that support reempowerment rather than dependence of families. The challenge of including parents as partners in care is one of the most rewarding privileges and responsibilities of pediatric nurses.

Constrained acetabular cup disassembly.

Dissociation of modular acetabular components in total hip arthroplasty has recently been reported. This case report describes two instances of polyethylene to metal dissociation with constrained polyethylene liners following total hip arthroplasty.

Resident training in a multidisciplinary breast clinic.

A multidisciplinary breast clinic was initiated at William Beaumont Army Medical Center involving resident and staff physicians from the Departments of Obstetrics and Gynecology, General Surgery, Radiology and Pathology. During the period August 1988 to May 1989, 2,186 mammograms (MOGs) were screened. For this report, 197 patients were evaluated. Of them, 187 patients had been referred to the breast clinic based on MOG findings. Pathologic specimen correlation with the mammograms was performed on a periodic basis. Thirty-four patients were biopsied based on either physical examination or MOG findings. Biopsy diagnoses included: normal tissue (1), fibrocystic disease (18), sclerosing adenosis (1), fibroadenoma (8), mastitis (1) and intraductal carcinoma (5). The Multidisciplinary Breast Clinic provided improved care through expedited patient management. Resident training was accomplished through refinement of examination and diagnostic skills, management of abnormal MOGs, needle aspiration of breast masses and improved communication between the different medical disciplines.