Rapid acute onset of bronchiolitis obliterans syndrome in a lung transplant recipient after respiratory syncytial virus infection.

Bronchiolitis obliterans syndrome (BOS) can have either an acute or chronic onset with an abrupt or insidious course. The diagnosis is typically achieved by physiological criteria with development of a sustained decline in expiratory flow rates for at least 3 weeks. We review the rapid development of acute BOS and bronchiectasis after respiratory syncytial virus infection in a lung transplant recipient, who had been doing well with normal pulmonary function for 3 years after lung transplantation.

Incubator weaning in preterm infants and associated practice variation.

OBJECTIVE: To evaluate the relationship of weight of preterm infants when first placed into an open crib with days to full oral feedings, growth velocity and length of stay (LOS), and to identify unwarranted variation in incubator weaning after adjusting for severity indices. STUDY DESIGN: A retrospective study using the ParadigmHealth neonatal database from 2003 to 2006 reviewed incubator weaning to an open crib in appropriate-for-gestational-age (AGA) infants from 22 to weeks gestation. Primary outcome measurements included days to full oral (PO) feeding, weight gain from open crib to discharge and length of stay. Models were severity adjusted. To understand hospital practice variation, we also used a regression model to estimate the weight at open crib for the top 10 volume hospitals. RESULT: In all 2908 infants met the inclusion criteria for the study. Their mean weight at open crib was 1850 g. On average every additional 100 g an infant weighed at the open crib was associated with increased time to full PO feeding by 0.8 days, decreased weight gained per day by 1 gram and increased LOS by 0.9 days. For the top 10 volume hospitals, severity variables alone accounted for 9% of the variation in weight at open crib, whereas the hospital in which the baby was treated accounted for an additional 19% of the variation. CONCLUSION: Even after controlling for severity, significant practice variation exists in weaning to an open crib, leading to potential delays in achieving full-volume oral feeds, decreased growth velocity and prolonged LOS.

Reconstructing medical problem solving competence: MACCORD.

The building of medical knowledge-based systems involves the reconstruction of methodological principles and structures within the various subdomains of medicine. ACCORD is a general methodology of knowledge-based systems, and MACCORD its application to medicine. MACCORD represents the problem solving behavior of the medical expert in terms of various types of medical reasoning and at various levels of abstraction. With MACCORD the epistemic and cognitive processes in clinical medicine can be described in formal terminology, covering the entire diversity of medical reasoning. MACCORD is close enough to formalization to make a significant contribution to the fields of medical knowledge acquisition, medical didactics and the analysis and application of medical problem solving methods.

Suicidal ideation in psoriasis.

BACKGROUND: Psoriasis has been associated with depressive disease and case reports of completed suicide. METHODS: 217 consenting psoriasis patients completed the Carroll Rating Scale for Depression (CRSD), a 52-item self-rated scale, with four of the items directly addressing wishes to be dead and suicidal ideation. The patients also self-rated the severity of their psoriasis. RESULTS: 9.7% of patients reported a wish to be dead, and 5.5% reported active suicidal ideation at the time of the study. The death wish and suicidal ideation were associated with higher depression scores (P < 0.0001) and higher patient self-ratings of psoriasis severity (P < 0.05). Patient self-reports of psoriasis severity correlated directly with the overall depression scores (r = 0.39), P < 0.0001). CONCLUSIONS: The comorbidity between depressive symptoms, suicidal ideation, and psoriasis severity is in contrast with reports that severe depression and suicidal ideation are mainly a feature of life-threatening medical disorders such as malignancies. Our finding may have important implications in the management of psoriasis.

Keratoses in patients with psoriasis: a prospective study in fifty-two inpatients.

Twenty-eight of 52 consecutive psoriasis inpatients admitted for therapy with the modified Goeckerman regimen had discrete, gray-white, asymptomatic, keratotic lesions approximately 4 mm in diameter at discharge from the hospital. In 18 of these 28 patients no keratoses were noted on admission. In 9 of 10 patients who had keratoses at admission, there was an increase in number at discharge. All patients with keratoses on admission had multiple, closely spaced previous admissions. No age, sex, or skin type predominance was evident in the group with keratoses compared with the remainder of the group (24 patients) who did not have keratoses. The development of keratoses was not related to the type or duration of psoriasis. Statistically significant predisposing factors were the number of UVB and PUVA treatments and the number of inpatient admissions. Fifty-two percent were located on the extremities, 33% on the trunk, and 15% on the face, head, and neck. Histologic examination of these lesions suggested that they may be a variant of seborrheic keratoses. We have not seen these lesions on patients receiving UVB, PUVA, or tar therapy for other diseases. This raises the possibility that these lesions may be unique to psoriasis and most likely are related to long-term therapy.

Pruritus associated with nocturnal wakenings: organic or psychogenic?

Pruritus that interferes with sleep is generally diagnosed as having an organic rather than a psychogenic basis. We compared the dermatologic and psychosocial parameters of 79 inpatients with psoriasis with moderate to severe pururitus with (W group; n = 46) and without (NW group; n = 33) wakenings from sleep in association with pruritus. At the time of the patients' admission, compared with the NW group the W group had more severe depressive psychopathologic features (p less than 0.05); were possibly alcoholic, according to behavioral criteria for alcoholism (p less than 0.005); reported a higher daily alcohol consumption (p less than 0.05); and had symptoms suggestive of periodic movements in sleep, or nocturnal myoclonus (p less than 0.05), a sleep physiologic disorder. The two groups did not differ with respect to pruritus severity or other dermatologic parameters at the time of admission or during inpatient treatment. Contrary to the generally accepted criterion for the organicity of pruritus, psychiatric and possibly sleep pathologic factors rather than primary dermatologic factors determined the wakenings from sleep as a result of pruritus.

A psychocutaneous profile of psoriasis patients who are stress reactors. A study of 127 patients.

Psoriasis is a chronic, relapsing, cutaneous condition with a 1%-2% prevalence in the general population. About 40% of psoriatics report that psychosocial stress significantly exacerbates their condition. However, the clinical characteristics of the subgroup of psoriatic patients who are stress reactors have not been delineated. At a practical clinical level it is therefore difficult to implement specific psychosocial treatments among the psoriatic population. In this study, we compared the psychocutaneous characteristics of patients who reported that stress exacerbated their psoriasis, i.e., the high stress reactors (N = 64) to the subgroup who reported no significant association between stress and their psoriasis, i.e., the low stress reactors (N = 63). The high stress reactors had more disfiguring disease clinically (p less than 0.02); psychologically they tended to rely more upon the approval of others (p less than 0.05) and experienced more psoriasis-related daily stress (p less than 0.005). The high stress reactors also reported more flare-ups of their psoriasis during the 6 months prior to admission (p less than 0.05). We have shown that the high stress reactors can be clinically delineated from the low stress reactors. Certain psychosocial interventions will most likely decrease the morbidity associated with psoriasis among the high stress reactors, and may possibly even result in a decline in the number of major flare-ups of the psoriasis.

Pruritus in psoriasis. A prospective study of some psychiatric and dermatologic correlates.

Among 82 inpatients with psoriasis, 67% (55 patients) reported moderate or severe pruritus. The degree of depressive psychopathology discriminated between the mild, moderate, and severe pruritus groups at admission. Prospectively, the change in depression scores correlated with the change in pruritus pretreatment to posttreatment. Pruritus severity did not correlate significantly with stress due to life events, age at onset, ethyl duration of psoriasis, age, sex, marital status, and average reported daily alcohol (ethanol) consumption. Among the objective dermatologic measures, including extent and severity of lesions, only the degree of perilesional irritation discriminated between the mild, moderate, and severe pruritus groups at admission, and prospectively, change in this measure correlated with the change in pruritus pretreatment to posttreatment. This finding was most likely related to the self-excoriation associated with pruritus. Intrapsychic factors (eg, the severity of depression) rather than external psychosocial or well-defined dermatologic factors, were the most significant correlates of pruritus in psoriasis.