Quantitative detection of seizures with minimal-density EEG montage using phase synchrony and cross-channel coherence amplitude in critical care.

Seizures frequently occur in paediatric emergency and critical care, with up to 74% being sub-clinical seizures making detection difficult. Delays in seizure detection and treatment worsen the neurological outcome of critically-ill patients. Gold-standard seizure detections using multi-channels electroencephalograms (EEG) require trained clinical physiologists to apply scalp electrodes and highly specialised neurologists to interpret and identify seizures. In this study, we extracted phase synchrony and cross-channel coherence amplitude across 4 and 8 pre-selected scalp EEG signals. Binary classification is used to determine whether the signal segment is seizure or non-seizure, and the predictions were compared against the gold-standard seizure onset markings. The application of the algorithm on a cohort of forty routinely collected EEGs from paediatric patients showed an average accuracy of 77.2 % and 76.5% using 4 and 8 channels, respectively. Clinical Relevance- This work demonstrates the feasibility of seizure detection with pre-defined 4 and 8 EEG electrodes with an average accuracy of 77%. This means for the first time seizure detection is possible using an EEG montage that can be applied readily at the bedside independent of expert input.

Mixed methods grant applications in the health sciences: An analysis of reviewer comments.

Our aim was to understand how reviewers appraise mixed methods research by analyzing reviewer comments for grant applications submitted primarily to the National Institutes of Health. We requested scholars and consultants in the Mixed Methods Research Training Program (MMRTP) for the Health Sciences to send us summary statements from their mixed methods grant applications and obtained 40 summary statements of funded (40%) and unfunded (60%) mixed methods grant applications. We conducted a document analysis using a coding rubric based on the NIH Best Practices for Mixed Methods Research in the Health Sciences and allowed inductive codes to emerge. Reviewers favorably appraised mixed methods applications demonstrating coherence among aims and research design elements, detailed methods, plans for mixed methods integration, and the use of theoretical models. Reviewers identified weaknesses in mixed methods applications that lacked methodological details or rationales, had a high participant burden, and failed to delineate investigator roles. Successful mixed methods applications convey assumptions behind the methods chosen to accomplish specific aims and clearly detail the procedures to be taken. Investigators planning to use mixed methods should remember that reviewers are looking for both points of view.

Advanced abdominal pregnancy: still an occurrence in modern medicine.

In a world bewildered by spectacular advances in imaging technology, the early detection of an abdominal pregnancy should be a feasible objective. A case of an advanced abdominal pregnancy is presented. Although the pregnancy was the result of in vitro fertilisation technology, the diagnosis was not suspected until 35 weeks gestation. Both ultrasound and magnetic resonance imaging (MRI) were used to achieve a diagnosis prior to delivery. The placenta was left within the peritoneal cavity but removal was necessitated for maternal symptomatology 4 months postdelivery. This case illustrates that despite the almost ubiquitous usage of prenatal ultrasound, extrauterine pregnancies may not be detected in a timely manner unless attention to basic ultrasound techniques is followed.

Dermatologic consultations in the hospital setting.

BACKGROUND AND DESIGN: Dermatologic practice occurs mainly in the outpatient setting. The reasons for, frequency, and impact of inpatient dermatologic consultation are largely unstudied. In this report, we prospectively studied dermatologic consultation in the major teaching hospital complex of a medical school. Over a period of 8 months, we prospectively recorded the demographics of the patients for whom consultation was requested, the provisional dermatologic diagnosis of the referring service, the final diagnosis of the dermatologic service, and the tests necessary to arrive at a final diagnosis. RESULTS: During a period of slightly over 8 months, dermatologic consultation was requested and delivered to 591 patients who were either hospitalized or being evaluated in the emergency department or other urgent care settings. The services requesting consultation most frequently were medicine (39%), pediatrics (14%), surgery (12%), psychiatry (6%), and neurology (3%). In 51% of consultations, the patients were younger than 45 years of age. Diagnostic tests, including Tzanck smear and potassium hydroxide preparation, confirmed the clinical diagnosis in up to 50% of cases. Dermatologic consultation changed dermatologic diagnosis and treatment in more than 60% of the patients. Generally, the dermatologic diagnoses most frequently missed by the referring service were common conditions with established treatment. CONCLUSIONS: Dermatologic consultation in the hospital setting improves dermatologic diagnosis and has an impact on treatment.

Susceptibility to effects of UVB radiation on induction of contact hypersensitivity as a risk factor for skin cancer in humans.

Normal, healthy human volunteers and patients with proved history of non-melanoma skin cancer have been tested for their capacity to develop contact hypersensitivity to dinitrochlorobenzene (DNCB) following exposure of buttock skin to acute, low-dose ultraviolet B (UVB) radiation. Using a radiation protocol that achieves virtually complete depletion of normal-appearing Langerhans cells from irradiated skin, it was learned that approximately 60% of healthy volunteers developed vigorous contact hypersensitivity (CH) when 2000 micrograms DNCB was painted on the irradiated site. These individuals were designated UVB-resistant, and were distinguished from other individuals, designated UVB-susceptible, who failed to develop contact hypersensitivity following an identical treatment protocol. It was then discovered that virtually all (92%) skin cancer patients exposed to UVB and DNCB failed to develop CH, i.e., were UVB-susceptible. In subsequent experiments, epicutaneous application of 2000 micrograms DNCB to unirradiated skin of UVB-susceptible individuals revealed a further distinction between normal persons and skin cancer patients. Approximately 45% of the latter (and none of the former) remained unresponsive (failed to develop contact hypersensitivity following this second attempt at sensitization), implying that they had been rendered immunologically tolerant. These tolerant individuals responded normally to the unrelated hapten, diphencyprone. We conclude that human beings resemble inbred strains of laboratory mice in that some individuals are UVB-susceptible, whereas others are UVB-resistant. Because the incidence of UVB-susceptibility was significantly higher in skin cancer patients, and as specific unresponsiveness could be demonstrated only in these patients, we propose that UVB-susceptibility, as we define it in this hapten system, may be a risk factor for the development of skin cancer.

Subcutaneous calcification in venous ulcers: report of a case.

We report on a 77-year-old woman with a recalcitrant leg ulcer that contained and extruded calcified material. Roentgenograms of the involved leg showed extensive subcutaneous calcification. The literature concerning subcutaneous calcification in venous insufficiency is reviewed. The patient responded to surgical debridement of the calcified tissue and subsequent skin grafting.

An ultraviolet B radiation protocol for complete depletion of human epidermal Langerhans cells.

We report an ultraviolet B (UVB) protocol that achieves essentially complete depletion of Langerhans cells (LC) from human skin, while leaving the skin clinically intact. Sixteen human volunteers of skin types II and III were exposed to 144 mJ/cm2 of UVB each day for 4 successive days, on a 2-cm-diameter circle of buttock skin. In each case the irradiated skin showed redness and mild edema but no vesiculation or ulceration. One hour after the last exposure a 4-mm punch biopsy was taken from the center of the irradiated site. The epidermal sheet from each sample was separated and exposed to CD-1 antibody (12 samples) or HLA-DR antibody (4 samples) and the density of LC was assessed by immunofluorescence light microscopy. In each case the epidermal LC population was severely depleted to less than 20 cells/mm2, from a baseline of approximately 565 cells/mm2, and in many cases no morphologically normal LC remained. This simple protocol thus provides intact human skin completely depleted of LC. Such skin will provide an appropriate model for the in vivo study of the immune function in human skin deprived of its epidermal antigen-presenting capacity.

Wrinkling due to middermal elastolysis. Report of a case and review of the literature.

We describe a 33-year-old woman with idiopathic loss of middermal elastic tissue, resulting in widespread fine wrinkling of the skin. This represents an example of the rarely reported entity middermal elastolysis. The literature is reviewed.

Leg ulcers following subcutaneous injection of a liquid silicone preparation.

We present an unusual case of leg ulcers occurring 23 years after the patient had received large-volume subcutaneous injections of a liquid silicone preparation into her legs for cosmetic reasons. Light microscopy of a biopsy specimen from the edge of the ulcer showed optically clear vacuoles in the dermis, together with a mixed cellular infiltrate. Scanning electron microscopic studies revealed amorphous spherules within the vacuoles, and energy-dispersive spectroscopy established the presence of silicon in these spherules. Nearby tissue not containing spherules did not show a silicon peak. This case adds to the growing documentation of morbidity associated with injections of silicone of uncertain purity.

Coexistent pemphigus vulgaris and Paget's disease of the nipple. An immunohistochemical study.

We report the coexistence of pemphigus vulgaris and Paget's disease of the nipple in a patient with a documented history of pemphigus and a 2-year complaint of an eczematous breast lesion. A biopsy taken from the lesion showed the characteristic histologic features of both pemphigus and Paget's disease of the nipple. Immunohistochemical technics revealed intercellular IgG deposits characteristic of pemphigus and intracellular staining with antibody to epithelial membrane antigen in the cytoplasm of Paget's cells. This report is the first describing the coexistence of these two distinct disease entities in one tissue sample. This case underscores the necessity of early biopsy of recalcitrant nipple lesions even in the presence of another, well-documented skin disorder.