Biomedical subjects
Publications and source records attributed to M Rademaker.
The above consensus management plan is not all embracing as there remain many areas of contention in the management of melanoma. As the knowledge of the aetiology and natural history of atypical naevi improves, so the recommendations are likely to alter. The purpose of these guidelines is to give the general practitioner a framework to better plan and manage their patients with malignant melanoma.
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The case of a 53-year-old man who developed chloracne, palmoplantar keratoderma and scleroderma after many years of exposure to a variety of chloracnegens is reported. Chloracne is a rare but important acneiform eruption associated with exposure to halogenated aromatic compounds used primarily in agriculture. However, to our knowledge, the association of palmoplantar keratoderma and scleroderma with exposure to chloracnegens has not been previously reported.
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AIMS: To document the association between erythema multiforme and Mycoplasma pneumoniae. METHOD: All cases of erythema multiforme presenting to the dermatology department of Waikato Hospital over the summer of 1992/3 were tested for mycoplasma serology. Trends in recorded cases of M pneumoniae infection were examined from data supplied by the virology department of Waikato Hospital. RESULTS: Four of seven cases of erythema multiforme were due to M pneumoniae infection. This was associated with a marked local increase in the number of M pneumoniae infections recorded in our hospital. CONCLUSION: Mycoplasma serology is an important investigation in the management of erythema multiforme, especially when associated with an outbreak of M pneumoniae infections.
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To assess the effectiveness of a case note audit in two dermatology units, the effect of policy changes in clinical practice, made following the identification of deficiencies in practice by an initial audit in 1987, were evaluated 2 years later by repeating the audit process, i.e. 'completing the audit circle'. The case notes of 200 new referrals of patients with psoriasis were audited, using a criteria set of 18 questions devised by a group of 66 dermatologists, in 1987 and again in 1989. Following the initial audit in 1987, policy changes were made at one centre (B) but not at the other (A). In the centre where no policy changes were agreed (A) there was no improvement in record keeping when re-audited in 1989. In centre (B), where a number of policy decisions were taken and protocols established, there was a highly significant improvement in record keeping (60% satisfactory completion of the criteria set in 1987 increased to 74% in 1989, P < 0.0001). Doctors in training grades performed best and were most responsive to the policy changes. The effectiveness of a criterion-based audit depends on a commitment to change, where indicated, and regular reinforcement of new policies at all levels of medical staff.
Pemphigus vulgaris (PV) is a rare but potentially fatal autoimmune bullous disorder which frequently affects the oral mucosa. Although the essential cause of PV is unclear, its onset has occasionally been associated with drug therapy, in particular penicillamine. The patient described in this paper was a 78-year-old diabetic man who developed oral lesions of PV following institution of glibenclamide therapy.
We have given a series of incremental intravenous injections of captopril to ten patients with chronic cardiac failure. Small doses of captopril produced significant changes in pulmonary artery end-diastolic pressure and right atrial pressure, up to a total cumulative dose of captopril of 2.5 mg, after which further injections had no significant effect. There were large changes in systemic vascular resistance and blood pressure up to a cumulative dose of captopril of 5.0 mg, after which the injection of larger doses caused no further significant changes. Small doses of intravenous captopril produced large increases in plasma renin activity and plasma angiotensin I concentrations up to a total cumulative dose of captopril of 1.25 mg, after which there were no significant further changes in either plasma renin activity or plasma angiotensin I concentration. However the plasma concentration of angiotensin II fell more slowly, no further change being recorded after a total cumulative dose of captopril of 10 mg. These results suggest that plasma renin activity is not the only determinant of plasma angiotensin II concentrations.
Laugier-Hunziker syndrome is an extremely rare disorder but is of some interest to dental practitioners. The importance of the condition relates to it being included in the differential diagnosis of pigmentary disorders of the oral mucosa with associated nail involvement. Two cases of the syndrome are described.
The effect of isotretinoin (Roaccutane) on serum steroids and urinary steroid metabolites was investigated in seven female patients receiving the drug for treatment of severe acne over a 16-week period. Serum concentrations of dehydroepiandrosterone sulphate (DHAS), androstenedione (A2), and free androgen index (FAI) were not significantly altered. There was a significant fall in testosterone during treatment and a significant reduction in the 24 h urinary excretion of androsterone, tetrahydrocortisone (THE) and tetrahydrocortisol (THF) from week 8 onwards and for aetiocholanolone and allo-THF from week 12 (P less than 0.05). Although pretreatment levels of urinary steroid metabolites were not abnormal, the ratios of the 5 alpha/5 beta metabolites (androsterone:aetiocholanolone and allo-THF:THF) were at the upper limit of the reference range and were lowered after treatment, suggesting that 5 alpha-reductase activity is sensitive to isotretinoin.
Lymphoproliferative and myeloproliferative malignancies have been noted in patients with systemic mastocytosis and urticaria pigmentosa. However, to our knowledge an association between mastocytosis and malignant melanoma has not been reported previously.
A family is described in which five of the six members with the Jackson-Lawler type of pachyonychia congenita also had varying degrees of hidradenitis suppurativa. We suggest an association between this type of pachyonychia congenita and hidradenitis suppurativa.
The adequacy of hospital note-keeping in 100 patients presenting with psoriasis at two teaching hospitals has been assessed. The criteria used were defined in consultation with a peer group of 60 British dermatologists. The pattern of record keeping was similar in both centres. Where differences existed between consultant (C) and non-consultant (J) staff, non-consultant staff completed the records more fully. There were differences between centres in the recording of patients' symptoms and disability, psoriasis type, and in the number of visits before discharge to general practitioners care. Both centres had a poor record of communication to general practitioners following patient default from the clinic. In both centres, the patient had only a one in 8 chance of subsequently being seen by a consultant if at the first visit they had been seen by a non-consultant. This simple case-note audit has highlighted the similarity of practice in the two centres and has resulted in practical improvements in record keeping.
OBJECTIVE: To determine the prevalence and severity of acne among schoolchildren in Glasgow. DESIGN: Secondary schools in Glasgow were divided by postcode into five socioeconomic cluster groups. Different numbers of schools were selected at random from the five groups to ensure proportional representation. One class from each registration year of the chosen schools was selected at random and the whole class recruited into the study. SETTING: 15 Secondary schools in Glasgow. SUBJECTS: 2014 Randomly selected schoolchildren aged 12-17 (5% of total secondary school roll). INTERVENTIONS: None. END POINT: Assessment of facial acne by two independent examiners by a recognised acne scoring system. MEASUREMENTS AND MAIN RESULTS: The prevalence of acne in boys increased from 40% (75/189) at age 12 to 95% (108/114) at age 16, and in girls it increased from 61% (114/187) at age 12 to 83% (136/164) at age 16. On a scale of 0 to 10 only 18 boys (1.8%) and three girls (0.3%) had grades of acne of 1.0 or greater; most of the pupils had grade 0.05-0.375 (minimal) acne. Nine per cent of boys (88/973) and 14% of girls (145/1041) had visited their general practitioner specifically for advice on and treatment for acne; only five pupils (0.3%) had been referred to a dermatologist. CONCLUSIONS: Both the prevalence and severity of acne have decreased over the past 20 years. This has probably been due to improvement of treatment for acne by primary care doctors and the greater availability and use of over the counter preparations for acne.
OBJECTIVE: To compare the long term effects of short term intravenous infusions of iloprost with those of oral nifedipine in patients with Raynaud's phenomenon associated with systemic sclerosis. DESIGN: Double blind, placebo controlled, randomised group comparison. SETTING: Dermatology outpatient clinic. PATIENTS: Twenty three patients with Raynaud's phenomenon associated with well documented systemic sclerosis (American Rheumatism Association criteria) and with typical abnormalities in fingernail folds on capillaroscopy. INTERVENTIONS: Twelve patients were randomised to receive intravenous infusions of iloprost starting at 0.5 ng/kg/min and increased by 0.5 ng/kg/min every 15 minutes to a maximum of 2.0 ng/kg/min for eight hours on three consecutive days with a further single infusion at week 8. Placebo capsules were given concurrently. Eleven patients were randomised to receive nifedipine, starting at 30 mg daily and increased to 60 mg daily after four weeks for another 12 weeks. Infusions of placebo were given in the same manner as the infusions of iloprost. One patient from each group withdrew because of social reasons and three patients receiving nifedipine withdrew because of side effects. END POINT: Reduction in number, duration, and severity of attacks of Raynaud's phenomenon, reduction in number of digital lesions, increase in digital blood flow. MEASUREMENTS AND MAIN RESULTS: Measurements were taken at 0, 4, 8, 12, and 16 weeks. Both regimens produced a reduction in the number, duration, and severity of attacks of Raynaud's phenomenon. The mean (SE) number of digital lesions was reduced with iloprost (from 3.5 (1.6) to 0.6 (0.3] and with nifedipine (from 4.3 (0.8) to 1.4 (0.5] after 16 weeks. Hand temperature and digital and microcirculatory blood flow were increased with iloprost but not with nifedipine. CONCLUSION: Both iloprost and nifedipine are beneficial in the treatment of Raynaud's phenomenon. With nifedipine, however, side effects are common. Short term infusions of iloprost provide longlasting relief of symptoms, and side effects occur only during the infusions and are dose dependent.
The clinical and histologic features of 26 cases of erythema induratum are reviewed. The characteristic cutaneous lesions on the legs of middle-aged women were violaceous, indurated nodules, 1 to 2 cm in diameter, which were painful, occasionally ulcerated, and could heal with scarring. The diagnosis was confirmed in all patients by a strongly positive Mantoux test result (1:10,000 dilution) and by clearing of lesions after antituberculosis therapy. The histologic features were varied but were predominantly those of a vasculitis with a paraseptal and lobular panniculitis. Although it was not possible to fulfill the required criteria for diagnosing tuberculosis in these lesions, we believe there is sufficient circumstantial evidence to support the hypothesis that erythema induratum is a true tuberculid.
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