Emergency department presentation of ‘delusional parasitosis by proxy’. Delusional parent,injured child

We report a case of 'delusional parasitosis by proxy'. A sixyear old child was brought to the emergency department by a mother with concerns that her son had a skin and scalp infestation. Despite the absence of any clinical findings being found on exam, the mother remained disproportionately concerned. Follow up care was recommended with the child's primary care. The mother returned to the ED with her child three weeks later with concerns that her son had an inflamed scalp and eyes. The mother remained insistent that the child was infested with bugs and she had sought care at two other locations where the child was prescribed permethrin on both visits. She had been applying the medication repeatedly. On exam the boy's scalp had been shaved and was erythematous and irritated; his eyebrows and eyelashes had also been shaved off and likely contributed to an irritant conjunctivitis from repeated applications of topical permethrin lotion. No evidence of infestation was identified. We recruited the assistance of the maternal grandparents, child protective services and primary care pediatrics and the child was removed from the mother's custody and placed into the custody of the grandparents. Six weeks later with basic skin care and erythromycin ophthalmic ointment for the eyes, the child's hair, eyebrows and eyelashes grew had grown in, and the scalp irritation had resolved. The mother had sought and received psychiatric care and was improving.     

Six tissue expansion sessions of the scalp for reconstruction of post-burn alopecia.

Postburn scalp alopecia has severe aesthetic and psychological implications. We describe herein a case of a 16-year-old girl suffering from postburn scalp alopecia consisting of approximately 70% of her scalp, with only some residual patches of hair in her left occipital and nuchal areas. The patient underwent six serial tissue expansions during a period of 8 years, thereby enabling coverage of a significant part of the scalp area, with advancement of the hair line laterally and anteriorly. The outcome of this case serves to reinforce the practice of multiple tissue expansion to the scalp, with minimal hair loss and some hair thinning, resulting in a satisfactory aesthetic outcome.     

Topical lotions utilized in outpatient rehabilitation clinics as a potential source of bacterial contamination

Soft tissue mobilization and massage requiring lotions or creams are commonly used interventions in outpatient rehabilitation clinics. For at least 50 years hand creams used in healthcare settings have been found to be contaminated by bacteria. The purpose of this study was to determine the current state of bacterial contamination of lotions used in clinics and to determine the efficacy of lotion preservatives to kill bacteria. Unopened containers of lotions were studied, along with 81 lotion containers used in 22 outpatient clinics in southeast Tennessee and northwest Georgia. Three sites on each container were sampled using sterile swabs. At a microbiology lab, bacterial growth media was inoculated and incubated. Of the 81 containers sampled, 16 supported bacterial growth (19.8%). Container threads displayed the highest contamination compared with other container locations (p < 0.01). No bacteria were found in unopened lotion containers, although when challenged with live bacterial cultures lotion preservatives did not kill bacteria tested. Enrichment cultures using lotions studied here supported the growth of several bacterial species. These findings suggest the need for standardized protocols to help reduce potential healthcare-associated infections due to use of lotions. Improved efficacy of preservatives added to lotions should be a priority.     

Unusual loss of body hair in childhood: Trichotillomania or alopecia

Hair loss (alopecia) is a relatively common problem in childhood and the underlying pathophysiology and manifestations are diverse. We report four cases of hair loss with unusual distributions and discuss the outcome of their management.One child had alopecia with unilateral loss of hair over the eyebrow. He received topical corticosteroids and tacrolimus and his condition resolved. A girl had scalp alopecia which evolved to alopecia universalis. The mother and the child were non-compliant with treatment. A boy had alopecia totalis not responsive to Western or alternative treatment. The fourth child had trichotillomania and bizarre loss of scalp hair. Mother and child received psychological counselling and the child's hair loss improved. It is important to differentiate between alopecia and trichotillomania as the management is very different. Diagnosis and treatment are based on clinical assessment, evaluation of coexisting psychosocial factors and exclusion of autoimmune and other underlying disorders. In alopecia totalis or universalis, alternative therapy is often sought and tried for prolonged periods but efficacy has remained unproven. These cases serve to illustrate the principles of management of children with unusual patterns of hair loss.     

Legal regulation mechanisms in the control of medicines

In 2002, a case was brought against the Secretary of State--sued on behalf of the Committee for the Safety of Medicine (CSM)--by a mother who in May 1986 gave aspirin to her 6-year-old daughter who was suffering from chickenpox (Smith vs. Secretary of State for Health, [2002]). The child deteriorated and following admission to hospital she was diagnosed as suffering from Reye's syndrome. As a consequence, the girl was left with a serious neurological handicap and was totally dependent on others for her care. In June 1986, the government issued a general public warning advising parents not to give aspirin in any form to children under 12 years old and told chemists to take all junior aspirin preparations off their shelves. This followed advice from the CSM that in this age group aspirin could trigger the fatal disease Reye's syndrome. The CSM had been aware of this danger in September 1982 following evidence in the USA. Further evidence was produced in 1985 and the CSM continued to monitor the situation. In April 1986, a meeting was held between the Department of Health (DoH) and members of the aspirin industry. It was subsequently agreed that the producers would withdraw stocks and there would be cooperation between the industry and the DoH rather than a public warning. In May 1986, the CSM recommended that the DoH should give a general public warning, which was made on 10 June 1986. The mother's case was that there was an unreasonable delay in publishing a warning following the CSM meeting on 26 March 1986. It was accepted that the administration of aspirin was a contributory factor in the development of the girl's neurological condition and that had her mother been aware of the warnings before May 1986 she would not have given her aspirin. Were the Secretary of State and CSM liable?     

An immunocompetent child with chromosomally integrated human herpesvirus 6B accidentally identified during the care of Mycoplasma pneumoniae infection

Human herpesvirus 6 (HHV-6) is the only virus known to integrate into human chromosomes and be transmitted from parents to offspring. Less than 1% of the population carries integrated HHV-6 in their genomes. Here, we report the case of a 9-year-old Japanese girl with an extraordinarily high copy number of HHV-6B in her genome. The integrated virus genome was detected by real-time polymerase chain reaction (PCR) in cerebrospinal fluid and serum during the treatment of meningoencephalitis and pneumonia caused by Mycoplasma pneumoniae infection. Furthermore, the HHV-6B genome was detected in hair follicle, plasma, and whole blood in the patient and her mother, but not in the patient's father. Fluorescence in situ hybridization revealed that the viral genome was integrated into chromosome 22. Therefore, these results emphasize the importance of screening for chromosomally integrated HHV-6 prior to starting unnecessary antiviral therapies, particularly for patients harboring HHV-6 with a high copy number.     

The first compound heterozygosity for HKalpha alpha allele and Southeast Asian deletion allele

BACKGROUND: In one program of newborn screening to detect deletional alpha-thalassemia with microarray, the microarray result of a 10-month-old girl showed that she was positive for the rightward deletion junction fragment, the Southeast Asian deletion junction fragment and alpha2. STUDY DESIGN: The girl and her parents were subjected to haematological and molecular analysis. RESULTS: The haematological data revealed that the family presented a typical alpha-thalassemic trait. The molecular analysis showed that the girl and her mother were compound heterozygosity for HKalpha alpha allele and Southeast Asian deletion allele, and her father is compound heterozygosity for alpha alpha allele and Southeast Asian deletion allele. CONCLUSIONS: We have detected a hitherto unreported compound heterozygosity for HKalpha alpha allele and Southeast Asian deletion allele. This case will provide some clinical implications for PCR-based diagnosis for deletional alpha-thalassemia.     

四种抗菌洗液杀菌效果的比较

目的了解市售含中草药类抗菌洗液杀菌效果。方法采用悬液定量杀菌试验方法进行了随机抽样检测。结果醋酸氯己定含量为125 mg/L和702 mg/L分别与中草药组成的肤阴洁抗菌洗液和洁阴舒洗液对大肠杆菌作用2 min,杀灭率达到100%;对金黄色葡萄球菌需要作用5和10 min,杀灭率可达到100%。舒敛爽抗菌洗液对大肠杆菌、金黄色葡萄球菌和淋病球菌作用5 min,杀灭率均可达到100%。妇阴康洗液对4种试验菌杀菌效果均比较差。结论4种含中草药的抗菌洗液均具有一定的杀菌作用,但其杀菌作用与含氯己定及其浓度没有直接关系。     

Social Support Provided by Public Health Nurses and the Coping of First-Time Mothers with Child Care

The purpose of this study was to look at the factors related to the first-time mother's coping with child care when her child is 3 months old. This study is part of an extensive longitudinal project in which the development of mothering skills of first-time mothers was followed up for 8 months postpartum. The data were collected with a questionnaire between March and September 1995, in a sample of 271 first-time mothers. The mothers filled in the questionnaire when their babies were 3 months old. Coping with child care was assessed using Spearman correlation coefficient and stepwise regression analysis. Positive correlation was found between the mother's competence, attachment to the child, health, depression, relationship with the spouse, sense of isolation and role restriction, and the mother's coping with child care. The strongest correlation existed between the mother's competence and her coping. Positive correlation was also found between the child's mood, demandingness and acceptability, and the mother's coping with child care, with the child's demandingness having the strongest correlation. Positive correlation was again found between social support--the average functional support the mother received from her own social network, plus affect, affirmation, and aid from the public health nurses--and the mother's coping with child care. The predictors included in the multivariate method were the mother's competence, health, depression, and attachment to her child; the child's mood and ease or difficulty of care; and the affect and affirmation from the public health nurse. The results show that the first-time mother's coping with child care, when the child is 3 months old, is affected by the characteristics of both mother and child, as well as by the social support received from their social network and from the public health nurses at the child welfare clinic.     

Mentally Ill Mothers of Young Children

When a mother is hospitalized for psychiatric treatment, nurses are presented with an opportunity to assess parenting disorders and identify early parent-child disturbances. The purpose of this article is to discuss the parenting issues recorded in 21 charts of hospitalized, mentally ill mothers who had a child less than 6 years old. Based on this chart renew, three themes related to parenting young children emerged: (1) how psychiatric symptoms affected the mother's ability to parent her children; (2) the difficulty the mother had riding the energy to care for her children; and (3) the mother's need to be with her children in spite of her difficulty caring for them. None of the charts contained assessments of the quality of the mother-child relationship or the mother's ability to resume her maternal role following discharge. The implications of these findings for nursing practice, education and research are discussed.     

Anticancer chemotherapy accelerates scalp hair loss with no androgenic involvement

The involvement of plasma testosterone in patients associated with scalp hair loss accelerated by anticancer drugs including aclarubicin and cisplatin was investigated. Scalp hair loss observed was minor in 12 and severe in 2 out of 31 patients. In patients without significant hair loss, the combination of aclarubicin and cisplatin produced a significant decrease in the plasma testosterone concentration in male patients and a significant increase in female patients 3 days after the anticancer chemotherapy. Six days after the chemotherapy, however, these concentrations returned to pretreatment values. Similar changes were observed in patients with minor or severe scalp hair loss induced by these drugs. These results suggest that aclarubicin and/or cisplatin may accelerate scalp hair loss with no androgenic involvement.     

First-time mothers and child care when the child is 8 months old

The aim of the present study was to examine those resources and strengths that mothers find helpful for coping with child care when the child was 8 months old. This study is part of a more extensive longitudinal study project in which the growth into motherhood of first-time mothers was followed for 8 months postpartum. Data were collected by using structured questionnaires between August 1995 and March 1996. The sample comprised 254 first-time mothers and 248 mothers returned the questionnaires by mail. The multivariate method used was a stepwise regression analysis. Predictors included in the multivariate method to explain coping with child care were as follows: the mother's competence, mother's attachment to the child, mother's self-concept, relation to the spouse, breastfeeding, decision-making support from the public health nurse and activity of the child. The strongest predictor was competence as a mother. The more competent the mother felt and the more attached the mother was to her child, the better her coping. The better the mother's self-concept and relationship with the spouse were, the better she succeeded in taking care of the child. If the mother still breastfed her child and received decision-making support from public health nurses, she coped better in child care. Finally the more active the child was, the more the risk for unsuccessful child care increased. The results indicate that the first-time mother's successful coping with child care when the child is 8 months old is associated with her own resources and attachment to the child as well as activity of the child and breastfeeding. A good relationship between the spouses and support for decision making from the public health nurse also contribute to coping with child care.     

Chemotherapy-induced alopecia: advice and support for hair loss

This article provides insight into the growth cycle of a hair follicle and the potential impact chemotherapy agents can have on this process, which often results in hair loss (alopecia). It explores the psychological consequences of chemotherapy-induced alopecia for an individual as a result of the perceptions of others as well as an individual's perception of his or her self-image. Despite the development of various forms of scalp cooling, chemotherapy-induced alopecia remains a major side effect for patients receiving chemotherapy; however, there have been improvements in wig provision and changing public opinion relating to baldness. Although chemotherapy-induced alopecia affects both males and females and all age groups, this article focuses on the potential impact for patients receiving chemotherapy as a form of treatment for breast cancer. As professionals we need to understand the social significance of hair in relation to a person's outward presentation and social interactions, along with the possible psychological implications of a person losing his or her bodily hair, and not just the head hair. We must aim to minimize the distress alopecia can cause by: ensuring we provide patients with up-to-date verbal and written information to enable them to prepare for losing their hair; helping them to preserve their self-image and minimize the psychological consequences of hair loss while receiving chemotherapy; and preparing them for their hair re-growth following completion of chemotherapy.     

Scalp laceration repair without prior hair removal

The effect on the infection rate of hair removal prior to scalp laceration repair has not been studied prospectively in the outpatient setting. Concern exists that not removing skin hair may lead to an increased incidence of serious wound infections. Sixty-eight scalp lacerations were repaired without hair removal and examined prospectively for infection. No infections were noted at 5-day follow-up. The mean patient age was 21.8 +/- 19.8 years, and the mean laceration length was 2.5 +/- 2.0 cm. The mean time from injury to repair of laceration was 2.2 +/- 2.8 hours. Sixty-three lacerations (92.7%) were repaired within 3 hours of injury. A prospective, randomized study in a select patient population to examine the effect of prior hair removal on infection rate is warranted.     

Bald scalp in men with androgenetic alopecia retains hair follicle stem cells but lacks CD200-rich and CD34-positive hair follicle progenitor cells

Androgenetic alopecia (AGA), also known as common baldness, is characterized by a marked decrease in hair follicle size, which could be related to the loss of hair follicle stem or progenitor cells. To test this hypothesis, we analyzed bald and non-bald scalp from AGA individuals for the presence of hair follicle stem and progenitor cells. Cells expressing cytokeratin15 (KRT15), CD200, CD34, and integrin, α6 (ITGA6) were quantitated via flow cytometry. High levels of KRT15 expression correlated with stem cell properties of small cell size and quiescence. These KRT15(hi) stem cells were maintained in bald scalp samples. However, CD200(hi)ITGA6(hi) and CD34(hi) cell populations--which both possessed a progenitor phenotype, in that they localized closely to the stem cell-rich bulge area but were larger and more proliferative than the KRT15(hi) stem cells--were markedly diminished. In functional assays, analogous CD200(hi)Itga6(hi) cells from murine hair follicles were multipotent and generated new hair follicles in skin reconstitution assays. These findings support the notion that a defect in conversion of hair follicle stem cells to progenitor cells plays a role in the pathogenesis of AGA.     

Parent and child behavior during immunization

The purpose of this study was to examine the relationship between a mother's rating of her own and her child's anxiety and their observed behavior during an immunization. Eighty-three preschool children and their mothers were observed in a health screening clinic while the child received an immunization. Each mother was asked to rate how anxious she and her child were immediately prior to the immunization. Both mother and child behaviors were observed and rated using separate 5-point behavior scales. The results of this study indicate that although child behavior during an immunization varied a great deal, most mothers reassured and very few admonished their children during the immunization procedure. Children with extremely reassuring parents fell into 2 distinct groups with half responding distressed and half non-distressed during the immunization. Mothers of these children who rated their children as highly anxious prior to the procedure had children who were most likely to be observed to be distressed during the procedure.     

Head lice infestation: bug busting vs. traditional treatment

The two main methods of managing head lice infestation in the UK are head lice lotions and bug busting; there is no conclusive evidence as to which of these methods is most effective. The aim of this study was to compare the effectiveness of the bug busting method with lotion. A pilot study in the form of a randomized controlled trial involving two semi-rural general practices was used. Thirty children aged 4-16 years were randomly assigned to two intervention groups. After initial dry combing to detect the presence of head lice, one group was treated with phenothrin lotion. The bug busting group received combing using special combs provided in the bug busting pack and hair conditioner. The main outcome measure was the number of adult live lice and nymphs at day 14. On day 14 in the bug busting group, total eradication of head lice had occurred in eight children; in the lotion group, total eradication had occurred in two children (P=0.052); number needed to treat 2.5 (95% CI: 2.19-2.81). These results suggest that bug busting performed by nurses in a controlled situation is an effective method of managing head lice infestation.     

The hair color-highlighting burn: a unique burn injury

A unique, preventable, 2.8 x 3.7-cm, full-thickness scalp burn resulted after a woman underwent a professional color-highlighting procedure at a hair salon. The burn appeared to result from scalp contact with aluminum foil that had been overheated by a hair dryer during the procedure. The wound required debridement and skin grafting and 3 subsequent serial excisions to eliminate the resulting area of burn scar alopecia. The preventive aspects of this injury are discussed.     

Diffuse hair loss in women

The complaint "Doctor, I am losing my hair" represents a particular challenge to the physician, and involves making a specific diagnosis, selecting an appropriate therapy, and expressing empathy for the patient's anxiety. Diffuse hair loss in women was formerly classified as an entity of its own. Since the identification of female pattern hair loss, most cases have been recognized to be due to androgenetic alopecia, often during phases of life characterized by fluctuations of sexual hormone levels or in connection with intake or cessation of hormonal therapy. The most difficult differential diagnosis includes androgenetic alopecia, chronic telogen effluvium, and psychogenic pseudo efflvuium. Androgenetic alopecia is due to androgen-induced, non-synchronized, progressive shortening of the hair growth cycle and gradually leads to thinning of the central scalp area. Idiopathic chronic telogen effluvium typically occurs in women, starting abruptly without a recognizable initiating factor, and involves the entire scalp area with increased shedding of telogen hair. It is believed to be due to synchronization phenomena of the cyclic hair growth. Psychogenic pseudo effluvium affects fashion-oriented, self-conscious women suffering of a discrepancy between the actual state of their hair and idealized expectations. Later the problem of age-related hair thinning oft becomes a surrogate for the more generalized problem of senescence. Rational therapy of androgenetic alopecia aims at blocking the androgen effect on hair follicles with estrogens and antiandrogens or at pharmacologically reversing vellus hair transformation with topical minoxidil. In contrast, women with idiopathic chronic telogen effluvium should be reassured that their problem is rather a state of exaggerated "hair shedding" than of actual "hair loss".     

The diagnosis of the carrier state for the Lesch--Nyhan syndrome.

Skin biopsies from the mother of a classical case of the Lesch-Nyhan syndrome grew only wild type fibroblasts. This suggested that she is not a heterozygous carrier of the mutant X-linked structural gene which causes the syndrome, and that a fresh mutation caused the disorder in her son. Evidence of mosaicism was sought in skin fibroblasts, hair follicles, jejunal mucosa, cultured bone marrow cells and phytohaemagglutinin (PHA) stimulated lymphocytes from known hemizygotes and heterozygotes for the so-called complete, and partial deficiencies of hypoxanthine guanine phosphoribosyltransferase (HGPRT). These studies were designed to determine the genetic status of the mother of the propositus and to determine if the genetic diagnosis could be improved by the simultaneous study of this wider range of tissues. The results are compatible with the mother of the propositus being a non carrier of a mutant gene causing the Lesch-Nyhan syndrome in her son. Only the study of cultured skin fibroblasts, and of the enzyme levels in hair follicles, contributed diagnostically useful information in this case.