GENERALIZED PUSTULAR PSORIASIS PRECIPITATED BY TOPICAL CALCIPOTRIOL CREAM

An 18-year-old woman had a 3-year history of previously stable plaque-type psoriasis that covered most parts of her body, arms, and legs. In June 1993, she started treatment with calcipotriol cream, which was prescribed by her dermatologist. Two weeks after starting this treatment, she had an exacerbation of her psoriasis with a generalized pustular eruption and she was admitted to the dermatology unit of “A. Sygros” Hospital. On admission, the clinical examination revealed a bright red erythema of most of her skin and numerous pinhead-sized pustules that covered all the psoriasis lesions (Fig. 1). The eruption covered the patient's body, legs, and arms, whereas flexures and genitalia remained free. She also complained of malaise. The patient's laboratory studies showed the following values: hemoglobin 12.8 g/dL; hematocrit 39%; WBC 14,000/mm³; platelets 28,000/mm³; erythrocyte sedimentation rate 48/h. The blood chemistry surveys were all in the normal range and so were all enzyme studies. Urinalysis was normal. Chest x-ray showed no abnormality. Previous treatment During the 3-year history, the patient had been using different treatments to control her disease. The last treatment was fluocinamide 0.05% cream, which she had stopped 8 weeks before starting treatment with calcipotriol. On clinical examination no signs of cutaneous atrophy, suggesting the overuse of topical steroid, was found. Histopathologic Findings A 4-mm punch biopsy was taken from a lesion and it revealed the epidermis to be slightly acanthotic and the formation of intraepidermal pustules underneath the stratum corneum with spongiform pustules at the shoulders of the lesion. In the dermis there was a perivascular infiltrate of lymphocytes and a few neutrophils with dilatation of blood vessels (Fig. 2). Course Calcipotriol cream was immediately withdrawn and treatment with methotrexate (MTX) was started (25 mg i.m. weekly). The dose was gradually decreased and discontinued 8 weeks later with no relapse of pustules or the plaque-type psoriasis until now.     

Morbidity of prophylactic inguinal lymphadenectomy with saphenous vein preservation for squamous cell penile carcinoma

BACKGROUND: Inguinal lymphadenectomy has an essential role in the cure of patients with inguinal metastasis from penile cancer; however, this procedure is associated with a significant morbidity. In recent years, modified lymphadenectomy with saphenous vein preservation has been postulated to reduce morbidity. Herein, we present our recent experience with prophylactic inguinal lymhadenectomy and saphenous vein preservation in patients with invasive penile carcinoma and non-palpable inguinal lymph nodes. METHODS: Seven patients with invasive squamous cell penile carcinoma, who underwent bilateral prophylactic inguinal lymphadenectomy with saphenous vein preservation between 1995 and 2001, were reviewed retrospectively. Mean age was 67.7 years. The pathological stage of the primary tumor was pT2 in four and pT3 in three patients respectively. Postoperative complications were defined as minor--wound infection, seroma formation requiring drainage, and skin necrosis, and major-- deep venous thrombosis, persistent seroma formation, flap necrosis requiring a skin graft, as well as permanent and disabling leg lymphedema. RESULTS: Minimum follow up was 2 years. Minor complications--wound infection--occurred in one patient (one groin). No major complications occurred. All patients are alive without evidence of disease recurrence. CONCLUSIONS: Prophylactic inguinal lymphadenectomy seems to offer reduced morbidity in high risk penile cancer patients without compromising survival outcome.     

Disorders of the Autonomic Nervous System in Patients With Brugada Syndrome: A Pilot Study

Autonomic Disorders in Brugada Syndrome . Introduction: The aim of this study was to examine autonomic disorders in patients with Brugada syndrome by performing a cardiac sympathetic innervation evaluation, a head‐up tilt‐test (HUT) and heart rate variability (HRV) analysis. Methods and Results: We enrolled 20 patients with Brugada syndrome (mean age 42.5 ± 8.8 years), 9 with spontaneous and 11 with an induced type 1 electrocardiogram (ECG) in the setting of symptoms and 20 age‐matched controls. All subjects underwent a HUT with parallel measurements of plasma catecholamines and cortisol, a ¹²³I‐metaiodobenzylguanidine single photon emission tomography, and HRV evaluation. Ten control subjects participated in the innervation portion of the study. The tilt‐test with clomipramine challenge was positive in 15 of 20 (75%) patients (7 spontaneous, 8 induced) and in 1 in controls (P < 0.01). A sympathoadrenal imbalance was shown in positive tests. The pattern of innervation in all groups was heterogenic and similar to controls with a trend towards lower measurements in patients with a spontaneous type 1 ECG and a positive HUT. HRV analysis did not reveal any significant differences during day and night. Four patients (20%) had sustained ventricular arrhythmias during a follow‐up of 31.1 ± 8.6 months, but no correlations with innervation or response to tilting were found. Conclusion: A high susceptibility to vasovagal syncope was observed in patients with Brugada syndrome, which could be disease‐related symptoms. Conversely, sympathetic innervation was observed to follow a physiological, heterogenic pattern; however, these factors did not have prognostic value for life‐threatening arrhythmias. (J Cardiovasc Electrophysiol, Vol. pp. 773‐780, July 2010)     

Absence of Effects of Short-Term Estrogen Replacement Therapy on Resting and Exertional QT and QTc Dispersion in Postmenopausal Women with Coronary Artery Disease

Women, on average, have a longer QT interval on the electrocardiogram and are at higher risk of developing torsade de pointes from antiarrhythmic therapy than men. Although endogenous estrogen may play a role in these sex differences, the effect of estrogen replacement therapy has not been examined. Ten women, 65 ± 7 years of age, wit/i stable angina pectoris, positive exercise test, and angiographically proven coronary artery disease (at least one ≥ 70%) stenosis were studied. All women had been postmenopausal for at least 1 year, and none had ever received hormone replacement therapy (HRT). The patients received standard dose HRT (0.625 mg/day oral conjugated estrogen) or matching placebo for 4 weeks in random order, with crossover after a 4-week washout period. Exercise testing using the standard Bruce protocol was performed at the end of the first and third months of the study. Antianginal medications remained unchanged throughout the study period. Compared to placebo, HRT caused a significant increase in plasma estradiol levels from 5.55 ± 1.66 to 31.11 ± 14.95 pg/mL (P = 0.001). QT and QTc, as well as QT and QTc dispersion, did not differ at rest and at peak exercise between the two exercise tests. Likewise, other test results, including angina score, exercise time, ST-T changes, blood pressure, heart rate, and double product were unchanged. Short-term HRT did not alter cardiac repolarization at rest and during exercise in postmenopausal women with known coronary disease.     

Fmoc/Trt-amino acids: comparison to Fmoc/tBu-amino acids in peptide synthesis

Model peptides containing the nucleophilic amino acids Trp and Met have been synthesized with the application of Fmoc/Trt- and Fmoc/tBu-amino acids, for comparison. The deprotection of the peptides synthesized using Fmoc/Trt-amino acids in all cases leads to crude peptides of higher purity than that of the same peptides synthesized using Fmoc/tBu-amino acids. © Munksgaard 1998.     

Circadian Modulation of Ventricular Tachycardia Cycle Length Variability in ICD Patients with Dilated Cardiomyopathy

VT is usually characterized by stability of the RR intervals after a few cycles from the onset. The aim of this study was to evaluate the VT cycle length (VTCL) variability in patients with dilated cardiomyopathy (DCM), in whom a third-generation ICD was previously implanted. Eighty-three episodes of VT were analyzed in 10 patients (8 male, 2 female, 65 ± 6 years) with DCM, and NYHA Class II (7 patients) or III (3 patients). As an index of VTCL variability, the coefficient of variance of the last 15 consecutive RR intervals (CVRR) of the detected and stored VT by the device was considered. The mean value of the RR intervals and the mean value of CVRR of the VT episodes recorded during day versus night time were compared. Fifty-five VT episodes were recorded during the day and 28 episodes during the night time. The mean RR intervals of VT episodes during day time was 335 ± 29 ms and during the night time was 350 ± 22 ms (P = NS). The mean CVRR of VT episodes during day time and night time were 2.83 ± 0.52 and 3.36 ± 0.48, respectively (P = 0.017). In conclusion, a circadian modulation of VTCL variability exists in patients with DCM. The VTCL variability is less during day time compared to night time. A possible explanation is a circadian alteration of sympathovagal balance modifying the electrophysiological properties of the arrhythmogenic substrate.