Macular Arteritis Mimicking Pigmented Purpuric Dermatosis in a 6-Year-Old Caucasian Girl

Abstract:   A 6-year-old Caucasian girl presented with a 4-month history of a mildly pruritic, brown and pink, focally petechial macules on the posterior aspect of her left leg, clinically consistent with a pigmented purpuric dermatosis. Biopsy, however, revealed lymphocytic inflammation with occlusion of the lumen of a small artery at the dermal–subcutaneous junction, characteristic of macular arteritis. This is a recently described entity that is not known to be associated with systemic disease, and remains stable over years without treatment. So far, it has not been reported in a Caucasian patient. We review the clinical and histologic features, as well as the laboratory evaluation of this case, and the previously reported cases.     

How many parents should we let into the operating room?

Objective:  This study compared anxiety of children with one and two parents present at anesthesia induction.
Methodology:  Baseline measures of parent and child anxiety were obtained; parents were randomly assigned to the two study groups. Validated and reliable tools were used to assess the outcomes of interest.
Results:  We found that observed anxiety of children as well as compliance of children with the induction process was not different between the two study groups. Parent's anxiety was also evaluated using two-way anova with repeated measures. A group by time interaction was demonstrated and parents in the one-parent group reported significantly higher anxiety than parents in the two-parents group ( M  = 48.6, sd  = 13.1 vs M  = 39.7, sd  = 11.5, P  < 0.02).
Conclusions:  We conclude that while allowing two parents into the operating rooms does not affect observed child anxiety, it does reduce parent self-reported anxiety. As the presence of multiple parents during invasive medical procedures is in congruence with family centered-care we recommend that institutions examine this modality.     

Recent Implications of Intrauterine and Postnatal Rubella

Many new facets of rubella virus infection, both natural and congenital, have been recently exposed. In its intrauterine role, the virus is curiously selective and it is possible that the genes of the fetus are important in determining both the occurrence and severity of infection. The risk to the fetus is highest if infection occurs in early pregnancy, but there is some risk up to 24 weeks gestation. Multiplicity of defects and chronic persistence of fetal infection are characteristic features of congenital rubella infection. The clinical manifestations, diagnosis and management of congenital rubella are discussed, with emphasis on the long term sequelae. Postnatal rubella may be difficult to diagnose, since many cases are subclinical and history is unreliable:— serological diagnosis is therefore critical during pregnancy. Vaccination programmes designed to prevent congenital rubella are evaluated; while these show promise, the ideal vaccine is yet to become available.     

Pityriasis lichenoides—an immune complex disease

Circulating immune complexes have been detected in patients with pityriasis lichenoides during disease activity when IgM and C3 have been observed in dermal vessels on direct immunofluorescence of fresh lesions. This implies that pityriasis lichenoides is an immune complex disorder and that deposited complexes play a part in the pathogenesis of the condition. There is a characteristic pattern of immunofluorescence which may be a diagnostic aid.     

HELISTAT ABSORBABLE COLLAGEN HEMOSTATIC SPONGES IN CUTANEOUS SURGERY IN HIV–1+ PATIENTS

Background. While biopsies are often required for adequate diagnosis of skin lesions in HIV–1 infected patients, these procedures result in the possible exposure of medical personnel to blood and contaminated instruments. To reduce exposure of medical personnel to contaminated needles we have used collagen sponges instead of sutures to control bleeding from punch biopsy sites in HIV–1 infected patients. Methods. A collagen sponge was placed in all punch biopsy sites in HIV–1 infected patients. In cases where there was clinical evidence of local infection the sponges were removed 5–6 minutes after hemostasis was obtained. Results. In over 500 biopsies in which Helistat collagen sponges were used, there have been no cases of secondary infection, and there have been no delays in healing. Conclusions. We believe that the use of these sponges provides a high degree of safety for the physician, which may assure that the commonly atypical clinical lesions seen in HIV–1 disease are biopsied. In addition, these sponges provide hemostasis, particularly significant in this patient population, and convenience, without a significant risk of secondary infection, and may provide some benefit in healing.     

Social determinants of cardiovascular reactivity: Effects of incentive to exert influence and evaluative threat

The effects on cardiovascular reactivity of incentive to influence the judgements of the experimenter and the threat of social evaluation were examined in a sample of 60 male and 60 female undergraduates. Participants either were guaranteed $5.00 to prepare and deliver a brief speech or were told that the money was contingent on an evaluation by the experimenter. Participants believed that their speech would be rated for either simple clarity or verbal intelligence. The contingent incentive increased systolic blood pressure reactivity by 6.5 mmHg (32%). Evaluative threat increased systolic reactivity by 7.1 mmHg (36%). These interpersonal processes could increase the risk of cardiovascular disease and are likely to affect the degree of cardiovascular reactivity in laboratory studies.     

The organization of care: its influence on health education practice on acute wards

Summary

• ? This paper explores the relationship between organization of care and nurses' health education practice at ward level and is based on data from a larger 2-year Department of Health-funded study examining the health education and health promotion role of the nurse in acute-ward settings.
• ? Concepts such as continuity of care, autonomy, accountability and responsibility are examined in terms of their association with organization of care and primary nursing in particular.
• ? Other factors closely associated with organization of care such as ward democracy and the empowerment of nurses, are also discussed in relation to ward-based health education practice.
• ? Data analysis reveals that the way in which care is organized on the ward may have a direct influence on the type, quality and consistency of health education advice given to patients.

     

Management of Ventricular Fibrillation with Transvenous Defibrillators Without Baseline Electrophysiologic Testing or Antiarrhythmic Drugs

Tranvenous Defibrillators Without EP Testing. Introduction : Baseline electrophysiologic study (EPS) is routinely performed in patients resuscitated from ventricular fibrillation (VF) to risk stratify and select patients for chronic antiarrhythmic drug therapy. The role of EP testing prior to insertion of a multiprogrammable implantable cardioverter defibrillator (ICD), however, is unclear.
Methods and Results: This study was a retrospective review of outcome in 66 survivors of an initial episode of out-of-hospital VF not associated with a Q wave myocardial infarction or reversible causes, treated with transvenous ICDs as first-line therapy. Patients were excluded from the study if they had a previous history of monomorphic ventricular tachycardia (VT), a clinical history suggestive of supraventricular tachycardia, or had undergone preoperative EP testing. Fifty-two of the patients (79%) were male with an average age of 58 ± 11 years. Coronary artery disease was present in 43 patients (66%), cardiomyopathy in 15 patients (23%), and valvular heart disease in 1 patient (1.5%). Seven patients (11%) had no detectable structural heart disease. The mean left ventricular ejection fraction was 0.40 ± 0.16. With an average follow-up of 25 ± 12 months, survival free of death from any cause was 100%. Twenty-three patients (35%) experienced 48 episodes of recurrent rapid VT or VF (average cycle length: 236 ± 47 msec) treated by their device. The mean time to first therapy was 223 ± 200 days. Only one of these patients also received antitachycardia pacing for two episodes of VT. One patient (1. 5%) temporarily received amiodarone after removal of an infected device that was subsequently replaced. No other patient received antiarrhythmic drug therapy.
Conclusion : After a cardiac arrest due to primary VF, select patients treated with multiprogrammable ICDs can be managed successfully without baseline EPS or antiarrhythmic drug therapy.