Treatment of the depressed and dysmorphophobic acne patient

Sixteen patients with minimal facial acne but with symptoms of dysmorphophobia related to their acne were treated with isotretinoin, 0.5 mg/kg/day, (n = 5); 1 mg/kg/day (n = 11) for 16 weeks. All 16 had previously received long-term antibiotic therapy with no 'perceived' improvement in their acne. Formal psychiatric assessment was not possible through lack of cooperation. Fourteen of 16 patients derived benefit from isotretinoin therapy in that all 14 were subsequently satisfied with the cosmetic results achieved. However, the incidence of relapse was greater than that for a control group, 14 requiring additional therapy in the form of antibiotics or further isotretinoin (seven patients) within 20 months of completing the original course. Patients with acne and dysmorphophobia represent an important group of patients who benefit from treatment with isotretinoin; if possible this should be in conjunction with psychotherapy.     

A randomized controlled trial of sedation in the critically ill

A randomized controlled trial comparing: a) a combination of oral chloral hydrate and promethazine to b) a continuous intravenous midazolam infusion, for maintenance sedation in critically ill children, was carried out. The level of sedation was assessed four hourly using a specifically devized sedation scale. Forty-four children entered the study of whom two were subsequently excluded. The number of satisfactory assessments (desired and actual levels of sedation equal) was significantly greater in the chloral hydrate and promethazine group (Chi-squared P <0.01; confidence intervals of the difference 0.06 to 0.20). The number of assessments at level 5 on the sedation scale (patient restless/distressed) was significantly greater in the midazolam group (Chi-squared P <0.05). The total number of satisfactory assessments in the two groups were only 61 and 48% respectively, suggesting that sedation can be considerably improved. Chloral hydrate and promethazine are more effective than midazolam as maintenance sedation in critically ill children. It is possible to prospectively study the efficacy of sedative drugs in critically ill children.     

Sickness Absence from Work and Influenza Immunization

The worth of influenza immunization for employees in U.K. industryhas been debated for more than a decade. In this study no evidencecould be found of a protective effect for sickness absence patterns.Other evidence is also cited that suggests routine influcnzalimmunization programmes for healthy adults of working age areno longer justilied. *Requests for reprints should be addressed to: Dr Robin Philipp, Department of Epidemiology and Community Medicine, University of Bristol, Bristol BS8 2PR.     

Tinea nigra palmaris

Tinea nigra is a clinically distinctive superficial mycosis of the palms, and occasionally the soles, caused by Phaeoannellomyces werneckii. A patient, resident in the United Kingdom, is described who acquired the infection in Thailand. The condition cleared after treatment with topical miconazole cream 2%.     

The spectrum of livedo reticularis and anticardiolipin antibodies

We document a study of 65 patients presenting to our clinics, over a 2-year period, with livedo reticularis. All patients were screened for the presence of anti-cardiolipin antibodies and assessed for the presence of central nervous system disease and features of the 'antiphospholipid' syndrome, including venous and arterial thromboses and foetal loss. Patients were also assessed for other clinical features such as Raynaud's phenomenon and valvular lesions. Twenty-eight anti-cardiolipin positive patients were compared with 37 anti-cardiolipin negative patients. There was a statistically significant difference in the incidence of cerebrovascular disease (including strokes and transient ischaemic attacks) thrombocytopenia, valvular heart lesions and foetal loss in the anti-cardiolipin positive patients as compared with the anticardiolipin negative groups.     

Keratin expression in pilosebaceous epithelia in truncal skin of acne patients

Summary This study compared the pattern of keratin expression in pilosebaceous follicles in uninvolved trunk skin of acne patients, comedones, and normal control skin by immunohistochemistry. using both immunofluorescent (IF) and immunoperoxidase (IP) techniques. The shape, size and gross morphology of truncal follicles varied greatly. There was no difference in keratin expression between normal skin and uninvolved skin of patients with acne. The upper part of the pilosebaceous duct expressed keratins K1, K5, K10 and K14, whereas the lower duct expressed keratins K5, K6, K14, K16, K17 and Kl9. The sebaceous gland showed considerable heterogeneity in keratin expression, with some lobules expressing keratins K1, K5, K7, K10, K14 and K17. The comedone wall showed a pattern of keratin expression similar to that of the upper follicle, except that there was, in addition, expression of keratins K6 and K16 suprabasally, and panepithelial expression of K17 in the comedone wall. IF techniques were found to be less sensitive than the IP method in the detection of individual keratins, but the use of multiple antibodies and many different transverse and longitudinal sections of follicles permitted full conclusions to be made. The increased expression of keratins K6, K16 and K17 in the comedone wall is likely to represent a secondary effect of increased cell turnover due to the primary underlying mechanism of comedogenesis. which is as yet unknown.     

Granulomatous hidradenitis suppurativa and cutaneous Crohn's disease

Three patients with concurrent hidradenitis suppurativa and Crohn's disease are presented. The notable histological feature in each hidradenitis resection was the presence of numerous discrete epithelioid granulomas in areas of non-inflamed dermis. The purpose of the study was to determine the incidence of epithelioid granulomas in 101 hidradenitis patients and their significance in relation to systemic granulomatous disease. Discrete epithelioid granulomas were identified in 8% of the resections (10 patients). One patient had Crohn's disease and one other pulmonary sarcoidosis. Seven patients with granulomatous hidradenitis neither had nor developed any other disease during the 3-year follow-up period. Clinical review identified a further two patients with Crohn's disease but associated with non-granulomatous changes in the skin resections. Foreign body type granulomas were identified in 25% of the resections adjacent to ruptured hair follicles, sinus tracts or nearby degenerate sweat glands. The study shows that, although foreign body type granulomas are a common finding in hidradenitis, the presence of discrete epithelioid granulomas in the dermis away from the site of active inflammation is unusual and should alert the pathologist to the possibility of systemic granulomatous disease such as Crohn's disease or sarcoidosis.     

ANTAGONISM OF ATRACURIUM-INDUCED NEUROMUSCULAR BLOCKADE BY NEOSTIGMINE OR EDROPHONIUM

Antagonism of atracurium-induced neuromuscular blockade by neostigmineor edrophonium has been studied using the tetanic (50 Hz) andtrain-of-four (2 Hz) or single twitch responses of the adductorpollicis muscle in 22 anaesthetized patients. A further ninepatients not given an anticholinesterase acted as a controlgroup. In two groups (six patients for each anticholinesterase)in whom antagonism was attempted at 95–98% blockade ofthe tetanic response, recovery of the tetanic response aftertwo or three doses of edrophonium 0.75 mg kg^–1 i.v. wasnot statistically different from that in the control group;recovery after two doses of neostigmine 2.5 mg i.v. was significantlyfaster (P < 0.001). Recovery of the single twitch responseafter antagonism with edrophonium, although longer than thatwith neostigmine (P < 0.01), was significantly shorter thanin the control group (P < 0.05). When edrophonium is givenat the commencement of recovery, the initial rapid antagonismof tetanic block is not sustained, whereas antagonism by neostigmineis more persistent and the recovery phase is significantly shortened.In a further two groups of patients (n = 5) given atracurium0.3 mg kg^–1 i.v. antagonism was not attempted until thepeak height of the tetanic contraction had reached approximately50% of the control value. It was found that recovery of thetetanic and train-of-four responses was significantly faster(P < 0.05–0.001) after antagonism with edrophonium0.75 mg kg^–1 i.v. than with neostigmine 2.5mg i.v. (approx.0.04 mg kg^–1). The train-of-four response recovered moreslowly than did the tetanic response after both agents (P <0.05–0.01). Department of Anaesthetics, University College Hospital, LondonWC1. ^*Clinical Investigation Department, Clinical and Applied researchDivision, The Wellcome Research Laboratories, Beckenham, Kent.     

A Predominantly Adrenaline-secreting Phaeochromocytoma

A 61-year-old woman who presented with diabetes, nausea, weightloss and sweating was found to have a phaeochromocytoma secretingadrenaline, with a small amount of N-methyIadrenaline. Therewas no significant increase in noradrenaline secretion. Shewas normotensive, and developed profound hypotension in responseto the -adrenergic antagonist phenoxybenzamine. These featuresare unusual in phaeochromocytoma, but similar features occurredin the very few previous reported cases of pure adrenaline-secretingphaeochromocytoma. We conclude that it is important to identifysuch patients, so that they should not be given -adrenergicantagonist drugs.