Pedal dermatophyte infection in psoriasis

BACKGROUND

Dermatophyte infections have been considered rare in psoriasis. However, there are data indicating that tinea unguium is as common or even more common in psoriasis compared with healthy controls. Tinea unguium is generally a secondary event to tinea pedis infection.

OBJECTIVES

To study the prevalence of tinea pedis and tinea unguium in psoriasis compared with a control group.

METHODS

Consecutive psoriasis outpatients aged 18-64 years attending a department of dermatology were examined. Samples for direct microscopy and culture were taken from the interdigital spaces, soles and toenails. Consecutive patients without signs of psoriasis or atopic dermatitis seeking examination of moles constituted the control group.

RESULTS

In total, 239 patients with psoriasis and 245 control patients were studied. The prevalence of tinea pedis was 8.8%[95% confidence interval (CI) +/- 3.6%] in the psoriasis group and 7.8% (95% CI +/- 3.4%) in the control group. The corresponding figures for prevalence of tinea unguium were 4.6% (95% CI +/- 2.7%) and 2.4% (95% CI +/- 1.9%), respectively. The differences found in the psoriasis vs. the control groups were not statistically significant.

CONCLUSIONS

This study does not support the hypothesis that the prevalence of tinea pedis and tinea unguium in patients with psoriasis differs from that in a normal population.

[A pop-up menu linked to a computerized drug prescribing system. Prescribing pattern's feedback via a simple and quick method]

It takes time for a GP to acquire sufficient experience of a new drug to be able to prescribe competently. This article describes a project studying the use of computerized records to afford a group of GP's swift feedback on recently introduced drugs of special interest. In the south-east of Sweden a network of primary health care centers has been created in two neighboring counties. The pharmacies of the region are also taking part. When new drugs of particular interest are introduced, each participating GP will automatically see a pop-up menu, asking questions pertaining to each computer-assisted prescription. In the pharmacies, patients are given a questionnaire regarding their expectations with respect to the drug. In this way it will be possible to provide the individual GP swift feedback from a large number of colleagues and patients concerning the drug's effectiveness in clinical practice. We have now been studying the COX-2 inhibitors rofecoxib (Vioxx) and celecoxib (Celebrex). Results show that a pop-up menu used in this way provides the general practitioner quick feed-back on prescribing behavior as well as drug effectiveness in clinical practice.

First long-term study of the seroresponse to the agent of human granulocytic ehrlichiosis among residents of a tick-endemic area of Sweden

The seroprevalence of granulocytic ehrlichiosis has been documented in several studies, but little data exists on incidence rates. Using sera stored from an earlier study on Lyme borreliosis, 290 residents of Aspö Island could be followed prospectively during two tick seasons (1992-1994). Immunoglobulin G antibodies to granulocytic ehrlichiosis were detected by an immunofluorescence assay using Ehrli- chia equi as antigen. Seroprevalence rates increased significantly over time, and at the 1994 follow-up, 28% of the residents were seropositive. Negative-to-positive seroconversion (incidence) rates were 3.9% and 11.1%, respectively, during the two seasons. A highly significant correlation was found between a positive serologic response for granulocytic ehrlichiosis and Borrelia burgdorferi. No such correlations were found for clinical Lyme borreliosis, self-reported arthralgia or number of recorded tick bites. It was concluded that granulocytic ehrlichiosis is highly endemic in this part of Sweden, with a seroconversion rate as high as 11% over a single tick season. Further studies are necessary to correlate these findings with clinical signs of human granulocytic ehrlichiosis.

Characterization of Lyme borreliosis isolates from patients with erythema migrans and neuroborreliosis in southern Sweden

Southern Sweden is an area of Lyme borreliosis (LB) endemicity, with an incidence of 69 cases per 100,000 inhabitants. The most frequent clinical manifestations are erythema migrans (77%) and neuroborreliosis (16%). There was no record of human Borrelia strains being isolated from patients in this region before the prospective study reported here. Borrelia spirochetes were isolated from skin and cerebrospinal fluid (CSF) from LB patients living in the region. A total of 39 strains were characterized by OspA serotype analysis, species-specific PCR, and signature nucleotide analysis of the 16S rRNA gene. Of 33 skin isolates, 31 (93.9%) were Borrelia afzelii strains and 2 (6.1%) were Borrelia garinii strains. Of six CSF isolates, five (83.3%) were B. garinii and one (16.7%) was B. afzelii. Neither Borrelia burgdorferi sensu stricto strains nor multiple infections were observed. The B. afzelii isolates were of OspA serotype 2. Three B. garinii strains were of OspA serotype 5, and the remaining four strains were of OspA serotype 6. All of the B. garinii strains belonged to the same 16S ribosomal DNA ribotype class. Our findings agree with earlier findings from other geographic regions in Europe where B. afzelii and B. garinii have been recovered predominantly from skin and CSF cultures, respectively. To further study the possible presence in Sweden of the genotype B. burgdorferi sensu stricto, which is known to be present in Europe and to occur predominantly in patients with Lyme arthritis, molecular detection of Borrelia-specific DNA in synovial samples from Lyme arthritis patients should be performed.

Bacterial adhesins: structural studies reveal chaperone function and pilus biogenesis

During the past year, remarkable progress has been made in understanding how periplasmic chaperones fold and protect protein modules that are destined for assembly into adhesive pili in Gram-negative bacteria. The first two three-dimensional structures of complexes of periplasmic chaperones with substrate pilus subunits have revealed much about the structural basis for chaperone-mediated folding and aggregation prevention, and have provided insight into the structure of adhesive pili.

Kinetics and mechanism for reduction of anticancer-active tetrachloroam(m)ine platinum(IV) compounds by glutathione

Glutathione (GSH) reduction of the anticancer-active platinum(IV) compounds trans-[PtCl4(NH3)(thiazole)] (1), trans-[PtCl4(cha)(NH3)] (2), cis-[PtCl4(cha)(NH3)] (3) (cha=cyclohexylamine), and cis-[PtCl4(NH3)2] (4) has been investigated at 25 degrees C in a 1.0 M aqueous medium at pH 2.0-5.0 (1) and 4.5-6.8 (2-4) using stopped-flow spectrophotometry. The redox reactions follow the second-order rate law d[Pt(IV)]/dt=k[GSH]tot[Pt(IV)], where k is a pH-dependent rate constant and [GSH]tot the total concentration of glutathione. The reduction takes place via parallel reactions between the platinum(IV) complexes and the various protolytic species of glutathione. The pH dependence of the redox kinetics is ascribed to displacement of these protolytic equilibria. The thiolate species GS is the major reductant under the reaction conditions used. The second-order rate constants for reduction of compounds 1-4 by GS- are (1.43 +/- 0.01) x 10(7), (3.86 +/- 0.03) x 10(6), (1.83 +/- 0.01) x 10(6), and (1.18 +/- 0.01) x 10(6) M(-1)s(-1), respectively. Rate constants for reduction of 1 by the protonated species GSH are more than five orders of magnitude smaller. The mechanism for the reductive elimination reactions of the Pt(IV) compounds is proposed to involve an attack by glutathione on one of the mutually trans coordinated chloride ligands, leading to two-electron transfer via a chloride-bridged activated complex. The kinetics results together with literature data indicate that platinum(IV) complexes with a trans Cl-Pt-Cl axis are reduced rapidly by glutathione as well as by ascorbate. In agreement with this observation, cytotoxicity profiles for such complexes are very similar to those for the corresponding platinum(II) product complexes. The rapid reduction within 1 s of the platinum(IV) compounds with a trans Cl-Pt-C1 axis to their platinum(II) analogs does not seem to support the strategy of using kinetic inertness as a parameter to increase anticancer activity, at least for this class of compounds.

Changing pattern of histological type, location, stage and outcome of surgical treatment of gastric carcinoma

BACKGROUND

There are indications that some features of gastric carcinoma are changing, with a possible impact on prognosis. The aim of this study was to examine any changes in type, location, stage, resection rate, postoperative mortality rate or prognosis for patients with gastric carcinoma in a well defined population.

METHODS

During 1974-1991, 1161 new cases of gastric adenocarcinoma were diagnosed in Ostergötland County, Sweden. Tumour location, Laurén histological type, tumour node metastasis (TNM) stage, radicality of tumour resection and postoperative complications were recorded after histological re-evaluation of tissue specimens and examination of all patient records. Dates of death were obtained from the Swedish Central Bureau of Statistics. Time trends were studied by comparing the intervals 1974-1982 (period 1) and 1983-1991 (period 2).

RESULTS

The proportion of diffuse type of adenocarcinoma increased (from 27 to 35 per cent), while that of mixed type decreased (from 16 to 9 per cent) and that of intestinal type was unchanged. The proportion of tumours located in the proximal two-thirds of the stomach increased (from 32 to 42 per cent) and the proportion of patients with tumours in TNM stage IV decreased (from 32 to 25 per cent). Overall tumour resection rates were unchanged, although the proportion of radical total gastrectomies increased (from 36 to 50 per cent). Excluding tumours of the cardia or gastric remnant after previous ulcer surgery, the 5-year relative survival rate after radical resection increased from 25 to 36 per cent and the postoperative mortality rate decreased for both radical (from 11 to 4 per cent) and palliative (from 18 to 6 per cent) resection.

CONCLUSION

The patterns of tumour histology, location and stage of gastric carcinoma have changed in the authors' region. These changes were paralleled by a significant improvement in survival and postoperative mortality rates.

Equipment for drug release testing of medicated chewing gums

An apparatus was specially designed and constructed for release testing of medicated chewing gums. The adjustable instrumental settings such as temperature, chewing frequency, chewing time, volume of test medium, distance between the jaws and twisting angle increased the versatility of the apparatus. Selection of the test medium was also an important parameter. Each sample was kneaded mechanically in separate test chambers and the drug release was followed by sampling and HPLC analysis. Different gum formulations were tested and the obtained results demonstrated satisfactory release curves for a variety of formulations and active ingredients. The tested gum formulations comprised nicotine, meclizine, dimenhydrinate and xylitol. The apparatus proved to be suitable in product control of commercial batches but also a useful tool in the research and development of medicated gum formulations.

Renal transplantation in patients with urinary diversion: a case-control study

BACKGROUND

Renal transplantation in Sweden in patients with ileal conduits or continent reservoirs was investigated in order to compare the outcome with regard to graft and patient survival as compared to controls.

METHODS

Patient data from the four transplantation centres in Sweden were collected on: treatment prior to transplantation, time needed for the operative procedure, and postoperative care and outcome in terms of renal function as well as graft and patient survival at 1 and 5 years. The pattern of urinary tract infection was also investigated. Each case with urinary diversion was matched with two non-diabetic controls.

RESULTS

Ten male and 12 female cases were found who had received 27 grafts between 1982 and 1996. Five patients had a Kock reservoir and 17 had a Bricker conduit. The time needed for the transplant procedure was significantly longer in the case group. After matching the case group with 54 controls, we found that the renal function was similar in both groups. Graft and patient survival was similar in both groups, over 90% after 1 year. Graft survival was about 70% after 5 years. Postoperative surgical complications in the case group were only seen in a few cases. The pattern of bacteria causing urinary tract infection was slightly different among the patients with ileal conduits or continent reservoirs.

CONCLUSION

Patients with ileal conduits or continent reservoirs have similar graft and patient survival rates as the general kidney transplant population. The presence of constant bacteriuria did not adversely affect survival. Prophylactic antibiotic treatment seems not to be warranted. There appears to be no indication for native nephrectomy, except in selected cases. The study did not show any advantage with regard to continent reservoirs vs ileal conduits.

Apparatus for studying in vitro drug release from medicated chewing gums

An apparatus for in vitro drug release testing of medicated chewing gums has been developed and is described in detail. The effects on the drug release when varying critical instrumental settings such as the chewing stroke frequency, the distance between the chewing surfaces, the twisting movements of these surfaces and the temperature of the test medium have been thoroughly investigated. It has been shown that the drug release can be tuned to obtain suitable drug release profiles for a number of products: Nicorette((R)) and Nicotinell((R)) (active substance nicotine), Travvell((R)) (dimenhydrinate), V6((R)) (xylitol) and an experimental formulation containing meclizine. The main usage of the present apparatus should be within quality control but the present study has also shown that it may be employed within development pharmaceutics since useful in vivo/in vitro relationships may be obtained due to the versatile settings of the critical instrumental parameters.

[Varying clinical picture and course of human granulocytic ehrlichiosis. Twelve Scandinavian cases of the new tick-borne zoonosis are presented]

In the twelve clinical cases of human granulocytic ehrlichiosis (HGE) so far identified in Scandinavia (ten in Sweden, two in Norway), clinical presentation varied from a mild febrile illness to a severe septic condition with such systemic complications as acute respiratory distress syndrome (ARDS). Laboratory verification was based on PCR (polymerase chain reaction) in ten cases, and on serology in two cases. Sequence analysis of 16S rDNA showed the infectious agents to belong to the Ehrlichia phagocytophila genogroup. Seroprevalence data indicate widespread human exposure to granulocytic Ehrlichia; mean seroprevalence, 15-20% of 1,000 clinical sera from tick-exposed patients (mainly from Sweden and Norway). Proposals for diagnostic criteria and procedures, and case management are presented in the article.

No increase in fracture incidence in patients treated for thyrotoxicosis in Malmö during 1970-74. A 20-year population-based follow-up

OBJECTIVES

To study whether there is an increased fracture incidence following thyrotoxicosis.

DESIGN

A case-control study.

SETTING

Malmö University Hospital, Malmö, Sweden.

SUBJECTS

All patients (n = 333) from the population of Malmö who were treated for thyrotoxicosis for the first time during the 5-year period 1970-74. A total of 618 controls were selected from the local municipality registry in Malmö. For each case the aim was to randomly select two age- and gender-specific controls, alive in 1993 and born the same year and month as the case.

MAIN OUTCOME MEASURES

Fracture incidence

RESULTS

Comparing survivors, there were no differences in the percentage of individuals with fractures (all, fragility, non-fragility) between the patients and the controls. Comparing all individuals and including all fractures, the percentage of individuals with fractures in the entire female patient group (24.6%) was lower (P < 0.05) than in female controls (33.1%). There was a similar but non-significant pattern between male patients and controls. The mean number of all fractures was lower in male patients than in controls (P < 0.05), but no significant difference was noted between female patients and controls. For fragility fractures, there were no significant differences in the percentage of individuals with fractures or in the mean number of fractures between female or male patients and controls.

CONCLUSION

In conclusion we found no increased incidence of fragility fractures in patients with previous thyrotoxicosis as compared with controls. Our results do not support the suggestion that screening for osteoporosis should be performed in patients with previous thyrotoxicosis.

Serological evidence of Ehrlichia infection in Swedish Lyme borreliosis patients

We studied sera from patients who had participated in a prospective study of borreliosis in Sweden and had acquired tick bites in areas of the country with a high prevalence of granulocytic ehrlichial infections in animals. The sera were examined for IgG anti Ehrlichia antibodies by an indirect immunofluorescence assay using a locally isolated bovine Ehrlichia antigen. Confirmation of the serological results was done at the Unité des Rickettsies, Marseille, France. Three out of 37 of the investigated patients and 1 out of 100 investigated healthy blood donors had significant antibody titres to granulocytotropic Ehrlichiae. No patient or blood donor had specific antibody titres to Ehrlichia chaffeensis. These data suggest that Scandinavian Ehrlichia species can infect and evoke immunological response in tick-exposed humans.

Natural history and long-term consequences of Lyme disease in children

Lyme disease is the most common vector-borne infection affecting children living in temperate parts of the western hemisphere. The widespread anxiety about the long-term consequences of the illness, however, finds no support in the literature. Although the number of long-term follow-up studies is limited, the prognosis in children treated for Lyme disease seems to be extremely favourable.

Threat assessment: defining an approach for evaluating risk of targeted violence

Although the field of risk assessment has made tremendous advances in the past 20 years, assessments of targeted violence continue to pose a significant challenge to law enforcement, mental health, and other professionals. These specific and critical assessments require an innovative approach. The threat assessment model, developed and refined by the U.S. Secret Service, provides a useful framework for thinking about assessments of potential for targeted violence. In this paper, we attempt to define this approach as it has been developed by the Secret Service, and apply it within the existing professional/scientific literature on risk assessment. We begin with a brief review of existing models and approaches in risk assessment, and identification of some gaps in our existing knowledge as it relates to assessments of targeted violence. We then proceed with an outline of the threat assessment approach, including a review of principles and guiding operational questions, and discussion of its use in assessment of targeted violence.

Predialysis patient education: effects on functioning and well-being in uraemic patients

This study evaluated the effects of a predialysis patient education programme on functioning and well-being in 28 uraemic patients. The programme consisted of four group sessions with the following themes: renal disease and dietary restriction, active renal replacement therapy, physical exercise, and the impact of chronic renal failure on economy, family and social life. Three to 9 months after having started dialysis the patients were evaluated regarding symptoms, perceived health (Health Index), functional (SIP) and emotional (STAI) status. Twenty-eight patients already on dialysis treatment informed according to conventional routines constituted the comparison group. There were no significant differences between the groups regarding age, sex, educational or social background, duration of kidney disease, choice of dialysis treatment, cause of renal disease and laboratory tests except for s-urea. The patients who participated in the education programme scored significantly better mood, less mobility problems (HI), less functional disabilities (SIP) and lower levels of anxiety (STAI) compared to the comparison group. There were no significant differences between the two groups regarding symptoms and overall health. The differences between the groups prevailed during the first 6 months on dialysis treatment, after which the differences disappeared. In the comparison group age correlated significantly to anxiety and overall SIP, which was not the case in the experimental group. In conclusion, the experimental group that participated in a predialysis patient education programme, showed better functional and emotional well-being than the non-educated comparison group. The positive effects of participating in an education programme prevailed during the first 6 months of dialysis treatment. Moreover, the younger patients seemed especially to benefit from participation in a predialysis patient education programme. It is suggested that patient education should be ongoing for patients with end-stage renal failure initiated during the predialysis stage and continued after maintenance dialysis has been established.

Rapid increase in volume of the remnant after hemithyroidectomy does not correlate with serum concentration of thyroid stimulating hormone

OBJECTIVE

To study the effect of postoperative thyroxine on the volume of the thyroid remnant after lobectomy for benign nontoxic goitre.

DESIGN

Prospective, randomised study.

SETTING

University hospital, Sweden.

SUBJECTS

50 consecutive patients who underwent lobectomy for benign non-toxic goitre.

INTERVENTIONS

Patients were randomised postoperatively to take thyroxine 0.1 mg or placebo daily.

MAIN OUTCOME MEASURES

The median volume of the remaining thyroid lobe measured by ultrasound. Serum concentrations of thyroxine, triiodothyronine (T3) and thyroid stimulating hormone (TSH) were measured preoperatively and 1, 3, 6, 12 months postoperatively.

RESULTS

The median volume of the remaining lobe had increased significantly compared with preoperatively by 1 month postoperatively by 30% in the thyroxine group and 25% in the placebo group (p < 0.01). The difference between the groups was not significant. After the first month the volume did not change significantly. In the thyroxine group, the TSH concentration was unchanged and the thyroxine concentration increased significantly throughout the study. In the placebo group there was a significant increase in TSH concentration and a significant decrease in that of thyroxine at all follow-up examinations.

CONCLUSIONS

There is a significant increase in the volume of the remaining thyroid 1 month after lobectomy that persisted throughout the first year. Thyroxine given in a dose that kept the serum TSH concentration at the same level as preoperatively did not seem to influence volume changes; consequently we consider that these are caused by factors other than TSH.

Bicarbonate and bicarbonate/lactate peritoneal dialysis solutions for the treatment of infusion pain

A randomized, double-blind, cross-over study was undertaken to determine the effects of novel bicarbonate (38 mM) and bicarbonate (25 mM)/lactate (15 mM) containing peritoneal dialysis (PD) solutions on infusion pain in patients who experienced inflow pain with conventional lactate (40 mM) solution. Pain was assessed using a verbal rating scale and the validated McGill Pain Questionnaire (MPQ). Eighteen patients were recruited to the study. Both novel solutions resulted in highly statistically significant reductions in inflow pain compared to the control lactate solution, as assessed with both the verbal rating scale and the MPQ. For all pain variables assessed, the bicarbonate/lactate solution was more effective than the bicarbonate solution in alleviating pain. In conclusion, both solutions reduced the infusion pain experienced with control solution, but the bicarbonate/lactate solution appears to be the most effective. In contrast to the most widespread current treatment, which is the manual injection of sodium bicarbonate, the bicarbonate/lactate solution does not have the associated increased risk of peritonitis.

Lyme borreliosis in rheumatological practice: identification of Lyme arthritis and diagnostic aspects in a Swedish county with high endemicity

To prospectively study the prevalence of Lyme arthritis, 100 consecutive patients referred to a rheumatology out-patient clinic and 115 patients with a classified rheumatological disease were included. Individuals seropositive for antibody against the Borrelia burgdorferi sensu lato complex were examined for clinical signs or a history of Lyme borreliosis. Positive titres against B. burgdorferi s.l. were found in 7/100 and 15/115, respectively. Among the 100 referred patients. Lyme arthritis was diagnosed in five cases. Carpal tunnel syndrome was the presenting clinical feature in two of them. One of the 115 individuals with a previously classified rheumatological disease was re-classified as Lyme arthritis. All cases of Lyme arthritis improved after oral antibiotic treatment. This study revealed Lyme arthritis to be a common disorder in this part of Sweden and the diagnosis should be considered in patients with acute or recurrent episodes of mono- or oligoarthritis.

Does prophylactic treatment with felodipine, a calcium antagonist, prevent low-osmolar contrast-induced renal dysfunction in hydrated diabetic and nondiabetic patients with normal or moderately reduced renal function?

Twenty-seven patients (15 diabetics and 12 non-diabetics) with normal to moderately reduced renal function underwent femoral angiography with a low-osmolar contrast agent, iohexol (Omnipaque), under perexaminatory hydration. Fourteen patients were randomised to pretreatment with oral felodipine extended release (Plendil) 10 mg and 13 patients to placebo 3-4 h before angiography. GFR measured with [51Cr] EDTA-clearance decreased 24 hours after the angiography in the felodipine group from GFR 52.5 +/- 18.6 (mean +/- SD) to 46.2 +/- 16.5 ml/min (p < 0.01) and in the placebo group from 70.6 +/- 18.6 to 62.6 +/- 26.4 ml/min (p < 0.01). Serum creatinine increased significantly in the felodipine group from 128 +/- 61 to 139 +/- 67 mumol/l (p < 0.05) but not in the placebo group (122 +/- 54 to 125 +/- 51 mumol/l (ns)). The values of serum creatinine returned to baseline levels 7 days after angiography. During hydration there was only a slight reduction of GFR after angiography with iohexol. Thus, felodipine had no major effect on GFR after iohexol but, as baseline GFR tended to be lower in the felodipine pre-treated patients, it might have had some renoprotective effect in patients with more advanced renal failure.