[Dermatological consultation behind bars: an analysis on a three-year period in a French prison]

BACKGROUND

Since 1994, health care in French prisons is managed by the public hospital system. The hospitals created ambulatory consultation units for prisons and detention centers. Skin problems rapidly became a frequent reason for consultation. This is the first systematic assessment of needs concerning dermatological consultation in prisons.

MATERIAL AND METHODS

A monthly dermatology consultation was established at the Colmar detention center in May 1996. We reviewed the files of all prisoners who attended between May 1996 and May 1999. Data collected concerned motivation for the consultation, drug use and serology for HIV and hepatitic C virus.

RESULTS

There were 280 consultations for 180 prisoners. All were men, mean age 30 years, who represented 16% of the total prisoner population. Most consulted for one or more benign skin conditions. The two most frequent conditions were acne (29%) and mycoses (13%). Drug use was found in 36% of the consulting prisoners (64/180). One was HIV-positive. Hepatitis C virus serology was positive in 19% of those tested (28/149), and in 39% of the drug users and 2% of the non-drug users. Motivation for consultation did not differ between drug users and non users, neither between seropositive and seronegative patients for hepatitis C virus.

DISCUSSION

This survey confirms the demand for dermatology consultation in the prison population and points out the frequency of hepatitis C virus in prisoners. A monthly specialized consultation was able to meet the basic demands concerning dermatology. Adapted management of hepatitis C virus in the prison population setting remains a difficult challenge.

[Mercury erythema after accidental exposure to mercury vapor]

Mercury exanthem can be considered as a systemic contact dermatitis following exposure to mercury vapor in patients with a prior sensitization to mercurials. It is characterized by a symmetrically distributed erythematous eruption appearing predominantly in the major flexural areas, in the neck, the lower portion of the abdomen and the upper anteromedial part of the thighs. In some cases, small pustules develop over the erythematous surfaces. We report our observations of two patients with mercury exanthem after exposure to mercury vapor caused by a broken thermometer. One of these patients presented with an unusual bullous form of mercury exanthem. Although diagnosis of mercury exanthem can be essentially based on clinical features, confirmation of the patient's exposure to mercury should be obtained. Cutaneous patch tests often prove the sensitization to mercurials.

Role of metformin accumulation in metformin-associated lactic acidosis

OBJECTIVE

To investigate the role of metformin accumulation in the pathophysiology of metformin-associated lactic acidosis.

RESEARCH DESIGN AND METHODS

We used high-performance liquid chromatography to measure plasma metformin concentrations in 14 patients who experienced lactic acidosis (pH < 7.35 and lactate concentration 5 > mmol/l) while receiving chronic metformin treatment. Their treatment was generally based on alkalinization and dialysis therapy.

RESULTS

Clinical shock and/or evidence of tissue hypoxia was found in all patients with the exception of one who had a nonsteroidal anti-inflammatory drug-induced anuria. Ten patients had significant metformin accumulation (plasma metformin concentrations 4.1-84.9 mg/l, normal value 0.6 +/- 0.5 mg/l before drug intake), generally because of failure to withdraw metformin despite intercurrent pathological conditions affecting its renal elimination (serum creatinine concentrations ranging from 269 to 1,091 mumol/l). There was no metformin accumulation (plasma metformin 0.03-0.7 mg/l) in the four other patients, who had less severe renal failure (serum creatinine 140-349 mumol/l). The severity of the patient's general condition did not predict early hospital mortality (death before discharge from the intensive care unit) even in patients in shock. Whereas it was high in those without metformin accumulation (only 1 of 4 patients recovered), early hospital mortality was low in the 10 patients with metformin accumulation and was not related to its extent (3 patients died with end-stage hepatic failure or cardiac failure). Correlation studies showed a positive correlation between serum creatinine and plasma metformin and between plasma metformin and arterial lactate but, for the latter correlation, only in patients with metformin accumulation.

CONCLUSION

Metformin-associated lactic acidosis is not necessarily due to metformin accumulation; true type B (aerobic) lactic acidosis, i.e., without an apparent associated hypoxic factor, seems exceptional. Neither the severity of the clinical picture nor the degree of metformin accumulation predicted survival; rather, the prognosis was dependent upon the severity of the associated pathological conditions.

[Acute adreno-cortical insufficiency. Eight case-reports (author's transl)]

Four female and four male adults, with acute adrenocortical insufficiency were admitted to a medical intensive care unit over a period of five years (1975-1980). Three of them were under treatment for Addison's disease. The clinical picture combines fever with signs of shock and dehydration. Increased pigmentation of the skin and laboratory data suggest the diagnosis, which is established by the serum cortisol assay. The etiology was tuberculosis in four patients. Cortical retraction was found in three others. One case followed interruption of non-substitutive corticotherapy. After 48 hours of adéquate therapy, all patients had recovered.

[Exercise-induced malignant hyperthermia in a patient with familial ichthyosis vulgaris. Muscular carnitine deficiency as contributing factor (author's transl)]

A young soldier with familial ichthyosis vulgaris developed malignant hyperthermia after an intensive exercise. Ichythyosis was considered as a predisposing factor, but the finding of a low muscular carnitine level raises the problem of a relationship between exercised-induced malignant hyperthermia and lipid metabolism disorders.

[Severe drug complications: current prevalence amongst patients admitted to adult intensive care units (author's transl)]

A retrospective study involving nine teaching hospital mixed intensive units provided information concerning severe drug complications amongst patients admitted to these departments over the past ten years. Amongst a total of 63717 patients admitted, there were 1132 drug complications (1.8%) without any predominance in terms of sex. Mortality was high (252 patients, i.e. 22.2%), being all the greater in older patients. Details concerning the various drug complications are given, the most common being anaphylactic shock and haemorrhage due to anticoagulants. These statistics are compared withthose already published by hospital departments of internal medicine.

[Inappropriate secretion of anti-diuretic hormone in a case of intermittent acute porphyria (author's transl)]

The authors report the case of a patient who presented, during two exacerbations of intermittent acute porphyria, a grave psychiatric syndrome secondary to severe hyponatraemia. The later was due to inappropriate secretion of anti-diuretic hormone confirmed by laboratory tests and the stimation of anti-diuretic activity in the urine. The course was favourable under the effects of symptomatic treatment including sodium supplements and fluid restriction. The anti-diuretic syndrome disappeared on each occasion without sequelae at the time of regression of the exacerbation of porphyria.