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SummaryBackground The irritant sodium lauryl sulfate (SLS) is known to cause a decrease in the stratum corneum level of natural moisturizing factor (NMF), which in itself is associated with changes in corneocyte surface topography. Objective To explore this phenomenon in allergic contact dermatitis. Methods Patch testing was performed on patients with previously positive patch test reactions to potassium dichromate (Cr), nickel sulfate (Ni), methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI), or p-phenylenediamine. Moreover, a control (pet.) patch and an irritant (SLS) patch were applied. After 3 days, the stratum corneum from tested sites was collected, and NMF levels and corneocyte morphology, expressed as the amount of circular nanosize objects, quantified according to the Dermal Texture Index (DTI), were determined. Results Among allergens, only MCI/MI reduced NMF levels significantly, as did SLS. Furthermore, only MCI/MI caused remarkable changes at the microscopic level; the corneocytes were hexagonal-shaped with pronounced cell borders and a smoother surface. The DTI was increased after SLS exposure but not after allergen exposure. Conclusions MCI/MI significantly decreased NMF levels, similarly to SLS. The altered corneocyte morphology suggests that skin barrier damage plays a role in the pathogenesis of MCI/MI contact allergy. The DTI seems to differentiate reactions to SLS from those to the allergens tested, as SLS was the only agent that caused a DTI increase.

BACKGROUND: Knowledge of the ethnic differences and effects of photodamage on the relative amounts of natural moisturizing factor (NMF) together with filaggrin processing enzymes in facial stratum corneum is limited. Our aim was to characterize the activities of calpain-1 (C-1), bleomycin hydrolase (BH) and the levels of pyrrolidone carboxylic acid (PCA) as a marker for total NMF levels and to relate them to plasmin activities and corneocyte maturation. METHODS: Enzyme activities, PCA levels and corneocyte maturation were determined from facial tape strippings of photoexposed cheek and photoprotected post-auricular areas (PA) of healthy Caucasian (C), Black African (BA) and albino African (AA) female subjects living in South Africa. RESULTS: PCA concentration levels were of the order AA > BA > C subjects, and the highest activities of BH were present in the AA subjects. BH activities were greater on the photoexposed sites for the BA and C subjects, but they were only numerically elevated in the AA subjects. Photoprotected sites had an increase in C-1 activity in pigmented groups (C and BA), whereas in the AA subjects, the opposite was measured. Plasmin activities were greater on the cheek compared with the PA site for the AA and C subjects, but the activity was low in the BA subjects. In both test sites, the AA, but not the BA and C subjects, had smaller, parakeratotic and less mature corneocytes. CONCLUSION: Variation in PCA levels has been found for different ethnic groups in this study (AA > BA > C subjects). The values in the AA subjects are surprising as one might expect that the lack of pigmentation, and thereby increased photodamage, might lead to lower levels. Increased BH, but not C-1 activity, was observed in the AA subjects indicating that BH is associated with PCA production to a greater extent. Surprisingly, corneocyte maturation is still impaired with elevated PCA levels in AA subjects. The higher levels of plasmin and BH activities on the cheeks, especially for AA and C subjects, suggest that they can be used as markers for epidermal photodamage.

Objective: To compare lateral internal anal sphincterotomy with 2% diltiazem in the treatment of chronic anal fissure in terms of fissure healing and complications. STUDY DESIGN: Randomised controlled trial. PLACE & DURATION OF STUDY: Dept of general surgery, Victoria hospital, Bangalore. From June 2013 to May 2014 with a minimum follow up of 6 months. METHODOLOGY: Sixty patients were randomly assigned into two treatment groups. Group A was assigned to apply 2% diltiazem paste while, in group B lateral internal sphincterotomy (LIS) was done. Response to the treatment was assessed in terms of fissure healing, pain relief and occurrence of complications. Follow up of the patients was carried out at the end of 2nd, 4th, and 6th week of treatment. RESULTS: In group A 5 patients had healing at 2 weeks, 12 at 4 weeks, and 22 at 6 weeks. In group B 14 patients had healing of fissure after 2 weeks, 24 at 4 weeks, 27 at 6 weeks. 4 patient in group A and 3 in group B had no healing. In this study overall healing rate after 6 weeks with diltiazem was 73.33% and 90% with LIS. CONCLUSION: 2% diltiazem cream is in par with Lateral internal sphincterotomy. The need for hospital stay is abolished; psychological and financial burden on the patient is reduced. With a healing rate close to 90%, topical Diltiazem can be considered as the first line of treatment of chronic anal fissure especially in patients who are not fit or not willing for

Background. To compare the core hand and knee examination skills gained by undergraduates taught either by trained patient educators (PEs) or by doctors. Methods. A total of 50 final year medical students were randomized to receive training from PEs or doctors. Group A were taught hand examination by a PE with rheumatoid arthritis, and knee examination by a PE with osteoarthritis. Group B was taught hand and knee examination by a consultant rheumatologist plus an untrained patient with appropriate signs. All students were taught an established core skills set in small group workshops. Students then undertook two validated objective structured clinical examination (OSCE) stations with two blinded assessors. Pre- and post-teaching questionnaires established the students’ self-reported levels of skills (SRS) and a student evaluation of teaching (SET). The study was analysed as an equivalence trial. A mean difference in OSCE scores of 10% was assumed to be of educational significance. Results. Although the SET scores of both groups were high, the doctor-led group received higher scores. Aside from this, the two student groups did not differ significantly. There were no significant differences in mean hand OSCE (mean difference ¼ 0.88, P ¼ 0.28, 95% CI ¼� 0.73 to 2.49) or knee OSCE (mean difference ¼ 0.28, P ¼ 0.7, 95% CI ¼� 1.19 to 1.75) scores. Both the upper and lower confidence intervals for each mean difference fell within the 10% range (� 2.8 to 2.8 for the hand, and � 2.5 to 2.5 for the knee) and equivalence was assumed. Conclusions. Adequately trained PEs can deliver clearly structured undergraduate skills, teaching with equivalent learning outcomes to those of rheumatology consultants. PEs are a valuable development to augment musculoskeletal education in the face of expanding student numbers.

Paediatric anaesthetists are at higher risk of exposure to waste anaesthetic gases, which often exceed set safety limits. Recommended personal diffusive sampling techniques for monitoring exposure to waste anaesthetic gases may not give a true profile of exposure and hence biological sampling may also be necessary. We evaluated the exposure of paediatric anaesthetists to nitrous oxide and sevoflurane as assessed by personal environmental and biological samples. The influence of venue and technique, and the strength of the relationship among the various sampling techniques were analysed. The study found that exposure to nitrous oxide during paediatric anaesthetic inductions is still a major problem, although exposure to sevoflurane was usually within the accepted limits. The type of breathing system used and the presence of scavenging seem to influence this exposure, though surprisingly, the induction technique or the methods of airway control do not. No significant relationship was found between the various biological indicators measured.

Where practicable, exposure to a hazardous substance should be eliminated or adequately controlled. A postal questionnaire survey was sent to 10% of consultants from the Association of Anaesthetists of Great Britain and Ireland, to identify the level of use of nitrous oxide in current anaesthetic practice and identify any change of practice over the last 5 years. Details of anaesthetic practice were requested in three areas: nitrous oxide usage, availability of medical air on anaesthetic machines and the use of total intravenous anaesthesia. Replies were received from 320 consultants (75%). Of these, 49% felt that, over the last 5 years, their use of nitrous oxide had decreased. Twenty per cent of anaesthetists felt that there should be some restriction in availability of nitrous oxide. Where medical air was available, 32% felt that they would use it frequently. A total of 263 (83%) stated that they use total intravenous anaesthesia to some extent. The results showed that, although 49% of consultant anaesthetists had reduced their use of nitrous oxide, this was due to medical considerations rather than concerns over health and pollution issues arising from the use of nitrous oxide.