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SUMMARY A case of primary amyloidosis is described, during the course of which transient, purpuric haloes appeared around long-standing Campbell de Morgan spots, forming target-like lesions of the skin. CASE REPORT A 78-year-old man presented with features of congestive cardiac failure. The only skin lesions at presentation were a number of long-standing Campbell de Morgan spots. Further investigation showed him to have nephrotic syndrome and a renal biopsy revealed extensive amyloid deposition in the glomeruli and small renal arteries. In addition there were persistent clinical, ultrasonic and biochemical signs suggesting hepatic involvement as well as electrocardio graphic, echocardiographic and clinical features suggesting cardiac involvement with amyloid. Serum eleetrophoresis showed no paraproteinaemia, but screening for Bence-Jones proteinuria was positive and the urine contained both kappa and lambda chains. The patient responded well to diuretics. During the course of his follow-up he was noted to develop purpura of the uvula at a time when his clotting studies were normal apart from a slight reduction in his Factor X estimation (62",,, compared with the normal range of 70",, to 130",,). As this lesion faded over the next 7 days, purpura appeared as a halo around a number of his Campbell de Morgan spots (Fig. i). Over the ensuing weeks these initial purpuric areas faded but others appeared, in crops, around different Campbell de Morgan spots. Biopsy of one of the typical lesions showed it to be a haemangioma with amyloid deposition in the walls of the blood vessels (Fig. 2), in the connective tissue between the vessels and in the basement membranes of the sweat glands. The patient died suddenly at home 6 months after initial presentation. These target lesions appeared in crops throughout the course of his illness.

Blood-pressure screening in a family health centre identified 114 patients (53 male, 61 female) with diastolic pressures of 95 mm Hg and greater after three readings in the seated position (mean 163 [SEM 2]/104 [1] mm Hg). All were instructed in the use of the 'Copal UA 231/251' electronic sphygmomanometer and produced a series of readings taken at home over 3 days. They were recalled after 2 weeks and 4 weeks for repeat clinic measurements of blood pressure. Blood pressure fell on successive clinic visits; at the final visit only 59 patients (31 male, 28 female) had diastolic pressures of 95 mm Hg or greater. Average day-time home blood-pressure measurements (155 [2]/94 [2] mm Hg) were significantly lower than the screening blood-pressure measurements but were not significantly different from those at the third clinic visit (154 [2]/97 [1] mm Hg). Home blood-pressure measurements were successful in predicting outcome at the third clinic visit in 90 (79%) patients; home-monitored pressures suggested normotension when the final clinic visit diastolic blood pressure was still above 95 mm Hg in only 16 (14%) patients. Only 2 of these had a final clinic diastolic pressure above 105 mm Hg. Home monitoring represents a practicable and acceptable alternative to repeated clinic measurements in the initial assessment of hypertensive patients.

Summary We report two cases of acquired immune deficiency syndrome (AIDS), apparently without the usual exposure factors, in whom a temporal association was detected after detailed epidemiological investigation. The index case, a 45 year old housewife, had provided terminal home-nursing care for a 33 year old African man, who died from an undiagnosed encephalitis. At that time she had fissures of the skin of both her hands. Review of post-mortem pathology specimens of the African man allowed a retrospective diagnosis of AIDS with cerebral toxoplasmosis to be made. The type of home-nursing care given by the index case was quite different from that normally provided by health care workers with the training and facilities to prevent the spread of infection.

Summary Bleomycin, an anti-neoplast ic antibiotic produced by Slreptomyces verticullis, is widely used in the trentment of malignant lytnphomas and squamous cell carcinomas. Like other anti-metabolite drugs it has been associated with a number of cutaneous side effects such as alopecia and stomatitis'. Bleomycin can also produce a characteristic cutaneous reaction; linear streaking', two cases of which are reported herein. Case reports Case ] The patient was a 55-year-old man who was treated with daily radiotherapy for nasopharyngea! carcinoma. In addition, he was given twice-weekly intramuscular injections of 15 mg bleomycin. Seven days after the first dose of bleomycin (total dose 30 mg) he complained of an itchy rash on his trunk and over the pressure areas of his knees

In this study the authors used the Haemostatometer, a new instrument to monitor the pattern of hemostatic plug formation that occurs in holes in poly ethylene tubing through which nonanticoagulated blood is flowing under stand ard conditions. The pattern and speed of blood coagulation, subsequent to hemostasis, was also monitored. Simultaneously, the time until expulsion of he mostatic plugs formed was measured and considered as spontaneous thrombo lysis time (STT). In 10 healthy volunteers, blood samples were drawn and tested before and ninety minutes after administration of 10 mg oral nifedipine. After nifedipine, the initial phase of primary hemostasis was delayed (p < 0.05), the clotting time lengthened (p < 0.01), and the STT shortened (p < 0.01). The au thors conclude that the effect of nifedipine on hemostasis and thrombolysis could contribute to its therapeutic efficacy.

With the increased use of condoms, contact dermatitis to rubber is being seen more often. To develop a rubber condom suitable for use by rubber sensitive people, a "hypoallergenic" condom, which is washed in ammonia to reduce the residues of rubber accelerators, has been manufactured. Fifty patients allergic to various rubber accelerators were patch tested with an ordinary condom and the new washed condom. Fifty patients undergoing routine patch test investigation who were not allergic to rubber were also tested as controls. Twenty two of the rubber sensitive patients had a positive reaction to the new rubber condom compared with four of the control patients. Washing rubber condoms in ammonia does not appear to reduce the residues of rubber accelerators sufficiently for their use by rubber sensitive people. A non-allergenic condom is required.Contact dermatitis to rubber is more common with increased use of condoms, due to the acquired immunodeficiency syndrome (AIDS). A condom has been produced which is washed in ammonia to reduce the residues of rubber accelerators for use by people sensitive to rubber. Testing done on rubber sensitive people indicate that 44% of them reacted to the washed condom and therefore would be unable to use them as well. Contact dermatitis to rubber is a well established clinical problem; 5- 10% of all patients are allergic to rubber compounds including gloves and footwear. There may be many unreported cases because the doctor has not considered this, or the patient was too embarrassed to inform the doctor. Washing the condom in these solutions reduces the shelf life of the product from 5 years to 18 months. Condoms made of sheep gut made in the US can be used by rubber sensitive patients, and also polyurethane condoms made in Denmark are available. There is a need for more development of non-rubber or non-allergenic condoms.

OBJECTIVE--To compare the long term effects of short term intravenous infusions of iloprost with those of oral nifedipine in patients with Raynaud9s phenomenon associated with systemic sclerosis. DESIGN--Double blind, placebo controlled, randomised group comparison. SETTING--Dermatology outpatient clinic. PATIENTS--Twenty three patients with Raynaud9s phenomenon associated with well documented systemic sclerosis (American Rheumatism Association criteria) and with typical abnormalities in fingernail folds on capillaroscopy. INTERVENTIONS--Twelve patients were randomised to receive intravenous infusions of iloprost starting at 0.5 ng/kg/min and increased by 0.5 ng/kg/min every 15 minutes to a maximum of 2.0 ng/kg/min for eight hours on three consecutive days with a further single infusion at week 8. Placebo capsules were given concurrently. Eleven patients were randomised to receive nifedipine, starting at 30 mg daily and increased to 60 mg daily after four weeks for another 12 weeks. Infusions of placebo were given in the same manner as the infusions of iloprost. One patient from each group withdrew because of social reasons and three patients receiving nifedipine withdrew because of side effects. END POINT--Reduction in number, duration, and severity of attacks of Raynaud9s phenomenon, reduction in number of digital lesions, increase in digital blood flow. MEASUREMENTS AND MAIN RESULTS--Measurements were taken at 0, 4, 8, 12, and 16 weeks. Both regimens produced a reduction in the number, duration, and severity of attacks of Raynaud9s phenomenon. The mean (SE) number of digital lesions was reduced with iloprost (from 3.5 (1.6) to 0.6 (0.3] and with nifedipine (from 4.3 (0.8) to 1.4 (0.5] after 16 weeks. Hand temperature and digital and microcirculatory blood flow were increased with iloprost but not with nifedipine. CONCLUSION--Both iloprost and nifedipine are beneficial in the treatment of Raynaud9s phenomenon. With nifedipine, however, side effects are common. Short term infusions of iloprost provide longlasting relief of symptoms, and side effects occur only during the infusions and are dose dependent.

OBJECTIVE--To determine the prevalence and severity of acne among schoolchildren in Glasgow. DESIGN--Secondary schools in Glasgow were divided by postcode into five socioeconomic cluster groups. Different numbers of schools were selected at random from the five groups to ensure proportional representation. One class from each registration year of the chosen schools was selected at random and the whole class recruited into the study. SETTING--15 Secondary schools in Glasgow. SUBJECTS--2014 Randomly selected schoolchildren aged 12-17 (5% of total secondary school roll). INTERVENTIONS--None. END POINT--Assessment of facial acne by two independent examiners by a recognised acne scoring system. MEASUREMENTS AND MAIN RESULTS--The prevalence of acne in boys increased from 40% (75/189) at age 12 to 95% (108/114) at age 16, and in girls it increased from 61% (114/187) at age 12 to 83% (136/164) at age 16. On a scale of 0 to 10 only 18 boys (1.8%) and three girls (0.3%) had grades of acne of 1.0 or greater; most of the pupils had grade 0.05-0.375 (minimal) acne. Nine per cent of boys (88/973) and 14% of girls (145/1041) had visited their general practitioner specifically for advice on and treatment for acne; only five pupils (0.3%) had been referred to a dermatologist. CONCLUSIONS--Both the prevalence and severity of acne have decreased over the past 20 years. This has probably been due to improvement of treatment for acne by primary care doctors and the greater availability and use of over the counter preparations for acne.

The TX pacemaker uses a conventional transvenous electrode to sense T-waves of paced ventricular complexes and it adapts the pacing rate to varying physiological demands by responding to changes in the QT or, more correctly, the stimulus artifact-to-T-wave (stimulus-T) interval. This pacing system was assessed in 13 patients. The relation between heart rate and stimulus-T interval and the effect of programming on the performance of this pacemaker were studied on several occasions in each patient. Treadmill exercise performance during TX pacing mode was compared with atrial synchronized ventricular (VAT) and asynchronous ventricular demand (VOO and VVI--70 beats per minute) pacing modes. T-wave sensing problems arose in three patients. In one, this was overcome by reducing the pulse amplitude from 5.0 to 2.5 V. In another patient, spontaneous recovery of T-wave sensing occurred 5 months after pacemaker implantation. T-wave sensing deteriorated with the passage of time in most patients. Satisfactory rate response as assessed by treadmill exercise testing and Holter monitoring was achieved in 12 patients through adjustments of two programmable parameters: the slope that defines the alteration in heart rate in response to a millisecond change in stimulus-T interval and the "sensing window" that is the interval during which T-waves can be sensed and a rate response is possible. Exercise performance was significantly better during rate responsive pacing (TX) mode as compared with VVI pacing but was comparable to that during VAT pacing. The resting heart rate/stimulus-T interval can be described by the following linear regression equation: stimulus-T interval = 466 - 1.68 X paced-rate, r2 = -0.62. This relation, however, was subject to wide inter- and intra-patient variation. Consequently, given identical programmed parameters and exercise protocol, the chronotropic response differed significantly from patient to patient and in the same patient from one occasion to another. Our results show that a physiologically beneficial chronotropic response can be achieved in most patients. However, reprogramming, based on results of exercise tests and Holter monitoring, may be necessary to adjust for changes in T-wave sensing and the heart rate/stimulus-T interval relation and, thus to ensure that the pacemaker continues to function optimally.

Diabetics have an increased risk of developing coronary, cerebral, and peripheral vascular occlusions. The mechanism of the accelerated haemostatic/thrombotic system is not known and studies on 'hyperactive platelets' and the fibrinolytic system in diabetes are inconclusive. We have used the Haemostatometer to assess haemostasis and thrombolysis in diabetic patients. The Haemostatometer, a new instrument, allows quantitative measurement of haemostasis by monitoring the pattern of haemostatic plug formation (HPF) in holes punched through polyethylene tubing through which non-anticoagulated blood flows under standard conditions (1,2). The pattern and speed of blood coagulation subsequent to HPF was also measured as was the spontaneous thrombolysis time (STT) (taken as the time until expulsion of the haemostatic plug from heparinised blood). Blood was sampled from 20 diabetic patients (10 insulin (IDD) and 10 non-insulin dependant (NIDD)) as well as 20 age mathched controls. All values are for mean ± SEM. Both IDD and NIDD had shorter bleeding times (HPF) than did controls: 2.16 ± 0.44 min vs 3.08 ± 1.14 min (p=0.03) (the initial phase of HPF was even more significantly shorter: 0.53 ± 0.06 min vs 1.03 ± 0.14 min (pThe shortened bleeding time (HPF) in diabetics is most probably a manifestation of hyperactive platelets and could contribute to the increased risk of thrombosis seen. In NIDD the prolonged thrombolysis (STT) may be a contributing factor to the development of diabetic angiopathy, which is thought to be prevented by good diabetic control (ie insulin). This suggests that the diabetic vascular endothelium retains some capacity to generate plasminogen activator in response to insulin.(1). Gorog P and Kovacs IB. Haemostasis 16: 337-345, 1986.(2). Gorog P. Angiology 37: 99-105, 1986.

Comprehensive and accurate health information for the consumer has the potential to improve patient care and health outcomes. NZDermNet, the web site of the New Zealand Dermatological Society, was established in 1996. Its consumer health information section includes more than 250 pages of information about skin diseases and their treatment. It has proven popular with health professionals and patients. In 2002 an average of more than 5,000 visitors used the site daily.

A young woman presented with pellagra. Dietary intake of niacin was in excess of recommended guidelines. She had a low body mass index and was taking a number of alternative remedies. Resolution was rapid with oral nicotinic acid and discontinuation of the remedies.

INTRODUCTION: Population screening for melanoma remains controversial. There are no studies demonstrating that population screening increases survival. As prognosis of melanoma is directly related to Breslow thickness, a surrogate marker of survival is thickness of melanoma. The development of several self-referred, whole-body photography and sequential digital dermoscopy imaging services reflects the public’s concern regarding melanoma. AIM: To assess the ability of one of these services to detect melanoma at an early, thin stage. METHODS: Demographic and histological details from 100 melanomas diagnosed through self-referred whole-body photography and sequential digital dermoscopy imaging service compared to those diagnosed through traditional methods from data held by the New Zealand Cancer Registry. RESULTS: There were 52 invasive and 48 in-situ melanomas: 90% superficial spreading type, 6% lentigo-maligna type and 4% nodular on histology. Forty-eight were diagnosed on first visit; the remainder by serial digital dermoscopy. Thirty-five percent of patients reported having had previous primary melanoma. In 60%, patients had been concerned by the lesion, the rest (40%) detected solely by screening. Patients diagnosed by whole-body photography and sequential digital dermoscopy screening had thinner melanomas compared to the Registry data: 69%

A middle aged man suffered with insulin dependent diabetes, autoimmune Addison's disease, myxoedema, and severe ulcerative colitis, for which he had undergone subtotal colectomy with formation of an ileostomy. Granuloma annulare confined to the anterior abdominal wall was diagnosed in 1981. In 1983 an episode of severe colicky pain and excessive working of the ileostomy occurred associated with severe hyperglycaemia and increased irritation of the granuloma annulare. Laparotomy disclosed adhesions and numerous white nodules over bowel, mesentery, and peritoneum histologically identical with the skin lesions. Two further episodes of subacute small bowel obstruction occurred, and a repeat laparotomy showed widespread intra-abdominal granuloma annulare. Visceral granuloma annulare appears not to have been reported before, and in this patient exacerbation of the skin lesion was associated with poor diabetic control.

Summary We describe two patients with hypertrophic osteoarthropathy, spider naevi and elevated 24 h urinary oestrogen excretion associated with an adenocarcinoma. In one of the patients, the spider naevi and the clinical signs of hypertrophic osteoarthropathy disappeared and the 24 h urinary oestrogen returned to normal following removal of the tumour.

Une observation chez une femme de 73 ans, atteinte d'une fracture du poignet, traitee par pose d'une plaque de Vitallium. La reaction allergique est probablement due au cobalt present dans l'alliage

We aimed to assess the association between skin thickness and glycaemic control in children with type 1 diabetes. Forty-five children (51% males) aged 10.5 ± 2.1 years were studied. Thickness of skin layers were determined by ultrasonography, with participants having ultrasound scans of three anatomical regions (abdomen, thigh, and buttocks). Poorer glycaemic control (increasing HbA1c values) was associated with greater thickness of the dermis (p = 0.015), with an estimated thickening of 87 μm with every 1% increase in HbA1c. Our data suggest that dermal changes associated with poorer glycaemic control in adults are also observed in childhood.