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A 29-year-old Caucasian woman presented with a 3-month history of bilateral lower limb swelling with painful erythematous nodules on shins without ulceration. She had been taking minocycline for acne vulgaris for 3 years. Biochemical investigations showed deranged liver function test with positive ANA and mixed antinuclear factor (ANF) pattern. A skin biopsy was in keeping with a diagnosis of nodular vasculitis. Her skin lesions and liver function test improved within 3 months of stopping the minocycline treatment. This case report raises the awareness that minocycline could be a potential cause of nodular vasculitis, patients on minocycline should be closely monitored and minocycline should ideally not be prescribed for more than 12 weeks, given the possible adverse effects., (© 2023 Australasian College of Dermatologists.)

Thrombosis of the palmar digital veins is relatively rare, typically reported in women aged 35-65 years and most commonly occurring on the fourth digit. Clinical presentation varies and the lesion can present on the fingers or the palms of the hands. Diagnosis may be suspected clinically and confirmed on histology and radiologically. The condition can be managed conservatively or surgically. A 58-year-old woman presented with a 3-month history of a tender, skin-coloured nodule on her right palm. This was surgically excised, and the histopathological diagnosis was a thrombosed varix. As no underlying medical issues were raised on further testing, it was thought that her thrombosed varix was likely secondary to repeated trivial mechanical trauma, given that she was a housewife. A literature review yielded 36 cases of thrombosed varix, including our case. Most cases (85.3%) occurred in females, and the mean age of patients was 51.67 years, with two-thirds of patients between 35 and 65 years of age. The fourth digit and the proximal interphalangeal joint were the most commonly affected sites, respectively. Although rare, doctors should consider the possibility of a thrombosed varix when presented with tender and raised nodules on the palms or fingers., Learning Points: Thrombosis of the palmar digital veins is rare but can occur secondary to mechanical trauma and hypercoagulable states.Physicians should consider the possibility of a thrombosed varix when presented with a tender, raised and firm nodule on the hand or fingers, especially since some cases may be associated with hypercoagulable states which can have more serious sequelae., Competing Interests: Conflicts of Interests: The authors declare there are no competing interests., (© EFIM 2022.)

A young man was treated in hospital for sepsis, disseminated intravascular coagulation and multi-organ failure. He was a regular intranasal cocaine user up to 1 day prior to symptom onset. Clinical examination revealed extensive retiform purpura affecting both his lower limbs. Skin biopsy revealed widespread thrombosis in the small- and medium-sized vessels of the mid dermis and the subcutaneous fat with surrounding leucocytoclasis. There was also extensive ischaemic necrosis of the upper reticular and papillary dermis and focal ischaemic necrosis of the epidermis. These findings were in keeping with a thrombotic vasculopathy with associated cutaneous ischaemic necrosis, likely associated with levamisole-adulterated cocaine (LAC). An autoimmune screen showed extremely raised levels of anti-B2-glycoprotein IgM, IgG and anti-cardiolipin IgG antibodies, usually seen in antiphospholipid syndrome (APS). The literature describes how APS could be secondary to various underlying conditions, including LAC, and that levamisole toxicity may mimic APS and hence be missed., Learning Points: Levamisole is a common adulterant found in cocaine; the resultant toxicity can present with cutaneous manifestations, namely retiform purpura and skin necrosis, similar to antiphospholipid syndrome.Patients presenting with such features should be asked about illicit drug use, specifically cocaine, and investigated by screening urine for drugs of abuse and serum antihuman elastase antibody when possible., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interest, (© EFIM 2022.)

Objective: The purpose of this report is to provide insight from pediatric stakeholders with a shared desire to facilitate a revision of the current United States regulatory pathways for the development of pediatric healthcare devices., Methods: On August 5, 2020, a group of innovators, engineers, professors and clinicians met to discuss challenges and opportunities for the development of new medical devices for pediatric health and the importance of creating a regulatory environment that encourages and accelerates the research and development of such devices. On January 6, 2021, this group joined regulatory experts at a follow-up meeting., Results: One of the primary issues identified was the need to present decision-makers with opportunities that change the return-on-investment balance between adult and pediatric devices to promote investment in pediatric devices., Discussion/conclusion: Several proposed strategies were discussed, and these strategies can be divided into two broad categories: 1. Removal of real and perceived barriers to pediatric device innovation; 2. Increasing incentives for pediatric device innovation.

A 91-year-old Caucasian man on warfarin for atrial fibrillation presented in view of sudden-onset haemoptysis with fresh bleeding with clots immediately after having eaten a piping-hot traditional cheesecake (pastizz) and burning the soft-palate of his mouth. The haemoptysis had resolved by the time that the patient had arrived to hospital. On examination, a 2 cm by 2 cm dark red, solitary mass could be seen just anterior to the uvula. This was not causing any pain or discomfort to the patient. Blood results were mostly unremarkable except for a raised international normalised ratio (INR) of 3.53. The patient was administered 5 mg vitamin K orally in attempt to lower the INR level and warfarin was subsequently omitted for 7 days. He was also prescribed oral steroids on discharge. The lesion resolved in 7 days and warfarin was restarted then with no further consequences., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: At least 50% of patients with heart failure (HF) may have sleep-disordered breathing (SDB). Overnight in-hospital polysomnography (PSG) is considered the gold standard for diagnosis, but a lack of access to such testing contributes to under-diagnosis of SDB. Therefore, there is a need for simple and reliable validated methods to aid diagnosis in patients with HF. The aim of this study was to investigate the accuracy of a non-contact type IV screening device, SleepMinder TM (SM), compared with in-hospital PSG for detecting SDB in patients with HF., Methods and Results: The study included 75 adult patients with systolic HF and suspected SDB who underwent simultaneous PSG and SM recordings. An algorithm was developed from the SM signals, using digital signal processing and pattern recognition techniques to calculate the SM apnoea-hypopnoea index (AHI). This was then compared with expert-scored PSG AHI . The SM algorithm had 70% sensitivity and 89% specificity for identifying patients with clinically significant SDB (AHI ≥ 15/h). At this threshold, it had a positive likelihood ratio of 6.3 and a negative likelihood ratio of 0.16. The overall accuracy of the SM AHI algorithm was 85.8% as shown by the area under a receiver operator characteristic curve. The mean AHI with SM was 3.8/h (95% confidence interval 0.5-7.1) lower than that with PSG., Conclusions: The accuracy of the non-contact type IV screening device SM is good for clinically significant SDB in patients with systolic HF and could be considered as a simple first step in the diagnostic pathway., (© 2016 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Objective: Hospitalization due to heart failure (HF) continues to be a major clinical and economic challenge. To reduce hospitalization, this paper proposes a novel home telemonitoring system for an early warning of acute decompensation in patients with chronic stable New York Heart Association class II-IV HF., Methods: It is based on deriving nocturnal respiratory related time series using a noncontact radio-wave bio-motion sensor. The system generates an alert when there is a change in the underlying probability distribution of the time series which can be regarded as a surrogate marker of patient stability., Results: The system's performance is evaluated using dual-site longitudinal data collected from 104 HF patients over 12-24 months. The system reported an average sensitivity of 0.62 to detect a change during an episode of acute decompensation and an average specificity of 0.67 on the blind validation set, when the frequency of alert was four weeks. The system also performed well to predict acute decompensation with an average sensitivity of 0.55 and specificity of 0.73 on the validation set, where an event window was defined as three weeks preceding an event., Conclusion: These results demonstrate that the design and implementation of such a system is a positive step toward developing noncontact systems capable of preventing acute decompensation, reducing readmissions to hospital and ensuring better quality of life for HF patients.

With the continuing development of new pacing and shock modalities, implantable cardioverter defibrillators must be able to recognize an increasingly wider range of arrhythmias so that therapy is delivered in an optimal way. Current rate-based systems can no longer meet this need. It is, therefore, necessary to develop new techniques that consider waveform morphology in addition to heart rate. Any developments, however, must be compatible with the strict power and space constraints imposed by implantable devices. Artificial neural networks offer a potentially viable way of meeting these objectives. In this article an artificial neural network based approach to the classification of arrhythmias from the ventricular intracardiac electrogram is described. It performs its classification on a set of easily extracted features that characterize waveform morphology and heart rate. Simulations showed that the artificial neural network performed better than a rate-based scheme similar to those used in some commercial devices.