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Background. Mechanically ventilated critically ill patients need the opportunity to communicate their physical and psychosocial concerns to nurses. However, these patients face the unique problem of lacking even the opportunity to communicate. Aims. The study aimed to describe the characteristics of communication opportunities for critically ill mechanically ventilated patients. Methods. The study was designed as a video-based descriptive observational study. Participants included seven mechanically ventilated critically ill patients at the intensive care unit, coronary care unit, or high care unit who were conscious and seven registered nurses (seven pairs). Videos were recorded continuously from 8 am to 4 pm, and the footage was then descriptively analyzed. Data collection took place between July 2019 and June 2020. Results. The total recording time was 668.0 minutes. Of these 668.0 minutes, nurses stayed in the Conversation Area of the Patient for 279.6 minutes, and of these 279.6 minutes, two-way face-to-face communication between nurse and patient occurred for 78.0 minutes. Of these 78.0 minutes, communications were started by nurses for 47.2 minutes (174 scenes) and by patients for 24.2 minutes (36 scenes). The patient-started two-way communication scenes included 37 instances of Patient-Intentional-Action that triggered the start of communication. Actions using the upper limbs were observed in 20 instances and represented the most frequently used body part. The head/face, lower limbs, or trunk were also used in some of the actions. Gestures were the most commonly used action type (14 instances). Other types included lip movement, grimace, leg flex/extension, and cough. Conclusions. We found that nurses tended to start communication more frequently than patients did and that patients demonstrated Patient-Intentional-Action with a variety of actions using various body parts. Communication opportunities for patients were created when nurses took the initiative to start communication or when they noticed and responded to the Patient-Intentional-Action. Our findings demonstrate that nurses need to recognize and always respond to Patient-Intentional-Action and to take the initiative in communicating rather than waiting for the patient to do so.

Cutaneous manifestations associated with myelodysplastic syndromes (MDS) are uncommon and can occur as specific or nonspecific lesions. Recognizing these cutaneous manifestations is important as they can precede blood or bone marrow transformation to leukemia. Granulomatous reactions have rarely been described as nonspecific lesions of MDS. These rare cases histologically resembled granuloma annulare, sarcoid, and a generalized dermal interstitial granulomatous dermatitis (IGD) which were not associated with leukemic infiltration. The authors report an interesting case of an IGD-like eruption evolving over the course of MDS with eventual progression to systemic leukemia. IGD is an inflammatory reaction that refers to a varied spectrum of histologic patterns and is associated with a variety of systemic illnesses and hypersensitivity reactions, including lymphoma and leukemia. In patients with MDS, surveillance for leukemia is a critical component of their follow-up care. Normally, this surveillance occurs through serial peripheral blood smears and bone marrow studies. IGD-like eruptions are a cutaneous reaction pattern that may serve as an additional clinical indicator of leukemic progression in patients with MDS. Although primarily a reactive pattern, this entity can rarely harbor leukemic blasts.

Dermatitis herpetiformis (DH) is an immune-mediated cutaneous disease occasionally associated with celiac disease, but rarely associated with systemic lupus erythematosus (SLE). The combination of DH and SLE is immunologically mediated and suggests a relationship between the two conditions. We describe a woman with DH and SLE with a novel HLA phenotype., (Copyright © 2009 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

The term Richter syndrome (RS) describes the transformation of chronic lymphocytic leukemia into a high-grade lymphoma. RS occurs in 3% to 10% of chronic lymphocytic leukemia cases, and its onset is often characterized by the abrupt development of systemic symptoms (eg, fever in the absence of infection, night sweats, and weight loss), progressive lymphadenopathy, and hepatosplenomegaly. RS frequently arises in the lymph nodes or bone marrow, and rarely presents with extranodal involvement, which includes the gastrointestinal tract, eye, testis, central nervous system, lung, kidney, and skin. We review the literature regarding the clinical course and treatment of RS, present a patient with primary cutaneous RS, and discuss the prognostic implications.

A 72-year-old man developed a primary cutaneous cryptococcal skin infection on the right forearm, which was responsive to oral fluconazole 400 mg per day. After 16 weeks of treatment, the skin lesion completely resolved without any residual scarring.

Various factors contribute to the development of porphyria cutanea tarda (PCT). In this case report, we describe a patient with hepatitis C infection and chronic renal failure. The individual mechanisms, which promote cutaneous disease, are discussed. Finally, we propose that each factor may have an additive effect in prolonging the skin lesions of PCT.

GBCCs are rare, tend to be multiple, often develop in sun-protected areas, usually occur in Caucasians without a family history of skin cancer, and have no clear association with immunological or psychiatric factors. Fear may be the underlying factor leading to neglect and chronicity of the tumors.

A 49-year-old immunosuppressed heart transplant recipient developed a superficial and subcutaneous granulomatous infection caused by Coniothyrium. The patient responded to a combination of surgical excision and antifungal agents. We review phaeohyphomycotic infections including this second report of a Coniothyrium infection.

Zabon (Citrus maxima) is a large citrus fruit belonging to the Rutaceae family and containing a variety of psoralens including 5-methoxypsoralen. We describe the first case reports of a phytophotodermatitis caused by zabon.

Septic embolization arising from infected pseudoaneurysms following percutaneous transluminal coronary angioplasty (PTCA) constitutes a distinct clinical and histopathologic entity. Pseudoaneurysms are a potential complication of both cardiac catheterization and PTCA. Repeated or prolonged catheterization increases the risk of bacterial seeding of these sites, resulting in septic embolization. Characteristic clinical features include fever within 2 to 5 days, unilateral embolic disease, and Staphylococcus aureus septicemia. Culture and examination of biopsy specimens of the embolic lesions typically demonstrate gram-positive microorganisms. We describe 2 patients presenting with ipsilateral palpable purpura, petechiae, and livedo reticularis caused by septic emboli from infected pseudoaneurysms. The recommended treatment includes administration of appropriate systemic antibiotics and surgical resection of the infected pseudoaneurysm. Both cholesterol and septic emboli should be considered in the differential diagnosis of ipsilateral embolic disease induced by invasive vascular procedures.

A case of perforating porokeratosis of Mibelli is presented. Clinically, the lesion was typical for porokeratosis of Mibelli. Nothing suggested a perforating disorder. Histologic examination revealed a well-developed cornoid lamella, and other histologic features typical of porokeratosis. A breach in the basal cell layer beneath the cornoid lamella resulted in transepithelial elimination of an amorphous material which on special stains proved to be collagen.

The sixth case of an allergic contact gingivostomatitis to gold crowns previously misdiagnosed as erosive lichen planus is reported. Patch tests to gold chloride (0.5%) and 0.05 cm3 intradermal gold sodium thiomalate (Myochrysine 50 mg/cm3) were positive at 48-72 h. Histopathology of the allergic contact gingivitis revealed a pseudolymphomatous inflammatory dermal reaction with a dense lymphohistiocytic and plasma cell infiltrate. Removal of the gold crowns resulted in a gradual resolution of the gingivostomatitis in 4-6 months, and the patient has remained free of clinical disease for over 3 years. A review of the reported cases of allergic gingivostomatitis to gold crowns revealed that each patient clinically presented with an erosive and ulcerative inflammatory response was usually associated with a clinical history of gold jewelry intolerance.

Five cases of Mycobacterium marinum skin infections were successfully treated with 2 gm of tetracycline hydrochloride daily for periods from four to 12 weeks. In each case, the isolated M marinum was sensitive in vitro to tetracycline at levels from 25 to 50 microgram/ml. Tetracycline is recommended as treatment for extensive or sporotrichoid M marinum infections.

Two male patients, each of whom had one or more risk factors for human immunodeficiency virus, subsequently developed findings of porphyria cutanea tarda preceding diagnosis of acquired immune deficiency syndrome (AIDS).

A case of intradermal BCG vaccination was complicated by a lupus-like tuberculosis cutis progressive for over 30 years. The patient had been vaccinated twice with BCG in the affected site. A review of other BCG vaccine-induced cases of lupus vulgaris indicates that the incidence of this complication is markedly increased following multiple BCG vaccinations, but is rare following a single BCG vaccination. In our patient a skin biopsy specimen was characteristic for lupus vulgaris. Acid-fast stains from the tissue and cultures from the affected site were negative. The patient was successfully treated with rifampin.

A young woman had a history of subcutaneous nodules, migratory arthralgia, myalgia, and lymphadenopathy. Histopathologic characteristics of the nodular subcutaneous lesion showed a massive lobular panniculitis characteristic of lupus erythematosus (LE) panniculitis. The diagnosis of LE panniculitis was established by demonstration of a positive linear basement membrane zone stain of the involved skin by direct immunofluorescence microscopy. Initial serologic findings showed negative antinuclear antibody (ANA) and anti-DNA antibody test results and a negative LE cell preparation. Subsequently, a positive ANA test result developed. The test result for extractable nuclear antigen was strongly positive, although initial test results for antibodies to ribonucleoprotein and Sm antigens were negative.