Nail anatomy de Berker, David, MD
Clinics in dermatology,
09/2013, Letnik:
31, Številka:
5
Journal Article
Recenzirano
Abstract The nail unit comprises the nail plate, the surrounding soft tissues, and their vasculature and innervation based upon the distal phalanx. The nail plate is a laminated keratinized structure ...lying on the nail matrix (15-25%), the nail bed with its distal onychodermal band (75-85%), and the hyponychium at its free edge. The distal part of the matrix, the lunula characterized by its half-moon shape, can be observed in some digits. The nail plate is embedded by the proximal and lateral folds. From the proximal nail fold, the cuticle (also known as the eponychium), adheres to the superficial surface of the proximal nail plate. The nail unit possesses a complex and abundant vascular network to ensure adequate blood supply. Finally, both the periungual soft tissues and the nail folds are innervated. The shapes, structure, and inter-relationships of these tissues are factors in the way nails present with disease and how we understand and manage those diseases. In particular, an understanding of the surgical anatomy is important for those undertaking diagnostic or curative operations on the nail. With this knowledge, the most appropriate surgery can be planned and the patient can be provided with accurate and clear guidance to enable informed consent.
UK guidelines for managing adults with Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), published by the British Association of Dermatologists (BAD) in 2016, outline a set of audit ...standards.
To audit current management of SJS/TEN in adults against standards in the BAD guidelines.
BAD members were invited to submit data on five consecutive adults with SJS/TEN per department over an 8-week period in 2022.
Thirty-nine (29%) dermatology centres in the UK participated and data for 147 adults with SJS/TEN were collected. Within 24 hours of the diagnosis being made or suspected, the following were documented: SCORTEN for 52% (76/147) of submitted cases, list of medications for 77% (113/147) and timelines for commencement/alterations of medications for 71% (104/147). Initial assessment was documented of the eyes by an ophthalmologist for 48% (71/147) of cases, mouth in 88% (130/147), genital skin in 70% (103/147) and the urinary tract in 63% (93/147). During the first 10 days after a suspected or confirmed diagnosis of SJS/TEN, daily assessments of the mouth were documented in 18% (26/147) of cases, eyes in 8% (12/147) and urinary tract and genital skin in 10% (14/147). Documentation regarding advice on i) avoidance of the culprit drug was present for 58% (76/130) and ii) requesting a MedicAlert® bracelet/amulet in 6% (9/147).
This audit suggests that a clinical review checklist might be needed to enable colleagues to maintain standards outlined in the guidelines, including documentation of SCORTEN, daily assessments of mucosal areas, and advice to avoid culprit drug(s) and request for a MedicAlert® bracelet/amulet.
Erythronychia de Berker, David
Dermatologic therapy,
11/2012, Letnik:
25, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Erythronychia is a term that covers a range of pathological patterns of red discoloration of the subungual tissues. The intensity of the red contrasts with the pale pink of the nail bed or the cream ...color of the lunula. It is typically due to one or more actors that include inflammation, vessel proliferation, and engorgement and focal thinning of the nail plate. This article describes the patterns both within an individual digit and when it extends to multiple digits. These patterns cover diverse inflammatory, infiltrative, and neoplastic diseases, and the correlation between these diagnoses and patterns is discussed alongside means of surgical diagnosis and cure.
Penicillin to prevent recurrent leg cellulitis Thomas, Kim S; Crook, Angela M; Nunn, Andrew J ...
New England journal of medicine/The New England journal of medicine,
05/2013, Letnik:
368, Številka:
18
Journal Article
Recenzirano
Odprti dostop
Cellulitis of the leg is a common bacterial infection of the skin and underlying tissue. We compared prophylactic low-dose penicillin with placebo for the prevention of recurrent cellulitis.
We ...conducted a double-blind, randomized, controlled trial involving patients with two or more episodes of cellulitis of the leg who were recruited in 28 hospitals in the United Kingdom and Ireland. Randomization was performed according to a computer-generated code, and study medications (penicillin 250 mg twice a day or placebo for 12 months) were dispensed by a central pharmacy. The primary outcome was the time to a first recurrence. Participants were followed for up to 3 years. Because the risk of recurrence was not constant over the 3-year period, the primary hypothesis was tested during prophylaxis only.
A total of 274 patients were recruited. Baseline characteristics were similar in the two groups. The median time to a first recurrence of cellulitis was 626 days in the penicillin group and 532 days in the placebo group. During the prophylaxis phase, 30 of 136 participants in the penicillin group (22%) had a recurrence, as compared with 51 of 138 participants in the placebo group (37%) (hazard ratio, 0.55; 95% confidence interval CI, 0.35 to 0.86; P=0.01), yielding a number needed to treat to prevent one recurrent cellulitis episode of 5 (95% CI, 4 to 9). During the no-intervention follow-up period, there was no difference between groups in the rate of a first recurrence (27% in both groups). Overall, participants in the penicillin group had fewer repeat episodes than those in the placebo group (119 vs. 164, P=0.02 for trend). There was no significant between-group difference in the number of participants with adverse events (37 in the penicillin group and 48 in the placebo group, P=0.50).
In patients with recurrent cellulitis of the leg, penicillin was effective in preventing subsequent attacks during prophylaxis, but the protective effect diminished progressively once drug therapy was stopped. (Funded by Action Medical Research; PATCH I Controlled-Trials.com number, ISRCTN34716921.).
Weight-loss after bariatric surgery improves insulin sensitivity, but the underlying molecular mechanism is not clear. To ascertain the effect of bariatric surgery on insulin signalling, we examined ...glucose disposal and Akt activation in morbidly obese volunteers before and after Roux-en-Y gastric bypass surgery (RYGB), and compared this to lean volunteers.
The hyperinsulinaemic euglycaemic clamp, at five infusion rates, was used to determine glucose disposal rates (GDR) in eight morbidly obese (body mass index, BMI=47.3 ± 2.2 kg/m(2)) patients, before and after RYGB, and in eight lean volunteers (BMI=20.7 ± 0.7 kg/m2). Biopsies of brachioradialis muscle, taken at fasting and insulin concentrations that induced half-maximal (GDR50) and maximal (GDR100) GDR in each subject, were used to examine the phosphorylation of Akt-Thr308, Akt-473, and pras40, in vivo biomarkers for Akt activity.
Pre-operatively, insulin-stimulated GDR was lower in the obese compared to the lean individuals (P<0.001). Weight-loss of 29.9 ± 4 kg after surgery significantly improved GDR50 (P=0.004) but not GDR100 (P=0.3). These subjects still remained significantly more insulin resistant than the lean individuals (p<0.001). Weight loss increased insulin-stimulated skeletal muscle Akt-Thr308 and Akt-Ser473 phosphorylation, P=0.02 and P=0.03 respectively (MANCOVA), and Akt activity towards the substrate PRAS40 (P=0.003, MANCOVA), and in contrast to GDR, were fully normalised after the surgery (obese vs lean, P=0.6, P=0.35, P=0.46, respectively).
Our data show that although Akt activity substantially improved after surgery, it did not lead to a full restoration of insulin-stimulated glucose disposal. This suggests that a major defect downstream of, or parallel to, Akt signalling remains after significant weight-loss.
This is the largest study of laboratory‐diagnosed onychomycosis in England for children younger than 17 years. The most common (91.5%) cultured organism in this population was Trichophyton rubrum. ...Candida species were isolated only from fingernails, and the majority were from children younger than 5 years. Continued analysis of fungal pathogens is vital to identify changing trends.
A 4‐year‐old girl presented with sparse, brittle hair on her entire scalp and keratosis pilaris on the nape of her neck. Subtle microscopic and macroscopic diagnostic features presented a challenge ...for physicians. Only repeated, optimized light microscopy revealed the diagnosis of monilethrix, a rare genetic hair shaft disorder with a variable phenotypic expression and inheritance pattern. We provide a short overview of methods that maximize the diagnostic yield in a clinical setting and of light microscopy to reach a rapid and accurate diagnosis in difficult cases. We conclude with essential learning points, including a link to assistance with hair microscopy from a tertiary center.
Retronychia: Proximal ingrowing of the nail plate de Berker, David A., MRCP; Richert, Bertrand, MD, PhD; Duhard, Edith, MD ...
Journal of the American Academy of Dermatology,
06/2008, Letnik:
58, Številka:
6
Journal Article
Recenzirano
Background Proximal nail fold inflammation can be caused by many diseases and has not previously been recognized as a result of posterior embedding of the nail. We describe a new pattern of ingrowth ...that we have termed retronychia (“retro”—Latin for backwards; “onychia”—Greek for nail). The term describes a combination of proximal nail plate ingrowth into the proximal nail fold which is associated with multiple generations of nail plate misaligned beneath the proximal nail. Objective To describe a new pattern of nail ingrowth which causes a specific form of proximal nail fold paronychia. Methods Collective cases were reported to a European Nail Society expert group. Results Persistent proximal nail fold inflammation can result from an episode of trauma that disturbs longitudinal nail growth and results in reverse embedding of the nail plate. This can cause pain, inflammation, and granulation tissue formation, and is typically relieved by avulsion and antiinflammatory treatment. Limitations We cannot demonstrate causality between the proposed precipitants and the clinical features. Conclusion Retroncyhia represents proximal ingrowth of the nail that occurs when the nail embeds backwards into the proximal nail fold. Nail plate avulsion with supplementary medical management is curative.
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