Biomedical subjects
Publications and source records attributed to S M Wilkinson.
A patient with persistent urticaria related to the premenstrual phase of the menstrual cycle is presented. Although systemic administration of progesterone provoked the eruption, we were unable to confirm that there was an immunological reaction to endogenous progesterone or oestrogen. Mechanisms whereby progesterone can augment subclinical types I and IV hypersensitivity reactions are discussed.
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Over the last decade in the United Kingdom there have been changes in the delivery of health care, technical advances in medicine, and rising public expectations for health care, all situations which effect nurses caring for cancer patients. Nursing cancer patients has frequently been described as stressful. In order to limit stress, it is necessary to monitor nurses' perceptions of its causes. This paper focuses on three studies which have identified cancer nurses' stressors between 1986 and 1993. Although no firm conclusions can be drawn from these results there is evidence to suggest sources of stress have changed. Work overload, lack of resources and staff shortages now seem to be major concerns for nurses. Conflicts with health-care workers (in particular doctors) has decreased, possibly due to improvements in pain and symptom control management. Patients' deterioration and death continues to cause nurses concern. Job satisfaction remains high, but it has declined since 1986. In order to maintain quality care for cancer patients it will be necessary to continue to provide good staff support, stress management and education in cancer care.
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To evaluate which corticosteroids are most useful for the detection of corticosteroid contact allergy in our population, 2123 patients were patch tested with a series of 6 corticosteroids, in parallel with a standard series, and other relevant investigations. 127 patients (5.98%) were allergic to one or more corticosteroids; 96 to tixocortol pivalate, 51 to hydrocortisone butyrate, 47 to budesonide, 11 to betamethasone valerate, 11 to clobetasone butyrate and 8 to clobetasol propionate. 511 patients with negative patch tests to the limited corticosteroid series were in addition tested to a further 12 corticosteroids; only 1 of these patients reacted to a corticosteroid. A combination of tixocortol pivalate and budesonide thus detected 91.3% of corticosteroid-allergic subjects. We believe that both these allergens should be included in the standard series and that there may be a case for extending this further.
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Nursing cancer patients has been identified as a particularly stressful occupation. However, most studies have been descriptive, and few have measured levels of stress. A study was set up to identify cancer nurses' general proneness to stress and characteristics of nurses who experience the most stress. Sixty-five registered nurses working on six wards in two hospitals identified the two most stressful incidents over the last 3 months and completed the Spielberger State-Trait Anxiety Inventory over an 8-week period. The state anxiety subscale was completed six times, the trait anxiety once. Data were analysed using SPSXX. Statistical tests included analysis of variance and the Kendall tau correlation coefficient. The nurses' general anxiety proneness was no different from the normal values for working females, and their overall state anxiety levels were only significantly higher than the normal values for working women under examination conditions on the first time of testing. Newly qualified nurses had a tendency to be more anxious compared with sisters and enrolled nurses. Most nurses reported high levels of job satisfaction. However, there was a statistically significant difference in nurses' anxiety levels between wards. The results suggest overall that the nurses in this sample were not experiencing high levels of stress. They were perhaps only stressfully satisfied.
Following publication of treatment guidelines for patients with psoriasis, a six-centre audit was undertaken to assess current therapeutic practice for two second-line treatments, PUVA and methotrexate. The audit consisted of random sampling of casenotes by external auditors from a paired dermatology department, and assessment by questionnaire. One hundred and eight PUVA and 118 methotrexate casenotes were audited. The commonest indications for treatment were: (a) failure of tropical therapy--PUVA (mean 81% of casenotes), methotrexate (84%); (b) repeated hospital admissions--PUVA (16%), methotrexate (25%). For both PUVA and methotrexate, some aspects of treatment were well documented: PUVA--psoralen dosage (91%), response to PUVA (89%), cumulative lifetime UVA dosage (81%); methotrexate--pretreatment assessment of full blood count (91%), urea and electrolytes (85%), liver function tests (84%). For other aspects documentation was less complete: PUVA--no documentation of presence/absence of skin cancer history (66%), note of photoactive drugs (32%); methotrexate--concurrent medication (69%), history of presence/absence of liver disease (36%). Another aspect which was poorly documented in both PUVA and methotrexate notes was whether advice on contraception/fertility had been given. There was no indication in 29 of 32 casenotes of females of child-bearing age receiving PUVA, and 52 of 63 case notes of relevant patients on methotrexate. This project has demonstrated that formal, multicentre audit based on published guidelines is a practical proposition.
Seven of 25 patients with cutaneous delayed-type hypersensitivity to hydrocortisone had an immediate reaction following the intradermal injection of hydrocortisone sodium succinate. Using an ELISA method, we found that these patients had significantly increased levels of IgG antibodies to hydrocortisone when compared with normal blood donors (P < 0.005) and nickel-allergic patients (P < 0.05). We suggest that these patients are at risk of developing type III and possibly type I reactions following the systemic administration of hydrocortisone and that, if needed, an alternative systemic corticosteroid should be used, for example betamethasone or dexamethasone.
Contact hypersensitivity from topical corticosteroids is becoming increasingly recognized; it is present in 2-5% of the patients attending contact dermatitis clinics. The use of a corticosteroid series containing tixocortal pivalate 1% (petrolatum), to detect hypersensitivity to hydrocortisone, and other steroids 1% (ethanol), depending on local corticosteroid usage, detects the majority of cases of corticosteroid hypersensitivity. In selected cases, the use of intradermal tests further improves the diagnosis of corticosteroid hypersensitivity. Corticosteroid hypersensitivity occurs most frequently among patients with stasis dermatitis. However, corticosteroid hypersensitivity is also common in other types of dermatitis, occurring as frequently as hypersensitivity to several allergens (e.g. wool alcohols and colophony) in the European standard battery. Although hypersensitivity has mainly been reported with corticosteroids applied to the skin, reactions may also occur on mucosal surfaces, following systemic administration and with sex steroids.
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