The art of the artifact

A 10-year old girl and her mother visited four dermatologists in several months because of erosions in her face, suspected for dermatitis artefacta. However, when previously confronted the patient denied this diagnosis. Immunofluorescence investigations were negative. After building a trusted physician-patient relationship and empathically confronting the mother,the mother herself was able to provide her daughter a narrow escape, which resulted in complete remission of her condition. Dermatitis artefacta is a spot diagnosis, however the treatment is challenging for both the physician and the patient. A trusting physician-patient relation is crucial and providing verbal and non-verbal support is essential. One way of doing this is asking the patient to keep a diary. In addition every patient deserves a thorough but compact investigation. Once internal causes have been excluded and a trustful relationship has been established one can precede to a narrow escape or confrontation. In this article we provide practical tricks on how to approach a patient with dermatitis artefacta.</p

Quality of life, treatment satisfaction, and adherence to treatment in patients with vesicular hand eczema:A cross-sectional study

Background Recurrent vesicular hand eczema frequently has a chronic course and needs long-term treatment. Objectives To evaluate health-related quality of life (HRQoL), treatment satisfaction, and adherence in patients with vesicular hand eczema. Methods Patients using one main treatment for at least three months were included. Data on HRQoL (Quality of Life in Hand Eczema Questionnaire [QOLHEQ]), treatment satisfaction (Treatment Satisfaction Questionnaire for Medication, version II), and treatment adherence (4-item Morisky Medication Adherence Scale) were collected. Univariate and multivariate regression analysis were used to predict variables associated with HRQoL. Results HRQoL was moderately impaired, with the highest impact in the QOLHEQ subdomain symptoms. Female sex, more severe hand eczema, and lower treatment satisfaction were associated with more impairment in HRQoL. Patients with severe/very severe hand eczema had significant lower "global satisfaction" scores compared with the other severity groups. The "global satisfaction" and treatment adherence in patients using systemic treatment were significantly higher compared with those with only topical treatment. Conclusions In patients with vesicular hand eczema disease severity affects both HRQoL and treatment satisfaction. Systemic treatment of severe hand eczema could improve the severity and as a result also HRQoL, treatment satisfaction, and medication adherence

Herbicide resistance-endowing ACCase gene mutations in hexaploid wild oat (Avena fatua): insights into resistance evolution in a hexaploid species

Many herbicide-resistant weed species are polyploids, but far too little about the evolution of resistance mutations in polyploids is understood. Hexaploid wild oat (Avena fatua) is a global crop weed and many populations have evolved herbicide resistance. We studied plastidic acetyl-coenzyme A carboxylase (ACCase)-inhibiting herbicide resistance in hexaploid wild oat and revealed that resistant individuals can express one, two or three different plastidic ACCase gene resistance mutations (Ile-1781-Leu, Asp-2078-Gly and Cys-2088-Arg). Using ACCase resistance mutations as molecular markers, combined with genetic, molecular and biochemical approaches, we found in individual resistant wild-oat plants that (1) up to three unlinked ACCase gene loci assort independently following Mendelian laws for disomic inheritance, (2) all three of these homoeologous ACCase genes were transcribed, with each able to carry its own mutation and (3) in a hexaploid background, each individual ACCase resistance mutation confers relatively low-level herbicide resistance, in contrast to high-level resistance conferred by the same mutations in unrelated diploid weed species of the Poaceae (grass) family. Low resistance conferred by individual ACCase resistance mutations is likely due to a dilution effect by susceptible ACCase expressed by homoeologs in hexaploid wild oat and/or differential expression of homoeologous ACCase gene copies. Thus, polyploidy in hexaploid wild oat may slow resistance evolution. Evidence of coexisting non-target-site resistance mechanisms among wild-oat populations was also revealed. In all, these results demonstrate that herbicide resistance and its evolution can be more complex in hexaploid wild oat than in unrelated diploid grass weeds. Our data provide a starting point for the daunting task of understanding resistance evolution in polyploids

Evidence-Based Management of Hand Eczema

Hand eczema is a common skin disease with a wide variation in morphology and a complex etiology based on endogenous and exogenous factors.The diagnosis of hand eczema is based on patient history, exposure assessment, physical examination, and the results of patch testing. Management of hand eczema starts with education of the patient on the etiology of the disease, and the needed changes in behavior regarding skin care and preventive measures, and avoidance of relevant exposure factors. In many cases, medical treatment is needed for successful management of the disease; use of medication can only be successful with proper education and avoidance of relevant exposure

Mechanism and Enantioselectivity in Palladium-Catalyzed Conjugate Addition of Arylboronic Acids to β‑Substituted Cyclic Enones: Insights from Computation and Experiment

Enantioselective conjugate additions of arylboronic acids to β-substituted cyclic enones have been previously reported from our laboratories. Air- and moisture-tolerant conditions were achieved with a catalyst derived in situ from palladium(II) trifluoroacetate and the chiral ligand (S)-t-BuPyOx. We now report a combined experimental and computational investigation on the mechanism, the nature of the active catalyst, the origins of the enantioselectivity, and the stereoelectronic effects of the ligand and the substrates of this transformation. Enantioselectivity is controlled primarily by steric repulsions between the t-Bu group of the chiral ligand and the α-methylene hydrogens of the enone substrate in the enantiodetermining carbopalladation step. Computations indicate that the reaction occurs via formation of a cationic arylpalladium(II) species, and subsequent carbopalladation of the enone olefin forms the key carbon–carbon bond. Studies of nonlinear effects and stoichiometric and catalytic reactions of isolated (PyOx)Pd(Ph)I complexes show that a monomeric arylpalladium–ligand complex is the active species in the selectivity-determining step. The addition of water and ammonium hexafluorophosphate synergistically increases the rate of the reaction, corroborating the hypothesis that a cationic palladium species is involved in the reaction pathway. These additives also allow the reaction to be performed at 40 °C and facilitate an expanded substrate scope

De kunst van het artefact

A 10-year old girl and her mother visited four dermatologists in several months because of erosions in her face, suspected for dermatitis artefacta. However, when previously confronted the patient denied this diagnosis. Immunofluorescence investigations were negative. After building a trusted physician-patient relationship and empathically confronting the mother,the mother herself was able to provide her daughter a narrow escape, which resulted in complete remission of her condition. Dermatitis artefacta is a spot diagnosis, however the treatment is challenging for both the physician and the patient. A trusting physician-patient relation is crucial and providing verbal and non-verbal support is essential. One way of doing this is asking the patient to keep a diary. In addition every patient deserves a thorough but compact investigation. Once internal causes have been excluded and a trustful relationship has been established one can precede to a narrow escape or confrontation. In this article we provide practical tricks on how to approach a patient with dermatitis artefacta

Patch test results of hand eczema patients:relation to clinical types

BACKGROUND: Allergic contact dermatitis is a well-known cause of hand eczema, although the influence of contact allergens on different clinical types of hand eczema remains still unclear. OBJECTIVE: To identify most common positive tested allergens among hand eczema patients and to define the relation between specific contact allergies and clinical types of hand eczema according to the guidelines of the Danish Contact Dermatitis Group (DCDG). METHODS: We included 1571 hand eczema subjects who were patch tested from 1 January 2002 to 31 December 2013. They were retrospectively classified according to the guidelines of the DCDG into six clinical types: recurrent vesicular hand eczema, chronic fissured hand eczema, hyperkeratotic palmar eczema, pulpitis, interdigital eczema and nummular hand eczema according to a newly developed flow chart. The prevalence of sensitizations and association with clinical type, atopic dermatitis, age and gender were studied. RESULTS: A total of 1395 subjects were classified into one of the six clinical types. The most frequently found clinical types were recurrent vesicular hand eczema (39.7%) and chronic fissured hand eczema (35.5%). Subjects with recurrent vesicular hand eczema were significantly more likely to have a contact allergy (OR 1.55), whereas subjects with hyperkeratotic palmar eczema and pulpitis were less likely to be sensitized (OR 0.51; OR 0.44). Overall, metals (nickel sulphate, cobalt chloride), fragrances and preservatives (methylchloroisothiazoline/methylisothiazoline, methyldibromoglutaronitrile) were the most frequent sensitizers in patients with hand eczema. This did not deviate in the different clinical types, although subjects with recurrent vesicular hand eczema were significantly more frequently sensitized to nickel sulphate and other allergens compared to other clinical types of hand eczema. CONCLUSION: In the diagnostic work up of hand eczema subjects with recurrent vesicular hand eczema should be patch tested, especially women of older age, although the need for patch testing in males with hyperkeratotic palmar eczema might be less imperative