Adult epiglottitis is a relatively rare but potentially lethal disease. It seems to be increasing in incidence in other countries. The objective of this study was to examine the common presentations and clinical course of adult epiglottitis in Hong Kong. Retrospective review of 80 consecutive cases of adult epiglottitis admitted between 2000 and 2005. A rising trend in the incidence of adult epiglottitis was observed. The mean age (SD) was 49 years (15.7) and the male-to-female ratio was 2.5:1. Disease presentation was nonspecific and sore throat was the most common symptom. All patients were admitted to hospital; 47 (59%) patients were admitted to the intensive care unit (ICU) and 31 (39%) had provision of an artificial airway. Mean (SD) length of stay in ICU and hospital was 1.9 (2.2) and 6.3 (2.9) days, respectively. Six patients (7.5%) were complicated by epiglottic abscess formation. No deaths occurred in this series. Patients who required airway intervention had a higher ICU admission rate and a higher bacterial identification rate. Flexible laryngoscopy was more sensitive than lateral neck radiography in diagnosing epiglottitis (100 vs. 81.4%). The laryngoscopic finding of a narrowed airway was strongly related to the requirement for airway intervention (odds ratio=23.7, 95% confidence interval=4.2-132.6, P<0.001). A high index of suspicion is required for making the diagnosis of adult epiglottitis. Proper airway assessment and close monitoring are of the utmost importance in patient management. Flexible laryngoscopy is the key investigation of choice in the emergency department.

Dermatological surgery performed in an outpatient setting is common and generally perceived as safe, but the potential for serious adverse events does exist. Furthermore, there is a current lack of guidelines regarding preoperative and intraoperative monitoring of such patients. This is a retrospective study that involved a written questionnaire sent to current practising New Zealand dermatologists. Aspects investigated include their practice relating to preoperative assessments and intraoperative monitoring during standard dermatological procedures, and the resulting rate of adverse events. We found that most respondents performed dermatological procedures in dedicated theatres in outpatient clinics. The majority of survey respondents would screen for and optimize risk factors prior to surgery. Most respondents would not record vital sign measurements either preoperatively or intraoperatively. Antibiotic prophylaxis was generally only prescribed if clinically indicated, and anticoagulation and antiplatelet therapies were in the majority of cases never withheld prior to surgery. Infection (<3.5%) and bleeding (<2%) were the most common postoperative complications, with other serious adverse events being extremely rare. Although dermatological surgery continues to be safely performed in the outpatient setting, attempts should still be made to identify patients who are at higher risk for surgery and extra precautions should be applied to these selected patients.

meticulous physical examinations and taking a detailed history were essential in considering metastatic disease, which was confirmed by performing a histological examination. We have described an uncommon case of digital cutaneous metastasis, which could easily have been overlooked. We emphasize the importance of maintaining a high index of suspicion of neoplastic processes for lesions associated with cases of atypical clinical histories or morphologies. References1 Sur YJ, Kang YK, Bahk WJ et al. Metastatic malignant tumour in the hand. J Plast Surg Hand Surg 2011; 45:90-5. 2 Gottlieb JA, Schermer DR. Cutaneous metastases from carcinoma of the colon. JAMA 1970; 213:2083. 3 Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients. J Am Acad Dermatol 1993; 29:228-36. 4 Wu CY, Gao HW, Huang WH, Chao CM. Infection-like acral cutaneous metastasis as the presenting sign of an occult breast cancer. Clin Exp Dermatol 2009; 34:e409-10. 5 Flynn CJ, Danjoux C, Wong J et al. Two cases of acrometastasis to the hands and review of the literature. Curr Oncol 2008; 15:51-8.

A 33-year-old woman presented with a 4-day history of fever and abdominal pain, 7 days after undergoing a cesarean section. She had diffuse erythroderma, and the blood pressure was 85/48 mm Hg. A workup revealed elevated creatinine and liver-enzyme levels, and specimens of urine and specimens from the vagina were cultured and grew Staphylococcus aureus. Her condition worsened over the next day, with acute respiratory distress; subsequently, desquamation of her hands occurred. A diagnosis of staphylococcal toxic shock syndrome was made. Desquamation is characteristic of staphylococcal toxic shock syndrome, typically occurring 1 to 2 weeks after the onset of illness and typically involving the palms and soles. Staphylococcal toxic shock syndrome is associated with a wide variety of clinical settings, such as menstruation, postpartum and postsurgical states, barrier contraceptive use, staphylococcal pneumonia, sinusitis, and superinfected skin lesions. With supportive care and the administration of floxacillin, the patient recovered completely. The skin changes resolved within 4 weeks after the onset of illness.