Insulin sensitivity and resistin expression in nitric oxide-deficient rats

AIMS/HYPOTHESIS

The aim of this study was to investigate changes in insulin sensitivity and expression of the gene encoding resistin (Retn) in adipocytes from long-term nitric oxide (NO)-deficient rats.

METHODS

Male Sprague-Dawley rats received [Formula: see text]-nitro-L: -arginine methyl ester (L-NAME 0.5 mg/ml) in their drinking water for 4 weeks, while control rats received plain drinking water. During the experimental period, changes in plasma glucose, insulin and C-peptide levels were measured. After administration of L-NAME for 4 weeks, insulin sensitivity was evaluated in vivo and in vitro. An insulin binding assay was also performed to determine the number and binding affinity of insulin receptors in adipocytes. Adipocyte Retn mRNA levels were examined using northern blotting.

RESULTS

Successful induction of NO deficiency was demonstrated by an increase in systemic blood pressure. No difference in plasma glucose levels was found between the two groups. Compared with the control rats, plasma insulin and C-peptide levels were significantly decreased in the NO-deficient rats, and insulin sensitivity was significantly increased. Insulin-stimulated glucose uptake and insulin binding capacity, but not binding affinity, were significantly increased in adipocytes isolated from NO-deficient rats. In addition, adipocyte Retn mRNA levels, but not plasma resistin levels, were significantly decreased in NO-deficient rats, and the Retn mRNA levels were negatively correlated with insulin sensitivity.

CONCLUSIONS/INTERPRETATION

Insulin sensitivity was increased in NO-deficient rats and this was associated with insulin binding capacity and downregulated Retn expression. These findings suggest that NO plays a regulatory role in metabolism. Dysregulation of NO production may result in the development of metabolic disorders.

Temporal differences in relative phasing of gait initiation and first step length in patients with cervical and lumbosacral spinal cord injuries

STUDY DESIGN

Comparison group design.

OBJECTIVE

To compare the temporal distance factors during gait initiation between patients with incomplete cervical spinal cord injury, incomplete lumbosacral spinal lesion, and unimpaired control adults.

SETTING

Human performance and movement analysis laboratory, Taiwan.

PARTICIPANTS

Five patients with an incomplete cervical spinal cord injury (Group 1), five patients with an incomplete lumbosacral spinal lesion (Group 2) and nine unimpaired control adults (Group 3).

METHODS

Subjects underwent a three-dimensional gait analysis. The total gait initiation period, reaction time, each relative phasing of gait initiation and the length of the first step were identified by using the kinematic measurement system.

MAIN OUTCOME MEASURES

The total gait initiation period (start of the auditory cue for gait initiation to heel-strike of the first swing leg); each relative phasing of gait initiation indicated that the duration of the preparatory phase (start of auditory cue for gait initiation to heel-off of the first swing leg), the duration of the push-up phase (heel-off to toe-off of the first swing leg), and the duration of the single-stance phase (toe-off to heel-strike of the first swing leg) established by the total gait initiation period; and the length of the first step.

RESULTS

The gait initiation period was greater in Groups 1 and 2 than that of Group 3 (P<0.05). Each relative phasing including the duration of the preparatory phase, the push-up phase, and the swing phase relative to the total gait initiation period, did not differ among Groups 1-3 (P>0.05). The length of the first step, measured while the nonpreferred leg stepped first in Groups 1 and 2, was shorter than that of Group 3 (P<0.05).

CONCLUSIONS

Patients with incomplete cervical spinal cord injuries or lumbosacral spinal lesions took more time in gait initiation than unimpaired control adults. The first step length also reduced in these patients while the nonpreferred leg stepped first, as compared to unimpaired control adults. The data indicated that centrally programmed gait initiation might be preserved in ASIA-D spinal patients who, in this study, executed gait initiation with varying temporal distance strategies to compensate for peripheral impairments, as compared to unimpaired control adults.

Use of the Dermatology Life Quality Index (DLQI) in a midwestern US urban clinic

BACKGROUND

The Dermatology Life Quality Index (DLQI), a self-administered general dermatology quality of life instrument, was originally developed and published in a dermatology clinic at University Hospital of Wales.

OBJECTIVE

Our goal was to test the feasibility of having patients answer the DLQI in a busy dermatology clinic and to find out to what extent results vary from those published in Wales. We also wanted to examine the validity of the index in terms of the correlation between DLQI scores and stage of illness (disease severity).

METHODS

We administered the DLQI to 200 consecutive patients who were seen in a dermatology clinic at Indiana University Medical Center. Results were examined in light of results found by those who originated the DLQI. A pilot group of patients were given the DLQI and rated for severity of disease by means of the Dermatology Index of Disease Severity (DIDS).

RESULTS

Overall, the DLQI is easy to administer and can be completed within 3 minutes. The scores in our study were compatible with those previously reported by the DLQI originators. There was a "ceiling" effect in that 11% of the patients indicated no quality of life impairment on the DLQI rating. This index shows stratification with severity of disease.

CONCLUSION

The DLQI is an easy and efficient instrument for assessing quality of life in dermatology patients. Patients needed minimal assistance with the form. Our results were similar to those of the DLQI originators, and this further shows reliability and validity of the DLQI. In addition, this study further supports the use of DLQI as a quality of life instrument suitable for use in international studies.

Neurourologic findings in patients with traumatic thoracolumbar vertebra junction lesions

OBJECTIVE

To investigate neurourologic involvement in injuries to the thoracolumbar vertebra junction with magnetic resonance imaging (MRI) and electrophysiologic and urodynamic measurements and to characterize the neurogenic mechanisms of voiding dysfunctions.

DESIGN

Baseline comparisons among 3 anatomic groups before neural repair.

SETTING

Tertiary care center.

PATIENTS

Thirty-five T11 to L2 spinal cord injury patients consecutively admitted to a rehabilitation unit. Eight patients (Group 1) had above-conus lesions without denervation and polyphasic waves revealed in the anal sphincter electromyography; 13 patients (Group 2) had conal and/or above-conus lesions and anal sphincter electromyographic abnormalities; and 14 patients (Group 3) had below-conus lesions and anal sphincter electromyographic abnormalities.

MAIN OUTCOME MEASURES

Comparison of features identified on pudendal nerve terminal motor latency, urethral pressure profiles, and multichannel voiding pressure-flow study.

RESULTS

The pudendal nerve terminal motor latency in Group 3, showing a significantly higher abnormal ratio (100%; p =.011, Fisher's exact test), indicated that cauda equina lesions might be the cause. Urodynamic data from Group 3 showed a significant decrease in maximal urethral closure pressure (48 +/- 17cm H2O, p =.0022, analysis of variance [ANOVA], repeated measure) and an increase in bladder capacity (429 +/- 194mL, p =.037, ANOVA, repeated measure). There were no significant changes in the other groups.

CONCLUSION

Neurourologic abnormalities are less predictable with injuries to thoracolumbar junction, except in patients with cauda equina lesions.

The specialty of the treating physician affects the likelihood of tumor-free resection margins for basal cell carcinoma: results from a multi-institutional retrospective study

BACKGROUND

Basal cell carcinoma (BCC) is the most common cutaneous malignancy. Surgical experience and physician specialty may affect the outcome quality of surgical excision of BCC.

METHODS

We performed a multicenter retrospective study of BCC excisions submitted to the respective Departments of Pathology at 4 major university medical centers. Our outcome measure was presence of histologic evidence of tumor present in surgical margins of excision specimens (incomplete excision). Clinician experience was defined as the number of excisions that a clinician performed during the study interval. The analytic sample pool included 1459 tumors that met all inclusion and exclusion criteria. Analyses included univariate and multivariate techniques involving the entire sample and separate subsample analyses that excluded 2 outlying dermatologists.

RESULTS

Tumor was present at the surgical margins in 243 (16.6%) of 1459 specimens. A patient's sex, age, and tumor size were not significantly related to the presence of tumor in the surgical margin. Physician experience did not demonstrate a significant difference either in the entire sample (P <.09) or in the subsample analysis (P >.30). Tumors of the head and neck were more likely to be incompletely excised than truncal tumors in all the analyses (P <.03). Compared with dermatologists, otolaryngologists (P <.02) and plastic surgeons (P <.008) were more likely to incompletely excise tumors; however, subsample analysis for plastic surgeons found only a trend toward significance (P <.10). Dermatologists and general surgeons did not differ in the likelihood of performing an incomplete excision (P >.4).

CONCLUSION

The physician specialty may affect the quality of care in the surgical management of BCC.

Predicting sentinel and residual lymph node basin disease after sentinel lymph node biopsy for melanoma

BACKGROUND

The selection of patients for sentinel lymph node biopsy (SNB) and selective lymphadenectomy for histologically positive sentinel lymph nodes (SLND) are areas of debate. The authors of the current study attempted to identify predictors of metastases to the sentinel and residual nonsentinel lymph nodes in patients with melanoma.

METHODS

The Indiana University Interdisciplinary Melanoma Program computerized database was queried to identify all patients who underwent SNB for clinically localized cutaneous melanoma. Demographic, surgical, and histopathologic data were recorded. Univariate and multivariate logistic regression analyses were performed to identify associations with SNB and nonsentinel lymph node positivity. Classification tree and logistic procedures were performed to identify the ideal tumor thickness cutpoint at which to perform SNB.

RESULTS

Two hundred seventy-five SNB procedures were performed to stage 348 regional lymph node basins for occult metastases from melanoma. Of the 275 melanomas, 54 (19.6%) had a positive SNB, as did 58 of 348 basins (16.7%). Classification and logistic regression analysis identified a Breslow depth of 1.25 mm to be the most significant cutpoint for SNB positivity (odds ratio 8. 8:1; P = 0.0001). By multivariate analyses, a Breslow thickness cutpoint >/= 1.25 mm (P = 0.0002), ulceration (P = 0.005), and high mitotic index (> 5 mitoses/high-power field; P = 0.04) were significant predictors of SNB results. SLND was performed in 53 SNB positive patients, 15 of whom (28.3%) had at least 1 additional positive lymph node. SLND positivity was noted across a wide range of primary tumor characteristics and was associated significantly with multiple positive SN, but not with any other variable. SNB result correlated significantly with disease free and overall survival.

CONCLUSIONS

Patients with a Breslow tumor thickness >/= 1. 25 mm, ulceration, and high mitotic index are most likely to have positive SNB results. SLND is recommended for all patients after positive SNB because it is difficult to identify patients with residual lymph node disease.

The frequency of histologically dysplastic nevi in 199 pediatric patients

Many uncertainties surround the definition, frequency, and significance of dysplastic nevi in children. Consequently the management of dysplastic nevi in the pediatric population has been largely derived from the studies of adults. Biopsies are usually performed on this young age group because of lesion change or abnormal appearance. One might therefore assume that the frequency of histologically diagnosed dysplastic nevi would be higher in children than in adults. We decided to attempt to verify this assumption by determining the frequency of dysplastic nevi diagnosed histologically in the pediatric population. To do this we reviewed 199 cutaneous pathology reports of nevi removed from patients less than 18 years old and submitted to a community-based dermatopathology laboratory. The diagnosis of dysplastic nevus was made based on histologic criteria recommended by the World Health Organization Melanoma Program. We found that 3 of 199 nevi submitted for histologic analysis met the histologic criteria for dysplastic nevus. There were no melanomas. Our data suggest that there is an extremely low frequency of histologically confirmed dysplastic nevi within the general pediatric population.

Lobular capillary hemangiomas: An epidemiologic report, with emphasis on cutaneous lesions

BACKGROUND

Lobular capillary hemangiomas (pyogenic granulomas) occur on both mucosal and cutaneous surfaces. There are conflicting data regarding the increased prevalence of lobular capillary hemangiomas in female versus male subjects. Some studies have noted a female predominance of lobular capillary hemangiomas, but other studies do not reveal such a disparity. Because of an increased prevalence during pregnancy, oral tumors are also known as "granuloma gravidarum" or "pregnancy tumors." A hormonal influence for these mucosal lesions has been postulated. There are, however, no studies that address a possible relationship between hormones and cutaneous lesions.

OBJECTIVE

This study presents the epidemiology of lobular capillary hemangiomas, with an emphasis on cutaneous lesions.

METHODS

We reviewed 63,759 dermatopathology reports from a regional, private dermatopathology laboratory and found 325 cases of lobular capillary hemangiomas over a 1-year period.

RESULTS

In our study of lobular capillary hemangiomas, cutaneous lesions accounted for 86%, with mucosal lesions representing only 12% of cases. Seven cases were excluded (one was intravascular, two were subcutaneous, and in 4 the location was not specified). Overall, male patients outnumbered female patients. The peak incidence for cutaneous lobular capillary hemangiomas was found in the second decade of life. The most common cutaneous sites were the trunk, upper extremities, and head. Mucosal lesions were primarily seen on the lips, gingiva, and tongue, and these affected females more than males by a ratio of 2:1, most commonly in the fourth decade of life.

CONCLUSION

Cutaneous lobular capillary hemangiomas were equally prevalent in male and female patients. This would refute a female hormonal influence in the induction of cutaneous lobular capillary hemangiomas. Our data may suggest a hormonal influence on mucosal lesions because mucosal lobular capillary hemangiomas were twice as common in female patients. However, the small number of lesions in our study precludes us from making such a conclusion.

Treatment of acetabular fractures: 10-year experience

BACKGROUND

Acetabular fracture is a controversial and difficult fracture to manage. We retrospectively evaluated the outcome of the traditional management of acetabular fractures.

METHODS

From 1987 to 1996, 112 cases of acetabular fracture presented at the Taipei Veterans General Hospital and were managed surgically in 73 cases and nonsurgically in 39 cases. The follow-up period was 90 (36-140) months.

RESULTS

In the nonsurgically managed group, congruent reduction was achieved in 29 cases (74.3%) and good to excellent functional results were achieved in 25 cases (64.1%). In the surgically managed group, congruent reduction was achieved in 60 cases (82.2%) and good to excellent functional results were achieved in 57 cases (74.3%). In 51 (45.5%) cases, early or late complications developed after management, including one femoral artery perforation, one screw penetration, three wound infections, one iatrogenic sciatic nerve injury, one deep vein thrombosis, 21 heterotopic ossifications, two chondrolyses, three avascular necroses of the femoral head and 18 cases of symptomatic traumatic arthritis.

CONCLUSIONS

The functional results correlated well with the final congruity of the joints and the severity of the complications.

Current therapy of cutaneous melanoma

Melanoma is a growing public health problem. Optimal care of the melanoma patient is multidisciplinary, but plastic surgeons and other surgical specialties play a central role in the management of these patients. Although surgery remains the mainstay of therapy for melanoma, several recent clinical studies have helped to clarify the biology of the disease and have changed the patterns of care for patients with melanoma. The advent of lymphatic mapping for interrogation of regional lymph nodes and interferon as the first effective postsurgical adjuvant therapy have had a major impact on the care of melanoma in the United States and elsewhere. This article will review the current clinical approach and therapy for cutaneous melanoma. The diagnosis, prognostic variables, staging evaluation, current surgical and medical treatment, and follow-up guidelines for patients with all stages of melanoma are reviewed. Recent studies, controversies, and directions of future investigational therapies will be discussed.

Ipsilateral hip and distal femoral fractures

We tried to find the trauma mechanism and treatment rationale of ipsilateral concomitant hip and distal femoral fractures involving the articular surface. Between 1988 and 1995, 15 cases of ipsilateral hip (confined to neck or trochanteric areas of the femur) and distal (confined to supra- and intercondylar area of the femur) femoral articular fractures were collected. The hip fractures consisted of 10 trochanteric fractures and five neck fractures, which were managed with reduction and fixation in 14 (Knowles' pin in eight, DHS in four and standard Gamma nail in two), and primary bipolar hemiarthroplastry in one. The distal femoral articular fractures were open in 11; these were managed with radical debridement, implantation of Septopal chains and immediate internal fixation, followed by prophylactic autogenous bone grafting 6 weeks later in the recent six cases (five Judet plates, four dynamic condylar screws and two condylar plates). The other four closed distal femoral fractures were managed with early reduction and internal fixation (two Judet plate, one dynamic condylar screw and one condylar plate). The union time was 20.3 (12-48) weeks for proximal fractures and 23.7 (12-36) weeks for distal fractures. Early infection developed in three cases. Nonunion of a femoral neck fracture developed in one case. The other complications were implant failure in one, coxa vara in one, refracture in one, delayed union in one and knee stiffness in one.

Sudomotor abnormalities in reflex sympathetic dystrophy

BACKGROUND

Intractable pain and sweating dysfunction can occur in patients with reflex sympathetic dystrophy (RSD). We, therefore, investigated autonomic function by measuring sympathetic skin response (SSR) in these patients. This method provides useful information regarding the pathophysiologic changes in and clinical evaluation of RSD.

METHODS

Twenty-six RSD patients and 22 age-matched normal subjects were involved in our investigation. Three significant stages of RSD were classified through three-phase bone scanning of the wrist, carpal and metacarpal bones. There were 11 patients in stage I RSD, nine in stage II and six in stage III. SSRs were recorded from the bilateral palms of each subject simultaneously using electrical stimulation of the median nerve in the wrist. Latency and amplitude side ratios were calculated and compared with the control group.

RESULTS

The affected/normal (A/N) hand amplitude ratios were significantly lower in stage I RSD, and stage II RSD patients exhibited significantly higher A/N amplitude ratios compared with the control group. A/N amplitude and A/N latency ratios in stage III RSD did not change significantly. The A/N latency ratios in stage I RSD were significantly higher than those of the control group and those of stage II RSD. In one stage I patient and three stage III patients, SSRs were bilaterally unobtainable.

CONCLUSIONS

It appears that abnormal SSRs may be associated with autonomic disturbance in RSD patients.

Temporal effects of isometric contraction maneuvers on threshold sural amplitude

OBJECTIVE

To investigate the effect of isometric biceps brachii contraction and neck flexion on the time course of threshold sural amplitude.

DESIGN

Twelve healthy subjects, who were asked to lie supine on an examination bench, performed 1 min of muscle contraction. The sural sensory nerve action potential was recorded before, immediately after, and at 2-min intervals after muscle contraction. The preexercise level of stimulus intensity remained unchanged for sural readings throughout the entire course of the experiment.

RESULTS

The temporal changes in sensory nerve action potential amplitudes for both maneuvers were similar (P = 0.9734, two-way interaction). The mean sural amplitude after neck flexion increased from 6.0 +/- 2.9 microV (SD) to 10.6 +/- 6.6 microV (SD) 10 min after contraction. Similarly, mean sural amplitude increased from 6.5 +/- 1.8 microV (SD) to 14.5 +/- 9.7 microV (SD) 8 min after biceps brachii contraction. Statistical analysis performed using repeated measures with post hoc least significant difference showed a significant temporal effect in the two groups (P = 0.04).

CONCLUSION

The temporal responses of threshold sural amplitudes after isometric biceps brachii contraction and central reinforcement neck flexion maneuvers are nearly identical with regard to increase in the amplitude.

Treatment of cerebral palsy with botulinum toxin: evaluation with gross motor function measure

The objective of this study was to investigate the effects of botulinum toxin A (BTA) injection in reducing muscular spasticity and improving locomotor function in children with cerebral palsy. Thirty-eight children with spastic cerebral palsy who were undergoing regular physical therapy were enrolled. Twenty-eight of these received BTA injection at the hip adductors and/or gastrocnemius, while the other 10, whose parents refused the BTA treatment protocol, served as the comparison group. The main outcome measures were: improvements in the severity of spasticity, walking distance, gross motor function (as assessed with the Gross Motor Function Measure, GMFM), and gait pattern (as assessed with the Physician Rating Scale, PRS), all measured 6 and 12 weeks after the start of BTA treatment. The severity of spasticity and walking distance at baseline did not differ significantly between the two groups. However, the severity of spasticity improved markedly in the BTA group, from 2.7 to 1.5 (Modified Ashworth Scale) at the hip adductor, and from 2.9 to 1.9 at the gastrocnemius at the 6-week follow-up. The walking distance improved from 46.17 m to 55.32 m at the 6-week follow-up, and to 66.6 m at the 12-week follow-up in the BTA group. Marked improvements in the quality of several gross motor functions were also noted in the BTA group. The improvements in spasticity, walking distance, and gross motor function were significantly greater in the BTA group than in the comparison group. The improvements in gait pattern did not differ significantly between the BTA and comparison groups. The findings of this study show BTA injection to be an effective treatment for reducing spasticity and improving gross motor function in children with spastic cerebral palsy. GMFM provides objective evidence regarding functional improvement after treatment in this patient population.

EMG power spectrum analysis of first dorsal interosseous muscle in pianists

PURPOSE

Long-term piano training may induce potential biochemical and structural adaptations in hand intrinsic muscles or alter the motor strategy in the nervous systems.

METHODS

This study investigated, by electromyography (EMG) and strain gauge, whether this pedagogical training is aerobic or anaerobic by nature. Changes in EMG power spectrum during incremental isometric muscle contractions before and after a sustained, fatiguing muscular performance were studied in the first dorsal interosseous muscle (FDI) of 13 female pianists and 15 sedentary controls. The maximal voluntary contraction (MVC) force of the FDI and the time needed to induce fatigue were also measured.

RESULTS

During fatigue, the median frequency (MF) shifted toward the low frequencies in both groups. The MF of 50% and 25%MVC subsequent to fatigue were significantly lower than those before fatigue in the control group (104.0 +/- 45.5 Hz vs 116.7 +/- 41.4 Hz at 50%, P < 0.05; 114.7 +/- 43.4 Hz vs 123.3 +/- 46.7 Hz at 25%, P < 0.05). There were no significant MF changes within the pianists before and after fatigue. The root mean squares (RMS) of 50%, 25%, and 10%MVC of control subjects after fatigue were significantly higher than those before fatigue, but not in pianists. There was no difference in MF and RMS between the two groups at any level of %MVC before or after fatigue, but the pianists tended to show higher MF at each level of %MVC. Although the MVC was similar in both groups, the pianists, however, needed a much longer time to induce fatigue than controls (14.3 +/- 5.8 min vs 5.8 +/- 3.3 min, P < 0.005).

CONCLUSIONS

These observations are discussed in terms of the training-induced metabolic adaptations, the changes in the strategy of motor unit recruitment, and the possibility of differences in muscle fiber composition. This study indicates that piano training should not be classified as power training, rather as endurance training. Such findings may also provide information about fine motor training for athletes and other professionals.

Hepatitis C virus and lichen planus: A case-control study of 340 patients

Lichen planus (LP) has been associated with liver disease, particularly hepatitis C virus (HCV) infection, in several studies to date. Most of these reports, especially the larger series, were conducted in Europe. In addition, the type of LP associated with HCV was reported to be oral LP in most studies. We conducted a case-control study in a US metropolitan population known to have a low seroprevalence of HCV infection to explore the impact of geography and endemicity of HCV on the association between cutaneous LP and HCV. The study comprised 340 patients with cutaneous LP (as case ) against 577 patients with psoriasis (as control-1 ). Hepatitis antibody titers and liver function abnormalities were our main outcome measures. Prevalence of HCV antibody among 149,756 regional volunteer blood donors (as control-2 ) was also used for comparison. Twelve (55%) of 22 patients with LP tested for HCV were antibody positive. This was significantly higher than 25% of 40 psoriasis patients tested for HCV antibody (P =.04) or than 0.17% of blood donors tested for HCV antibody (P < 10(-5)). Thus a small but significant percentage of US patients with cutaneous LP had HCV antibody. Because LP may be the first presentation of HCV infection, it is important for clinicians to actively look for such infection in patients with LP.

Acute postoperative aggravation of radiculopathy as a complication of free fat transplantation in lumbar disc surgery: case report

This case report illustrates a rare case of motor weakness caused by a free fat graft herniation. A 40-year-old woman who had undergone surgery for a herniated lumbar intervertebral disc experienced right lower leg weakness. On magnetic resonance image (MRI) a herniated free fat graft was noted. An emergent operation was performed and the herniated fat graft was removed. Postoperatively, the patient recovered well with improvement of the motor weakness. MRI is a good method for diagnosis of fat graft herniation. The mechanisms of this complication have been documented, and the size of the fat graft plays an important role. The methods for prevention of this herniation are also discussed. Although the transplantation of adipose tissue has many advantages, including the prevention of postoperative epidural fibrosis, great care is needed when applying a fat graft intra-operatively. When a postoperative neurologic deficit develops, herniation of the fat graft must be considered. An emergent operation is the treatment of choice for this particular complication.

Porphyria cutanea tarda and hepatitis C virus: a case-control study and meta-analysis of the literature

BACKGROUND

Porphyria cutanea tarda (PCT) and hepatitis C virus (HCV) infection have been associated in several reports with the prevalence of HCV exhibiting considerable regional variation. However, most reports were confounded by selection bias and a regional prevalence of HCV in the populations studied. In the United States, only a few cases of this association have been reported to date.

OBJECTIVE

We concluded a study to evaluate the association between PCT and HCV in a US population. We used a case-control study design to control the systemic error that may occur during a selecting process or sampling procedure.

METHODS

We reviewed the medical records of Wishard Memorial Hospital, a county hospital serving metropolitan Indianapolis, Indiana, to perform a retrospective case-control study of 26 patients with PCT (as case) against 149,756 regional volunteer blood donors (as control-1) and 51 patients receiving methotrexate for psoriasis (as control-2). HCV antibody titers and other liver abnormalities were our main outcome measures. We then performed a weighted meta-analysis of 17 reports that had at least 17 patients in their study populations.

RESULTS

Sixteen (94%) of 17 PCT patients tested for HCV were antibody positive. Among blood donors, only 255 or 0.17% were HCV antibody positive (P < 10(-5), two-sided chi-square test). Of 5 psoriasis patients tested for HCV, none were HCV antibody positive (P = .0002, two-sided Fisher's exact test). For geographic comparison, meta-analysis of the literature demonstrated a varying regional prevalence of HCV in PCT patients as follows: Northern Europe 17%, Australia/New Zealand 20%, and Southern Europe 65%.

CONCLUSION

Although a marked geographic variation was found in the worldwide prevalence of HCV in PCT patients, a very large percentage of US patients with PCT had HCV infection. Our results emphasize the need for clinicians to actively look for HCV in patients with PCT.

The diagnostic yield in submitting nevi for histologic examination

BACKGROUND

Dermatologists have expertise in the clinical diagnosis of benign melanocytic nevi. However, there are no data to confirm the accuracy of diagnosis. Differences in the diagnostic accuracy between dermatologists and nondermatologists with regard to cutaneous tumors has been infrequently studied.

OBJECTIVE

We examined the rate of malignant tumors occurring in lesions submitted for routine microscopic examination that were clinically diagnosed as benign melanocytic nevi.

METHODS

We conducted a study at a regional, non-hospital-based dermatopathology laboratory using specimens submitted by physicians of various specialties who were practicing in a 5-state Midwest region of the United States. The preoperative and postoperative diagnoses were examined on the basis of information provided by the clinician and of the subsequent histopathologic diagnosis. A total of 7734 cutaneous pathology reports were reviewed. Specimens submitted with a preoperative clinical diagnosis of mole or nevus, with or without a modifier, were examined and compared with postoperative microscopic diagnoses.

RESULTS

Of 1946 specimens clinically diagnosed and submitted as benign nevi, 45 (2.3%) were histologically diagnosed as malignant tumors. This included 12 melanomas, 30 basal cell carcinomas, and 3 squamous cell carcinomas. For specimens submitted by dermatologists, the rate of malignant tumors increased when clinical information suggested findings beyond the classic benign clinical presentation with the addition of modifiers such as irritated or atypical, or if a malignancy was considered in the differential diagnosis (trend for increasing clinical suspicion: P = .00002). Fewer dermatologists than nondermatologists mistook a malignant tumor for a benign nevus (1.3% vs 3.8%, P = .003).

CONCLUSION

Our data document that 2.3% of clinically diagnosed benign nevi were microscopically diagnosed as malignant tumors. Whether this malignancy rate in clinically diagnosed, benign, melanocytic nevi is above or below the threshold to establish a policy for submission for histopathologic examination remains to be determined as a collective societal and medical professional responsibility.

Risk factors of non-melanoma skin cancer in United States veterans patients: a pilot study and review of literature

OBJECTIVE

To identify risk factors of non-melanoma skin cancer (NMSC) in US veterans patients.

BACKGROUND

There are an estimated one million new NMSC cases annually in the United States alone. While other studies with varying foci have evaluated risk factors in different subsets of the general populace, none have examined veterans as a group with potentially unique exposures and risks.

METHODS

An investigation of risk factors for skin cancer through questionnaire and physical examination on 145 veteran patients with skin cancer and 59 veteran patients without a history of skin cancer was conducted.

RESULTS

Parents' ethnicity, actinic keratosis on the face or other anatomic sites, solar elastosis of the neck, facial telangiectasias, age of first sunburn, and residency in Indiana were risk factors significantly associated with the development of skin cancer. Other possible risk factors included smoking and radiation therapy.

CONCLUSIONS

We documented several risk factors which significantly increased the chance of developing skin cancer among veterans. These included ethnic background and solar damage of the skin among others. A review of the literature confirms these risks in the general population, but also further study is warranted to address risk factors like smoking and radiation, particularly in veterans populations. Identification of pertinent risk factors will help to identify high risk individuals, allow detection of new skin cancer at its earliest stage, and develop a profile of favorable lifestyle characteristics that reduce NMSC risk.

Melanoma in Kauai, Hawaii, 1981-1990: the significance of in situ melanoma and the incidence trend

BACKGROUND

The incidence of melanoma has often been portrayed as reaching 'epidemic' proportions. The reality of such an epidemic is, however, not clearly established due to the methods of data collection and interpretation. The population-based incidence data and incidence trend of melanoma from the Island of Kauai, Hawaii provide an illustration of this 'epidemic'.

METHODS

We used medical records housed at the dermatology clinic and pathology laboratory in Kauai to: identify residents of Kauai who had their first melanoma during the years 1981-1990; and to measure the 10-year population-based incidence of melanoma.

RESULTS

In Caucasians: A total of 53 Caucasian residents (29 men and 24 women), were identified with an initial episode of melanoma (MM) during the 10-year period. The average annual standardized incidence rate per 100,000 Kauai Caucasian residents was 36. Whereas the incidence of in-situ MM increased during the 10-year period, the incidence of invasive MM did not. The average patient age was 55 years. The trunk and the limbs were the most common anatomic sites of MM. In men, one third of MM occur on the back. In women, one third develop on the leg/thigh. Three patients (6%) had metastasis and eventually died of MM. Thirteen patients (25%) had other skin cancers such as basal cell carcinoma and squamous cell carcinoma at some time. In Filipinos, Japanese and Hawaiians: Three Filipinos (all women), two Japanese (one man and one woman) and one Hawaiian (man) had melanoma. The standardized incidence rates, to the U.S.A. Caucasian population, were 3.1, 0.8 and 2.1 per 100,000 residents, respectively.

CONCLUSIONS

The melanoma incidence in Kauai is one of the highest rates documented in the U.S.A. However, a decreased incidence of invasive melanoma during the 10-year period was unexpected. The finding of nonmelanoma skin cancer in these patients supports a common etiology among these skin cancers.

Effect of isometric contraction on threshold somatosensory evoked potentials

We previously described the augmentation of sensory nerve action potential amplitudes after near and remote isometric muscle contraction. In this study, we wished to determine if the sensory cortex was involved in this process. In this prospective, intrinsically controlled study, we studied threshold somatosensory evoked potentials in 12 normal subjects with stimulation of the median nerve at 5.1 Hz. The subjects were tested during the following conditions: baseline, 25%, and 75% maximum isometric abductor digiti minimi contraction for 4 min. Each of these conditions was recorded before, during, and 4 min and 8 min after contraction. Results showed that at 25% contraction, there was a significant temporal increase in N9 amplitude (2.1-2.6 microV; P = 0.05, analysis of variance, repeated measures) and a decrease in N20 amplitude with 75% contraction (1.9-1.6 microV; P = 0.03, analysis of variance, repeated measure). No significant changes were noted in the spinal cord or brainstem recordings. In conclusion, it appears that augmentation of the brachial plexus peripheral nervous system recording occurs concurrently with central inhibitory gating. The possibility of peripheral nervous system adaptability will be discussed.

Abnormal vagal cholinergic function and psychological behaviors in irritable bowel syndrome patients: a hospital-based Oriental study

Irritable bowel syndrome (IBS) patients in Western countries usually manifest autonomic nerve dysfunctions and abnormal psychological behaviors. The purpose of this study was to assess whether Oriental IBS patients with predominant bowel symptoms also exhibited similar abnormalities. We enrolled 40 IBS patients from the outpatient clinic and 20 controls with normal daily bowel habit for study. The IBS patients were further divided according to their predominant bowel habit: 20 were constipation-predominant and 20 were diarrhea-predominant. Sympathetic function was evaluated by sympathetic skin response (SSR) while vagal cholinergic function was determined by measuring R-R interval variation (RRIV) in electrocardiography during rest and deep breathing. Psychological parameters were assessed by scales of the Minnesota Multiphasic Personality Inventory (MMPI) and the Hopkins Symptom Checklist (HSCL-90). IBS patients, despite their bowel habit, showed normal SSR response. RRIV during deep breathing was significantly lower in constipation-predominant IBS patients than in controls or diarrhea-predominant IBS patients (16.5+/-3.1% vs 20.5+/-4.8% and 21.5+/-4.6%, P < 0.001). IBS patients also exhibited abnormal MMPI measuring scores on depression, hysteria, paranoia, and masculinity/femininity scales. In addition, they also had more severe psychological distress in the items of HSCL-90 measurement. In conclusion, vagal dysfunction characterizes Oriental constipation-predominant IBS patients seeking medical help. Abnormal psychoneurotic profiles also exist in these IBS patients, irrespective of their bowel habits.

Compound muscle action potential amplitude and area changes in normal subjects and patients with carpal tunnel syndrome

Lesions of mixed peripheral nerves are often diagnosed by means of electrodiagnostic tests, especially by motor and sensory conduction studies. In order to clarify the varying degrees of motor nerve involvement in patients with carpal tunnel syndrome (CTS), we designed this study for comparing the results of compound muscle action potential (CMAP) amplitude and area under the negative phase between normal persons (n = 662) and patients having CTS (n = 250). The CTS cases were categorized into two distinct groups, i.e., CTS-D (n = 120) having prolonged median sensory latency and normal needle examination, CTS-AD having prolonged median sensory latency and abnormal needle findings (n = 130). Subjects in the CTS-AD group showed significant reduction, both in CMAP amplitude and area from 3rd to 7th decades; however, in the CTS-D group there were significantly smaller CMAP amplitude from 5th to 7th decades but CMAP area demonstrated wide variations. These data indicate that CMAP amplitude and area are helpful in documenting motor nerve axonal loss, but care must be exercised when attempt is made to define axonal loss based either on area or amplitude because of the temporal dispersive effects.

Effect of nerve block on sural amplitude during remote muscle contraction

We previously reported that the median sensory nerve action potentials (SNAPs) increased in amplitude during both near (3) and remote (4) muscle contraction. The objective of the present project was to begin to study the pathway by which this occurred. The sural amplitude was measured after one min. of isometric biceps contraction and compared pre and post lidocaine nerve block in 10 healthy subjects. The baseline was defined as the least amount of current needed to elicit a minimal sural response pre contraction. This level of stimulus remained constant throughout the experiment. Results showed that the sural amplitude peaked 4 min. after muscle contraction. An 8.1 microV increase in sural amplitude from baseline was noted pre injection as 5 min. post contraction, and an increase of 13.4 microV was noted comparing pre to post injection amplitudes at the same time. Statistical analysis using two-way interaction comparing the time courses pre and post injection showed a 92% chance the responses were dissimilar Post hoc least significant difference (LSD) analyses were significant at 4 min. (p = .005) and 6 min. (p = 0.29) post contraction. In conclusion, the increase in sural amplitude after remote muscle contraction was no longer apparent after proximal sural nerve block. This suggests that the nerve itself is required in the final common pathway for the transmission of this induced signal.

Brachial plexopathy in gunshot wounds and motor vehicle accidents: comparison of electrophysiologic findings

OBJECTIVE

To characterize the extent and degree of severity in subjects with gunshot wounds (GSWs) to the brachial plexus and to investigate the association between type of injuries and the predominant level involved.

DESIGN

A cross-sectional, retrospective review of electrophysiologic data.

SETTING

Electromyography laboratory of a county hospital.

PATIENTS

Thirty consecutive patients with GSWs and 14 patients with traction brachial plexopathies during a 5-year period (1992 through 1996).

MAIN OUTCOME MEASURES

The injury was categorized according to the level predominantly involved, and each component of the four major levels of the plexus was analyzed. The association between type of injury and predominant level involved was assessed via two-tailed chi 2 test. The mean number of elements per subject to each level involved was compared between GSW and motor vehicle accident (MVA) patients using unpaired t test.

RESULTS

The type of injury (GSW vs MVA) is significantly associated with the level involved. GSWs were implicated in infraclavicular rather than supraclavicular injury. Compared with MVA, the GSW plexopathies had significant lower mean number of components involved at the root and cord levels, but higher at the terminal nerve branches of plexus. In GSWs, nearly two thirds of all components were severely injured and 60% were completely damaged.

CONCLUSION

These findings demonstrate that gunshot plexopathies are characterized with multielement distribution and a mixture of lesions with or without continuity.

Dermatoepidemiology. III. ABC principles for a critical review of the literature

EPIDEMIOLOGY

Is the study of disease occurrence in human populations. As a science, epidemiology emphasizes descriptive and analytic observation, clinical trial, behavioral intervention, and the practical utility of diagnostic tests. "Epidemiology" is derived from the Greek epi (among), demos (people), and logos (doctrine).

CLINICAL EPIDEMIOLOGY

Is the application of epidemiologic principles and methods to problems arising in clinical medicine, dermatology included. For dermatologists, understanding this discipline is as important as mastering other basic sciences, such as immunology, microbiology, and dermatopathology. The recognization of Lyme disease is a classic work of "infectious" disease epidemiology. In 1972, a disease characterized by erythema chronicum migrans and "endemic arthritis" clustered in Lyme, Connecticut. By 1975, an infectious agent was suspected to be the cause of the disease. In 1977, the tick was thought to be the vector; in 1980, the spirochete became the prime suspect and, in 1982, Borrelia burgdorferi was identified as the etiologic agent. The study of hexachlorobenzene exposure, resulting in porphyria turcica, is an example of classic "chronic" disease epidemiology. The illness began in 1955 when sporadic cases of porphyria occurred in eastern Turkey. In 1957, the first case with illness resembling congenital erythropoietic porphyria was described. In subsequent years, over 3000 patients developed "epidemic" porphyria. The cause was due to the ingestion of seed wheat which had been treated with fungicides containing 20% hexachlorobenzene.

EPIDEMIOLOGIC METHODS

For research, published elsewhere as Dermatoepidemiology. I., include descriptive observational study, analytic observational study, epidemiologic experimental study and tests for sensitivity, specificity, and positive/negative predictive value. Epidemiologic principles, instead, stress the correct interpretation of data, minimization of bias, and the appreciation of natural variations in collected data.

Electrophysiologic evaluation of autonomic function in cerebral palsy

The presence of clinical autonomic dysfunction in patients with neurologic diseases, such as multiple sclerosis, Parkinson's disease, and cerebrovascular accident, has become increasingly recognized in the past decade. Very few autonomic tests have been done on pediatric patients thus far. The purpose of this study was to investigate the autonomic function in patients with cerebral palsy using two noninvasive tests: sympathetic skin response (SSR) and R-R interval variation (RRIV). Twenty-four patients with cerebral palsy and 24 control subjects between the ages of 4 and 12 yr were enrolled in this study. There was no significant difference of mean latency, amplitude, or amplitude ratio of SSR between the two groups under electric stimulus, startling stimulus, and deep breathing conditions. No significant difference in frequency of absent response and asymmetric response was also noted. Mean heart rate under relaxed sitting condition was significantly higher in the study group. Significant negative correlation between heart rate and age was noted in the control group but was not present in the study group. Also, there was no statistical difference of mean RRIV between the two groups. No objective evidence of autonomic disturbance in patients with cerebral palsy was found in this study.

Reliability testing of the dermatology index of disease severity (DIDS). An index for staging the severity of cutaneous inflammatory disease

OBJECTIVES

To describe a new severity of illness index for inflammatory skin disease called the Dermatology Index of Disease Severity (DIDS), and to show its preliminary use and reliability in staging disease in patients with psoriasis and dermatitis.

DESIGN

Interobserver rating study using the DIDS with as many as 10 observers independently rating the same patient at a single point in time.

SETTING

Ambulatory care clinics at an academic medical center with patients from various socioeconomic backgrounds.

PATIENTS

Thirty-four patients with psoriasis and 15 patients with dermatitis were included in the study.

MAIN OUTCOME MEASURES

The severity of illness for each patient was rated as 1 of 5 stages: 0, no evidence of clinical disease; I, limited disease; II, mild disease; III, moderate disease; and IV, severe disease. The degree of interobserver concordance was measured by the Cohen kappa statistic.

RESULTS

All 5 stages were represented in the study of patients with psoriasis. The overall kappa statistic was 0.76, which is defined as substantial interobserver concordance. The use of the instrument in dermatitis showed good consensus in staging, where the kappa statistic was 0.41.

CONCLUSION

We introduce an easy and efficient instrument for staging the severity of illness in inflammatory cutaneous diseases. The reliability of the DIDS is demonstrated in patients with psoriasis and in patients with dermatitis.

The diagnostic yield of histologic examination of seborrheic keratoses

OBJECTIVE

To examine the diagnostic yield in submitting clinically diagnosed seborrheic keratoses for routine microscopic examination.

DESIGN

Retrospective examination of preoperative and postoperative diagnoses based on information provided by the clinician on the laboratory worksheet and the subsequent histopathologic diagnosis.

SETTING

A regional nonhospital-based dermatopathology laboratory with specimens submitted by physicians (dermatologists and nondermatologists) practicing in a 4-state midwestern region of the United States.

PATIENT MATERIAL

A total of 5592 cutaneous pathology reports were reviewed. Specimens submitted with a preoperative clinical diagnosis of seborrheic keratosis, with or without a modifier, were examined. A comparison group with the clinical diagnosis of melanocytic nevus was reviewed.

MAIN OUTCOME MEASUREMENT

Preoperative clinical diagnoses were compared with the microscopic diagnoses.

RESULTS

Of 577 specimens clinically diagnosed and submitted as seborrheic keratoses, 37 (6.4%) were histologically diagnosed as malignant tumors. The rate of malignant tumors increased when clinical information suggested findings beyond the classic clinical presentation, such as irritation, or when a malignant tumor was considered in the differential diagnosis. Two lesions that histologically proved to be melanomas were in this group. Comparison of the seborrheic keratosis group with the nevus group showed that seborrheic keratoses were more likely to be malignant tumors than were melanocytic nevi. Clinically diagnosed seborrheic keratoses submitted by dermatologists were more likely than clinically diagnosed melanocytic nevi to be melanomas.

CONCLUSIONS

Our data suggest that there were differences in the rate of malignant tumors between dermatologists and nondermatologists and that clinically diagnosed, surgically removed seborrheic keratoses are more likely than clinically diagnosed, surgically removed melanocytic nevi to be malignant tumors.

Xanthoerythrodermia perstans and alopecia mucinosa in a patient with CD-30 cutaneous T-cell lymphoma

Xanthoerythrodermia perstans (XEP) is a distinctive variant of large-plaque parapsoriasis. Along with alopecia mucinosa and lymphomatoid papulosis, there is a strong association between large-plaque parapsoriasis and evolving cutaneous T-cell lymphoma (CTCL). In some reports, large-plaque parapsoriasis was suggested to be a precursor lesion that converted to CTCL in 10 to 30 percent of cases. We describe a patient who presented clinically with both XEP and alopecia mucinosa and was subsequently shown to have CD-30 CTCL.

Diversion colitis: a cause of abdominal discomfort in spinal cord injury patients with colostomy

Diversion colitis is thought to result from nutritional deficiencies secondary to fecal diversion. Symptoms include hemorrhagic purulent rectal discharge, abdominal pain, and tenesmus. 5-Aminosalicylic acid (5-ASA) and N-butyrate enemas have been reported to help this condition non-spinal cord injury (SCI) patients. We report the case of a 49-year-old C6 ASIA B tetraplegic man who had received colostomy because of intractable ileus 10 years earlier. He presented with a 2-week history of rectal pain and bleeding. Abdominal and rectal examination on admission were unremarkable. Colonoscopy showed a partial stricture 70cm proximally to the rectum. The colonic mucosa appeared granular and friable with evidence of linear ulceration. Histopathologic study was consistent with colitis. The patient developed fever, abdominal distention, and extensive retroperitoneal air after endoscopy, suggesting colonic perforation. He was treated with daily 5-ASA suppository and total parenteral nutrition for the presumed diagnosis of diversion colitis, and intravenous antibiotics for perforated colon. After 6 weeks of treatment with 5-ASA, the patient had decreased rectal pain and bleeding. This experience suggests that diversion colitis may be a cause of abdominal discomfort in SCI patients and that 5-ASA may be used in the management of diversion colitis.

Outcomes research: an overview

During the past few years there has been significant interest in studying methods that document outcomes of medical care. Outcomes management should result in higher quality health care at lower cost. However, what does outcomes research mean and how does it apply to dermatology and specifically to the individual dermatologist? This article reviews the evolution of medical outcomes research and presents the status of the current instruments, indices, and methods.

Late facilitation of the human soleus H reflex induced by sustained isometric maneuver

Studying the effect of spinal cord reinforcement maneuvers (SCRMs) on H reflex assists in understanding aspects of motor control. Our objective was as follows: (1) to elucidate the effects of four neck positions (neck resting at neutral position (control); passive hyperflexion of the neck; hyperextension of the neck with simultaneous abdominal contraction; and sustained active neck hyperflexion); (2) to evaluate the temporal changes of soleus H reflexes repeatedly evoked after a period of sustained neck flexion. We used a prospective, intrinsically controlled trial of the effects of these SCRMs on the H reflexes and M-responses in ten healthy volunteers. Pre- and postmaneuver measures included H reflex and M-response latencies and amplitudes, H/M maximum amplitude ratio, and H threshold. The four maneuvers showed no significant effect on the H reflex or M-response measures. To investigate temporal changes in the H reflex amplitude, H reflexes were repeatedly evoked at two-minute intervals after a one-minute period of active neck flexion. The amplitude of the H reflex was enhanced (P = 0.0356; analysis of variance), and the post hoc least significant difference test was significant at four minutes postmaneuver. Peak magnitude of the H reflex occurred at four minutes after relaxation, and the response returned to pretest baseline at eight minutes. The results of this study document the time course of repeated H reflexes after SCRM, and the timing of the H reflex was found to be a contributing variable that should be considered in future study designs.

Neuropsychological sequelae after treatment for medulloblastoma in childhood--the Taiwan experience

The purpose of this study was to investigate the functional independence, intellectual performance and academic achievement of children treated for medulloblastoma at the Veterans General Hospital-Taipei. Adverse factors that it was thought would result in significant intellectual impairment were also studied. Nineteen patients with medulloblastoma located over the posterior fossa were enrolled in this study. Their mean age at tumor removal was 6.16 +/- 3.30 (range 2-14) years. Mean full intelligent quotient (FIQ) was 86.00 +/- 22.66, performance intelligent quotient (PIQ) was 85.29 +/- 21.23, and verbal intelligent quotient (VIQ) was 90.50 +/- 23.50. In 11 cases academic achievement at school was poor. Sixteen patients received radiation therapy after tumor removal. Significant negative correlations were noted between IQ and whole-brain irradiation dose (r = -0.72) and between IQ and years after radiation therapy (r = -0.63). The results indicate a need for ongoing attention and intervention to prevent, remedy or minimize deficits produced by the tumor itself and by the cancer treatment.

Intraoperative monitoring of skin temperature changes of hands before, during, and after endoscopic thoracic sympathectomy: using infrared thermograph and thermometer for measurement

OBJECTIVE

To investigate the roles of the second and third thoracic spinal segments in the preganglionic sympathetic innervation of the hand, and to compare skin temperature changes between thenar and other parts of palm before, during, and after endoscopic thoracic sympathectomy.

DESIGN

Twelve patients, four women and eight men, with severe palmar hyperhydrosis underwent endoscopic thoracic sympathectomy. The T3 segment was identified and dissected first, followed by T2 segment extirpation. Skin temperature changes of the hand were assessed by thermograph and thermometer simultaneously before, during, and after sympathectomy. Sympathetic skin responses were undertaken 1 day preoperatively and followed up 6 months postoperatively.

SETTING

An electrophysiological laboratory and operating room in a national medical center.

SUBJECTS

Twelve patients who sustained a profound degree of palmar hyperhydrosis.

INTERVENTIONS

Skin temperature differences of the hands were measured by infrared thermograph and thermometer before, during, and after endoscopic thoracic sympathectomy.

MAIN OUTCOME MEASURES

Group's average temperature differences, and sympathetic skin response (all or none response).

RESULTS

The T2 spinal segment is thought to be the main source of sympathetic outflow to the sweat glands of the hand. The group's average temperature changes were significantly higher at the 2nd through 5th fingers' tips than at the thenar after completion of T2 extirpation (p < .005).

CONCLUSIONS

Intraoperative monitoring of palmar skin temperature, as judiciously measured by infrared thermograph, yields useful information about the locations of the sympathetic segments and confirmation of their entire ablation by endoscopic thoracic sympathectomy.

The utility of submitting fibroepithelial polyps for histological examination

BACKGROUND

The fibroepithelial polyp (FEP) is a common cutaneous lesion that is often removed for medical or cosmetic reasons. We examined the utility of submitting clinically diagnosed FEPs for routine microscopic examination.

DESIGN

We reviewed 11500 consecutive cutaneous pathology reports. Materials submitted with the clinical diagnosis of FEP or a synonym were reviewed and the histopathologic slides were examined. A comparison group of specimens submitted with the clinical diagnosis of melanocytic nevus was reviewed.

SETTING

The biopsy reports were generated at a regional non-hospital-based dermatopathology laboratory providing service to physicians (dermatologists and nondermatologists) practicing ambulatory medicine predominantly within a 4-state region (Ind, Ky, Tenn, and WVa).

RESULTS

Of 1335 clinical specimens submitted as FEPs, there were 5 malignant tumors. In the comparison group of 697 clinically diagnosed melanocytic nevi, there were 6 malignant tumors. In comparison with clinically diagnosed melanocytic nevi, the likelihood that a lesion clinically diagnosed as FEP would be a malignant tumor on histological examination is very low (relative risk, 0.4). None of the lesions clinically diagnosed as FEPs by dermatologists proved to be malignant.

CONCLUSIONS

Our data suggest there is an extremely low prevalence of malignancy in lesions clinically diagnosed as FEPs. We conclude that cutaneous lesions diagnosed as typical FEPs by dermatologists need not be submitted for microscopic examination.

Quantitative measurement of improvement in sitting balance in children with spastic cerebral palsy after selective posterior rhizotomy

Severe muscular spasticity encountered frequently in patients with spastic cerebral palsy not only affects patient locomotor function but also causes musculoskeletal complications. Significant reduction of spasticity over pelvis and lower limbs after selective posterior rhizotomy (SPR) results in improvement of trunk stability, locomotor function, and function of upper limbs also. The purpose of this study was to investigate the difference of sitting balance before and after SPR using a quantitative measurement in sitting stability represented as dispersion index provided by the Chattecx Balance System. Seventeen children with spastic cerebral palsy, ten boys and seven girls, with a mean age of 5.06 yr, underwent SPR. Their sitting stability under static and dynamic, visual and nonvisual testing conditions was assessed before SPR and three mo after SPR. Their sitting balance showed significant improvement at postoperative evaluation except for the static-nonvisual testing condition. Dispersion index under the dynamic testing condition was significantly higher than under the static testing condition, which implies that dynamic sitting balance was worse than static sitting balance in these patients. There was no statistical difference of sitting performance between visual and nonvisual condition both preoperatively and postoperatively. Quantitative measurement of dispersion index provided by the Chattecx Balance System offers an objective evidence of improvement in sitting balance for children after SPR.

Guillain-Barré syndrome: an unusual complication after snake bite

The mortality rate of the Formosan krait bite has been reported to be 23%; death is from respiratory paralysis caused by neuromuscular junctions being blocked by bungarotoxin. This article presents the first case report of Guillain-Barré syndrome after snake envenomization. The patient presented with symmetric paresis and sensory signs in the upper and lower limbs, autonomic dysfunction, facial nerve involvement, and mild elevated cerebrospinal fluid protein at about 4 weeks after the bite. Electrodiagnostic studies revealed profound sensory and motor polyneuropathy. Repeated electrophysiologic findings confirmed nerve regeneration. The patient reached satisfactory functional outcome after a short-term intensive rehabilitation program despite severe axonal degeneration. This article also discusses the possible mechanism of immunopathogenesis of Guillain-Barré syndrome after krait bite.

Power spectrum analysis of EMG at different voluntary efforts in normal subjects

BACKGROUND

In the previous studies, the results from power spectrum frequency changes at different sustained forces have been quite conflicting. This was the result of enormous changing in firing rate and motor units recruited; these were deciding factors of electromyographic power spectrum. The aim of this study was to investigate the characteristics of rate coding and electromyograph (EMG) interference pattern in two EMG-computer sets.

METHODS

Thirty-nine healthy subjects were included in our study. Each was in a relaxed sitting position with forearm, wrist, and metacarpophalangeal joints fixed by straps. Two surface electrodes were attached to the muscle belly of extensor digitorum communis. EMG signals were processed at 10%, 25%, 50% and 100% of maximal voluntary contraction (MVC) using visual feedback from a dynamometer.

RESULTS

The amplitude in dB remained constant at different isometric forces. The rate-coding parameters showed non-significant decrease as the percentage of MVC increased, ashereas the time-domain parameters revealed significant increase with stepwise increase in force.

CONCLUSIONS

EMG power spectrum analysis provides an easy, painless way of assessing global recruitment/rate descriptions of motor units.

Keratoacanthoma in Japanese Hawaiians in Kauai, Hawaii

BACKGROUND

This is the first incidence report of keratoacanthoma (KA) in a Japanese ethnic population.

METHODS

The study was designed as a 5-year prospective incidence study using an island-wide survey of Japanese residents in Kauai, Hawaii, during the years 1983 through 1987.

RESULTS

Eleven Japanese residents of Kauai, three men and eight women, had KA. The crude incidence is 22.1 per 100,000 Japanese Kauaiian population. Two thirds of the lesions were on the extremities. No recurrence was noted, but a nonmelanoma skin cancer developed in some patients.

CONCLUSIONS

The incidence of KA in a Japanese ethnic population is not low. Ultraviolet light exposure must, in part, contribute to the development of KA. This is supported by fact that the incidence of KA in Japanese residents in Kauai is much higher than in Japan and that most of the KAS appear on exposed skin.

Nonmelanoma skin cancer in Japanese ethnic Hawaiians in Kauai, Hawaii: an incidence report

BACKGROUND

Incidence reports of nonmelanoma skin cancer (NMSC) in Japanese persons are limited. Most studies have relied primarily on hospital records or voluntary reporting systems.

OBJECTIVE

Our purpose was to determine the incidence of basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and Bowen's disease (BD) in a defined Japanese population.

METHODS

A prospective 5-year population-based incidence study was conducted on the island of Kauai, Hawaii from 1983 through 1987.

RESULTS

Thirty Japanese Kauai residents, 12 men and 18 women, developed BCC during the 5-year study period. At the same time, 24 Japanese, 6 men and 18 women, were identified with SCC, and 11 had BD, three men and eight women. When standardized to the Japanese population in Japan, the annual BCC incidence rate was 30 per 100,000 Japanese Kauai residents with an average patient age of 75 years. More than 80% of these BCCs were localized to the head and neck. New BCCs developed in four patients with BCC, but none was a recurrence of a previously treated lesion. Five patients with BCC had SCC or BD concurrently or at other times. The SCC incidence was 23 per 100,000 Japanese Kauai residents with an average patient age of 80 years. The head and neck were again the most common anatomic sites. New SCCs subsequently occurred in two patients, in one of whom a localized recurrence also developed. Five patients with SCC had BCC simultaneously or at other times. The incidence of BD was 13 per 100,000 Japanese Kauai residents with an average patient age of 74 years. The extremities were the most common anatomic sites. One patient later had a new BD lesion and a recurrent BD lesion. Two patients had BCC or SCC at other times.

CONCLUSION

We report incidence rates of BCC, SCC, and BD at least 45 times higher in the Japanese population in Kauai, Hawaii than rates for the Japanese population in Japan. Kauai's intense UV radiation and emphasis on outdoor activities may contribute. More Japanese women had NMSC than men, a sex difference not observed in Japan.

Squamous cell carcinoma in Kauai, Hawaii

BACKGROUND

It is estimated that over 100,000 new cases of squamous cell carcinoma are diagnosed in the United States annually. This number is compounded by an increasing concern over the ozone layer depletion and the continued sunbathing behavior of many individuals. This could be particularly acute in Hawaii, which may have the highest rates of skin cancer in the country. We believe the updated information on skin cancer is essential to address the magnitude of the problem.

METHODS

A prospective 5-year population-based incidence study was conducted on Kauai, Hawaii, between 1983 and 1987 to investigate the frequency of squamous cell carcinomas in resident Caucasians.

RESULTS

A total of 58 residents, 37 men and 21 women, were identified with an initial episode of squamous cell carcinoma during the 5-year period. The average annual incidence rate per 100,000 Kauai Caucasian residents, standardized to the 1980 U.S. white population, was 153 for men and 92 for women with a combined rate of 118. The average patient age was 66.4 years. The head and neck was the most common anatomic site, with the extremities second. Subsequent new squamous cell carcinoma occurred in 13.8% of patients. Only one patient (2%) developed a recurrence after treatment. Twenty-five patients (43%) had basal cell carcinoma simultaneously or at other earlier times.

CONCLUSIONS

In Kauai the incidence rate of squamous cell carcinoma is the highest yet documented in the United States. No consistent trend in incidence rates was appreciated during this 5-year period.

Neuromuscular injury during limb lengthening: a longitudinal follow-up by rabbit tibial model

Limb lengthening has been used for many years to correct congenital anomalies and unequal leg length. Some surgeons focus on bone genesis and anatomical alignment, and pay less attention to potential damage to muscles, nerves, and vessels during the gradual stretching. In an attempt to identify the presence and extent of neuromuscular abnormalities during leg elongation, a rabbit tibial osteotomy model was used for 17 male rabbits, and fixation-distraction apparatuses were applied at a rate of 1 mm lengthening per day. Electrophysiological test was used to investigate both hindlegs every 2 weeks for 8 weeks after surgery. Needle electromyography (EMG) showed denervation in the elongated legs with 14 limbs having peroneal nerve damage and 12 limbs having damage to the posterior tibial nerve. Nerve regeneration signs were found in ankle extensors and flexors beginning 2 weeks postoperatively. The results of nerve conduction studies revealed significant differences (P < .05) in CMAP amplitude (mV) and area (mV.mS) in ankle extensors and flexors between elongated and nonelongated legs. There was no significant side-to-side difference with respect to distal latency. The incidence of neuromuscular injury was common in these rabbits. These findings suggest that early detection of neuromuscular involvement by electrophysiological test is a practical way to assess neuromuscular function during limb lengthening.

Bowen's disease (squamous cell carcinoma in situ) in Kauai, Hawaii. A population-based incidence report

BACKGROUND

The incidence of Bowen's disease (squamous cell carcinoma in situ) is rarely investigated.

OBJECTIVE

Our purpose was to report the incidence of Bowen's disease in a defined Caucasian population in Kauai, Hawaii.

METHODS

We conducted a prospective 5-year population study.

RESULTS

We found 71 Caucasian residents, 44 men and 27 women, who had an initial episode of Bowen's disease during the 5-year period. The average annual incidence rate per 100,000 Caucasian residents of Kauai, standardized to the 1980 U.S. Caucasian population, was 174 for men and 115 for women, with a combined rate of 142. The incidence increased in older age groups. The mean age of the patients was 65.2 years. The most common anatomic site was the extremities. Subsequent Bowen's disease occurred in eight patients (11.3%). Recurrence after treatment developed in only one patient (1.4%). Twenty-six patients (36.6%) had concurrent skin cancers, either basal cell carcinoma or squamous cell carcinoma, or both. There was no increased incidence of internal malignancy.

CONCLUSION

The incidence of Bowen's disease is high in Caucasian residents of Kauai and is 10 times higher than that reported from a northern Midwestern community. Kauai's intense ambient UV light and greater opportunity for year-round outdoor activities likely contributes to this higher rate.