Increased risk of strontium ranelate-related SJS/TEN is associated with HLA

Severe adverse drug reactions (ADR) of Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) in some patients receiving strontium ranelate have been reported, but the risk factors are unclear. We show that HLA-A*33:03 and B*58:01 are significantly associated with patients who developed SJS/TEN; and provide the first evidence that genetic risk factors are involved in strontium ranelate-associated SJS/TEN.

INTRODUCTION

In this study, HLA as a genetic risk factor was assessed among osteoporotic patients prescribed with strontium ranelate that developed severe cutaneous adverse drug reactions (SCARs) compared with those who were tolerant.

METHODS

Genomic DNA isolated from peripheral blood mononuclear cells (PBMCs) of patients was HLA typed using sequencing-based typing method to determine their HLA profiles.

RESULTS

Osteoporotic patients who are currently on strontium ranelate were enrolled in the study (n = 76). Tolerant controls were defined as patients who received strontium ranelate for a minimum of 3 months (range 3 months to 8 years) with no reports of any cutaneous reactions as these reactions usually occur within the first 12 weeks after starting treatment. Retrospective cases of SJS/TEN were also identified (n = 5). The majority of the accrued samples were of Han Chinese descent: controls (n = 72) and cases (n = 4). All cases and controls were genotyped at four HLA genes, namely HLA-A, HLA-B, HLA-C, and HLA-DRB1. In comparing the samples of Han Chinese descent (72 controls and 4 cases), we found significant associations with HLA-A*33:03 (p = 0.002) and HLA-B*58:01 (p = 0.023). There was no significant association with any HLA-C or HLA-DRB1 alleles.

CONCLUSIONS

This study reveals that the occurrence of SJS/TEN in Han Chinese patients receiving strontium ranelate is HLA associated. This has important clinical implications for understanding the underlying mechanisms for this ADR as well as evaluating the potential role of genetic pre-screening for osteoporotic patients who may be prescribed strontium ranelate.

Danazol-induced Stevens-Johnson syndrome in a patient with systemic lupus erythematosus

A patient with Stevens-Johnson syndrome related to danazol is presented.

Topical calcipotriol ointment in the treatment of morphea

A 5-year-old girl presented with a 2-month history of an indurated hypopigmented, atrophic plaque of biopsy-documented morphea over the right hip area. Previous treatment with 0,1% betamethasone valerate cream twice a day for 3 months failed to improve the lesion. She was treated with calcipotriol ointment twice daily, with nightly occlusion to the plaque for 9 months, and this resulted in resolution. No side effects were noted.

Stevens-Johnson syndrome and toxic epidermal necrolysis: efficacy of intravenous immunoglobulin and a review of treatment options

Toxic epidermal necrolysis (TEN) is a rare, severe adverse drug reaction. Steven-Johnson syndrome (SJS) represents the milder end of the spectrum. The exact pathogenesis of TEN and SJS is still unknown and many drugs, including prednisolone, cyclosporin and intravenous immunoglobulin (IVIG), have been used in an attempt to halt the disease process. The use of IVIG in particular is controversial. We share our experience with the use of IVIG in six patients with TEN. We will also review the various proposed mechanisms underlying TEN, the mechanism of action of IVIG in TEN and summarise useful treatment options.

Phrynoderma: a forgotten entity in a developed country

Phrynoderma is a type of follicular hyperkeratosis attributed to various nutritional deficiencies, most notably vitamin A. We report a case of a 31-year-old mentally-deficient man who was a resident of a voluntary welfare nursing home. He presented with characteristic hyperkeratotic follicular papules on his trunk in a setting of low serum level of vitamin A and malnutrition. Although commonly seen in South and East Asia, it is rarely reported in Singapore. However, there is still a population at risk here--patients with malabsorption and eating disorders, and institutionalised persons. Phrynoderma should, therefore, be considered in the differential diagnosis in patients with hyperkeratotic folliculitis, especially when malnutrition is also present.

Pustular pyoderma gangrenosum: an uncommon variant which is easily misdiagnosed

Pustular pyoderma gangrenosum is a relatively uncommon clinical form of pyoderma gangrenosum; it presents with vesiculo-pustular lesions that do not develop into frank ulceration. We report a case of a 44-year-old man with associated ulcerative colitis, who was misdiagnosed as having necrotizing fasciitis. He underwent multiple debridements and a subsequent skin grafting procedure, but without improvement. The diagnosis of pyoderma gangrenosum is often challenging because there is no defining diagnostic clinical, laboratory, or histopathological feature. A high index of suspicion is, therefore, essential to diagnose pyoderma gangrenosum clinically because failure to do so in the early stages of the disease can lead to disfigurement and even unnecessary and detrimental surgery.

Delaying Acute Graft-Versus-Host Disease in Mouse Bone Marrow Transplantation by Treating Donor Cells with Antibodies Directed at l-Selectin and alpha4-Integrin Prior to Infusion

Acute graft-versus-host disease (GVHD) is still a major hurdle for successful bone marrow transplantation (BMT). Although many immunosuppressive drugs are available, none of them alone or in combination are able to completely abolish acute GVHD. The lifelong immunosuppression profoundly reduces the quality of life of BMT recipients. Therefore, new therapeutic approaches are needed. We previously reported that, in an acute GVHD model using SCID mice as recipient, incubating donor spleen cells with antibodies directed at CD49d and CD62L could significantly delay the occurrence of acute GVHD. To test the potential usefulness of this treatment in BMT, we examined this therapeutic protocol in a mouse BMT model. The present mouse BMT study confirmed our previous results that incubation of donor cells with antibodies directed at CD49d and CD62L prior to infusion into the recipient can effectively delay acute GVHD, allowing the recipients to recover from the side effects of total body irradiation. This one-time treatment is easy and simple and may be modified for clinical usage.

Thermosensory abnormalities and blood flow dysfunction in psoriatic skin

BACKGROUND

Accumulating data have shown evidence of involvement of cutaneous nerve fibres and neuropeptides in psoriasis. Although ample evidence of structural and biochemical data exist no studies have been done on assessing the function of small nerve fibres in this disease.

OBJECTIVES

To investigate the function of small nerve fibres in patients with psoriasis between psoriatic plaques and non-involved skin and in comparison with healthy controls.

METHODS

We performed computerized psychophysical thermal sensory testing of warmth, cold and heat pain thresholds and skin blood flow using laser Doppler imaging in psoriatic lesions vs. non-involved skin and healthy skin. We evaluated these parameters before and immediately after barrier perturbation, and 1 week after as a measure of barrier repair.

RESULTS

There is a significantly elevated warm and decreased cold sensation threshold in psoriatic skin compared with non-involved skin and skin of healthy controls in the same sites. These differences were particularly abnormal 1 week poststripping. The warm sensation threshold was significantly elevated in non-involved skin in psoriatics vs. skin of healthy controls after tape stripping. These findings suggest there is an abnormal function of cutaneous nerve fibres in response to trauma to the stratum corneum, which is not limited to the visible plaque but could be generalized and aggravated by stressful events. Skin blood flow was significantly elevated in psoriatic plaques and inversely correlated to warm sensation thresholds while in healthy controls a direct correlation was noted.

CONCLUSIONS

Our data demonstrate an abnormal thermosensory response in psoriasis.

Allopurinol hypersensitivity syndrome and acute myocardial infarction--two case reports

INTRODUCTION

Allopurinol hypersensitivity syndrome is an idiosyncratic drug reaction characterised by an acute and severe multiorgan disease. It usually begins 2 to 6 weeks after starting allopurinol. The most important and critical characteristics are the presence of visceral involvement and haematological abnormalities; hepatitis, interstitial nephritis and eosinophilia are most frequently seen. However, cardiac involvement has not been previously reported.

CLINICAL PICTURE

Two previously well young Chinese men presented with fever, rash and hepatitis 3 weeks after taking allopurinol. The clinicopathological presentation was typical of allopurinol hypersensitivity syndrome.

TREATMENT AND OUTCOME

Both men received systemic corticosteroid therapy and had full recovery. A few months later, they each had an acute myocardial infarction with a fatal outcome, despite minimal cardiac risk factors and no family history of coronary artery disease.

CONCLUSION

The immunologic process in allopurinol hypersensitivity syndrome may have caused coronary vasculitis and subsequent myocardial infarct. Alternatively, the idiosyncratic reaction may have damaged myocardium, with the resultant myocarditis masquerading as coronary artery disease. Patients with allopurinol hypersensitivity syndrome should be followed up for cardiac involvement.

Pemphigus vulgaris following varicella infection

We describe a 26-year-old Indian man who presented with chickenpox and subsequently developed pemphigus vulgaris 17 days after initial resolution of lesions. The mechanism of progression from one disease to the other is postulated to be that of epitope spreading or molecular mimicry.

Profile and outcome of childhood mycosis fungoides in Singapore

Mycosis fungoides (MF) is the most common form of cutaneous T-cell lymphoma. It usually occurs in middle-aged and elderly persons, although several reports have described its occurrence in young children. The aim of this study was to review the profile and outcome of childhood MF in Singapore from 1989 to 1998. A total of nine patients (six males and three females) were diagnosed with MF before the age of 21 years. There were four Chinese, four Malay, and one Indian. The age at the time of histologic diagnosis ranged from 6 to 20 years (mean 14.3 years). Eight of the nine patients presented with hypopigmented patches and plaques. According to TNM staging, three were in stage 1A and six in stage 1B. The treatment modalities included psoralen plus ultraviolet A (PUVA) (n = 5), UVB (n = 2), and potent topical steroids (n = 2). We found that PUVA induced a faster clinical remission, but maintenance PUVA was required to prolong the relapse-free interval. This study also highlighted the need to consider MF in the differential diagnosis of hypopigmented dermatoses in dark-skinned individuals, especially if they occur on the buttocks.

Juvenile xanthogranuloma and neurofibromatosis 1

A case of juvenile xanthogranuloma associated with neurofibromatosis type 1 in a 9-month-old Chinese boy is presented. The literature concerning the association between these two conditions and juvenile chronic myelogenous leukaemia is highlighted. The patient presently has no evidence of any haematological malignancy, but requires close follow-up.

Erythema nodosum in Singapore

A retrospective study was carried out of all patients presenting with erythema nodosum over a 3-year period (1994-1997) at the National Skin Centre, Singapore. There were 75 patients, aged 4-70 years with a peak (40%) in the 21-30-year-old age group; 65 were female and 10 were male, giving a female to male ratio of 6.5 : 1. Precipitating factors included viral respiratory tract infections and streptococcal pharyngitis in 20 cases (26%), tuberculosis in two cases (3%), pregnancy in three cases (4%) and miscellaneous conditions: Behcet's syndrome (two cases), gonorrhoea (one case), varicella (one case) and cat-scratch disease (one case). The cause was unknown in 45 cases (60%). The pattern of erythema nodosum in Singapore is similar to that reported in the Western literature except that sarcoidosis and inflammatory bowel disease are uncommon associations.

Porphyria cutanea tarda

Porphyrias are a group of rare metabolic disorders in which excessive quantities of porphyrins, or their precursors, are produced. They are due to specific enzyme deficiencies resulting in abnormalities in the control of the porphyrin-haem metabolic pathway. Porphyria cutanea tarda (PCT) is the most common of all the porphyrias. However this condition is rarely seen in our Asian countries. We describe a patient with PCT who presented clinically with blistering eruptions over the sun-exposed areas. Coral pink fluorescence of uroporphyrins in an acidified urine specimen is diagnostic. Definitive treatment involves the use of low-dose chloroquine and interval venesection.

An unusual case of pemphigus vulgaris presenting as bilateral foot ulcers

We describe an unusual presentation of pemphigus vulgaris, an autoimmune intraepidermal blistering skin disease associated with autoantibodies to the desmosome glycoprotein, desmoglein 3. A 60-year-old man presented with bilateral ulceration on the dorsum of the feet. These clinical features persisted for 4 months before more characteristic signs of pemphigus vulgaris, including mouth ulceration and skin erosions, developed. The atypical presentation led to a delay in diagnosis and initiation of the appropriate treatment. Pemphigus vulgaris may have unusual manifestations, such as nail dystrophy, paronychia, or granulation tissue-like lesions, but this case of bilateral foot ulceration highlights a further, perhaps unique, clinical presentation of this autoimmune disease.

An unusual case of cutaneous vasculitis

INTRODUCTION

We report an unusual case of a patient with clinical and histological features of cutaneous vasculitis. CASE PICTURE: A middle-aged Chinese male presented with livedo reticularis and digital gangrene without visceral involvement. Skin biopsy showed features suggestive of cutaneous vasculitis. Repeated testing for anticardiolipin antibody was negative.

TREATMENT

He was treated with two courses of intravenous prostacyclin and pulsed with one course of intravenous methylprednisolone. He was also put on oral prednisolone, pentoxifylline, aspirin, nifedipine and colchicine in addition to symptomatic therapy.

OUTCOME

There was gradual improvement of his toe discolouration and relief of pain.

CONCLUSIONS

This is an interesting case of cutaneous vasculitis, which has features of polyarteritis nodosa and the antiphospholipid syndrome, who responded well to intravenous prostacyclin, steroids, pentoxifylline, aspirin, nifedipine and colchicine.

Lichen amyloidosus: a bullous variant

INTRODUCTION

Lichen amyloidosus is a common skin disease seen among Asian patients.

CLINICAL PICTURE

Typical features range from macular hyperpigmentation to pruritic, lichenified, hyperpigmented papules. However, in this rare bullous variant of lichen amyloidosus, bullae and vesicles are present. Histopathologically, deposits of amyloid were seen in the papillary dermis, associated with an intraepidermal or subepidermal blister.

TREATMENT AND OUTCOME

No good treatment so far, but pruritus can be relieved by topical steroid.

CONCLUSION

It is important to screen for systemic amyloidosis with the relevant investigations as it can present similarly with blistering eruptions, in which the prognosis would be grave.

Neonatal lupus erythematosus: our local experience

INTRODUCTION

Neonatal lupus erythematosus (NLE) presents clinically with either cutaneous lesions or cardiac involvement and is related to the transplacental passage of anti-Ro antibodies from mother to foetus. We report a series of 10 cases seen at the National Skin Centre between 1990 and 1998 including a pair of siblings.

CLINICAL PICTURE

The female to male ratio was 2.3:1 and most presented with rash between 3 to 5 weeks of life while 4 had lesions at birth. Four of the 9 mothers had SLE, one was diagnosed to have a lupus-like illness, 2 had Sjogren's syndrome and the remaining two had very high ANA titres but the final diagnosis was uncertain.

OUTCOME

The rash resolved spontaneously by 3 to 6 months of age.

Benign cephalic histiocytosis in Singapore--a review of 8 cases

AIM OF STUDY

Benign cephalic histiocytosis (BCH) is a rare, benign, self-healing papular eruption that affects mainly children. The aim of this study was to characterise our Singapore children affected by this condition and to review some of the recent literature on non-Langerhans cell histiocytoses.

METHODOLOGY

The case records of all cases of BCH seen between January 1990 and December 1996 in our centre were retrieved and analysed. Further details not available in the case records were obtained via a telephone interview with the patients or their parents.

RESULTS

A total of 8 cases were seen. There was no sex preponderance or ethnic predilection. The average age of onset was 29 months. All patients began with small brownish papules on the face and sometimes the upper trunk, and most of the lesions regressed in less than 84 months.

CONCLUSION

BCH is a benign non-Langerhans cell histiocytosis in which spontaneous resolution is the rule. A small skin punch biopsy is simple, diagnostic and helpful in its management. The management of BCE is expectant and reassurance is sufficient. However the regression and resolution of the lesions may take up to several years.

One-year review of pityriasis rosea at the National Skin Centre, Singapore

Pityriasis rosea is a common, acute, self-limited papulosquamous eruption of possible viral aetiology. The aim of this study was to describe the profile of pityriasis rosea seen at a referral skin centre in Singapore. A retrospective chart review was conducted of all the patients with a diagnosis of pityriasis rosea seen during 1996. There were 368 patients; their ages ranged from 9 months to 82 years with a peak in the 20 to 29 years age group. There were slightly more males (1.2:1). The clinic incidence was 6.5 per 1000 cases. No ethnic predilection was noted and cases were seen evenly throughout the year. About a quarter of the patients gave a history of a viral infection shortly before or during the occurrence of the rash. Most cases had a typical truncal distribution. The herald patch was observed in 63 patients (17%). Inverse distribution involving mainly the extremities were seen in 22 cases (6%) and eczematised lesions were noted in 20 cases (5.4%). The two main differential diagnoses considered were tinea infection and secondary syphilis. A fungal scrape and a rapid plasma reagin test were done in 58 and 59 patients, respectively, and the results were negative. Treatment was symptomatic and consisted of topical steroids and antihistamines. Thirty patients (8%) were given oral prednisolone for extensive eruptions. The pattern of pityriasis rosea in Singapore is similar to that reported in other countries except for a male predominance and absence of monthly variation. A lower incidence and an older group of patients were also seen in our series as compared to African patients.

The epidemiology of atopic dermatitis at a tertiary referral skin center in Singapore

Atopic dermatitis is a common chronic, relapsing, pruritic ecematous skin condition with a predilection for the flexural areas and occurs in patients with a personal or family history of atopy. The aim of this study is to describe the profile of atopic dermatitis seen at the National Skin Centre in Singapore. A retrospective chart review was conducted of all the patients with atopic dermatitis seen during the first six months of 1994. There were 492 patients whose ages ranged from one month to 74 years with an equal sex ratio. The prevalence was 2%. The onset of the disease occurred before the age of 10 years in 61.2% of patients. In 13.6% of the patients, the onset was after the age of 21 years. Two hundred and fifty-four patients (52%) had "pure" atopic dermatitis without concomitant respiratory allergies. Two hundred and thirty-eight patients (48%) suffered from a "mixed" type, with 23% having allergic rhinitis, 12% having asthma and 13% having both asthma and allergic rhinitis. Two hundred and thirty-one patients (47%) had at least one first-degree family member with atropy: atopic dermatitis (17%), asthma (15%) and allergic rhinitis (15%). Most of the patients, 416 (84.5%), had subacute eczema at presentation. Ichthyosis vulgaris was present in 38 patients (8%) and pityriasis alba in 13 patients (3%). The most common infective complication was bacterial infection (impetiginized eczema, folliculitis, cellullitis) present in 95 patients (19%) followed by viral infections (eczema herpeticum, viral warts and molluscum contagiosum) in 17 patients (3%). Allergies were noted in 43 patients (9%) based on the history given. The most common was drug allergies (penicillin and co-trimoxazole) in 28 patients followed by food allergies in 11 patients. Common aggravating factors reported include heat, sweating, stress, thick clothing and grass intolerance. Most patients could be controlled with a fairly simple regimen of moisturizers, topical steroids and antibiotics for acute flares. Short courses of systemic steroids were used in 78 patients (16%). Three patients were treated with phototherapy, Two on UVAB and one on PUVA. The pattern of atopic dermatitis in Singapore is similar to that reported in the Western literature except for a lower prevalence and a significant proportion of adult onset atopic dermatitis.

The profile of atopic dermatitis in a tertiary dermatology outpatient clinic in Singapore

BACKGROUND

Atopic dermatitis is a common, chronic, relapsing, pruritic, eczematous skin condition occurring in patients with a personal or family history of atopy. The aim of this study is to describe the profile of atopic dermatitis seen at a tertiary referral skin center in a tropical multiracial country.

METHODS

A retrospective chart review was conducted of all the patients with atopic dermatitis seen during the first six months of 1994.

RESULTS

There were 492 patients, age range from 1 month to 74 years, with an equal sex ratio. The prevalence was 2%. The onset of the disease occurred before the age of 10 years in 61.2% of patients. In 13.6% of patients, the onset was after the age of 21 years. Two hundred and fifty four patients (52%) had "pure" atopic dermatitis without concomitant respiratory allergies; 238 patients (48%) suffered from a "mixed" type, with 23% having allergic rhinitis, 12% having asthma, and 13% having both asthma and allergic rhinitis; 231 patients (47%) had at least one first-degree family member with atopy: atopic dermatitis (17%), asthma (15%), and allergic rhinitis (15%). Most of the patients, 416 (84.5%), had subacute dermatitis at presentation. Ichthyosis vulgaris was present in 38 patients (8%) and pityriasis alba in 13 patients (3%). The most common infective complication was bacterial infection (impetiginized dermatitis, folliculitis, cellulitis) present in 95 patients (19%), followed by viral infections (dermatitis herpeticum, viral warts, and molluscum contagiosum) in 17 patients (3%). Allergies were noted in 43 patients (9%). The most common was drug allergy (penicillin and cotrimoxazole) in 28 patients, followed by food allergy in 11 patients. Common aggravating factors reported included heat, sweating, stress, thick clothing, and grass intolerance. Most patients could be controlled with a fairly simple regimen of moisturizers, topical steroids, and antibiotics for acute flares. Short courses of systemic steroids were used in 78 patients (16%). Three patients were treated with phototherapy: two on combined UVA and UVB (UVAB) and one on oral psoralen photochemotherapy (PUVA).

CONCLUSIONS

The pattern of atopic dermatitis in Singapore is similar to that reported in the Western literature, except for a lower prevalence and a significant proportion of adult-onset atopic dermatitis.

Fixed drug eruptions in children

To determine the anatomic location and offending drug in fixed drug eruptions (FDE) in children, we performed a 5-year retrospective analysis. Thirty-five children with FDE were evaluated. The most common cause of FDE was the combination drug trimethoprim-sulfamethoxazole.

Treatment of linear IgA bullous dermatosis of childhood with colchicine

Linear IgA bullous dermatosis of childhood is the most common immunobullous disorder of childhood. First-line treatment includes dapsone or sulfapyridine. We report a child with linear IgA dermatosis who was treated successfully with colchicine after developing hemolytic anemia from dapsone. We recommend colchicine as an alternative therapy for linear IgA dermatosis of childhood in patients in whom first-line treatment is contraindicated or who fail first-line treatment or develop side effects from it.

Bacterial skin infections at a tertiary dermatological centre

BACKGROUND

Bacterial skin infections are common clinical problems encountered in most fields of clinical medicine. Staphylococcus aureus and group A streptococci are common invaders of eczematous, traumatised or immunocompromised skin. Advances in pharmacology have introduced a wide array of new antibiotics into the physician's armamentarium, but the rising incidence of bacterial resistance continues to be a problem. A retrospective study was carried out on 331 patients at the National Skin Centre, Singapore, to establish the causes of common primary and secondary pyodermas, as well as to determine the antibiotic sensitivities of the microorganisms responsible.

METHODS

A retrospective study of the medical records of 331 patients seen at the Centre for skin infections between October 1995 and May 1996 was done. Skin cultures and antibiotic sensitivity testing was carried out and the data analysed. Both primary pyodermas (impetigo, folliculitis, furuncles/carbuncles and cellulitis) and secondary pyodermas (infected ulcers and infected eczemas) were included. The results of bacterial isolation cultures and sensitivity of the organisms isolated to the commonly used antibiotics such as cloxacillin, penicillin, erythromycin and the tetracyclines were analysed.

RESULTS

Staphylococcus aureus was the commonest organism isolated from both primary and secondary pyodermas, accounting for 67% and 46.7% of the organisms isolated, respectively. There was no significant difference in the racial representation in each of the various skin infections, but there was a significantly greater female representation in the infected ulcers. The secondary pyodermas had a significantly higher incidence of gram negative organisms causing infections, as well as culture results showing multiple bacterial pathogens. The methicillin resistant strains of S. aureus were commoner in the secondary pyodermas, and accounted for 4.2% of the total organisms isolated and 7% of the total strains of S. aureus. The S. aureus had a high rate of resistance (89.5%) to penicillin and ampicillin, but was very sensitive (93%) to cloxacillin, cephalexin and cotrimoxazole. The incidence of erythromycin resistance was 18.7%.

CONCLUSIONS

In patients with primary pyodermas, cloxacillin should be the first line antibiotic used, with erythromycin as a useful but less preferred alternative. The favoured combination of ampicillin and cloxacillin has little place in routine treatment of skin infections, except for cellulitis and infected eczemas. A cephalosporin can also be used in these conditions if single drug therapy is desired. The secondarily infected ulcers are difficult to treat and would probably require the use of combination therapy in view of frequent mixed infections.

Acute pyoderma gangrenosum does not require surgical therapy

Pyoderma gangrenosum is an uncommon ulcerative skin disorder that is often associated with underlying systemic diseases, the most common of which is inflammatory bowel disease. We report an illustrative case of a 36-year-old woman with pyoderma gangrenosum occurring at surgical sites and at sites of trauma. She had associated Crohn disease. Multiple surgical procedures were performed on this patient, without improvement. Pyoderma gangrenosum can mimic a necrotizing soft tissue infection. Early recognition of the characteristic lesion may prevent unnecessary operations and facilitate effective control with appropriate medical therapy.