Atopic dermatitis management: comparing the treatment patterns of dermatologists in Japan, U.S.A. and U.K.

BACKGROUND: The incidence of atopic dermatitis (AD) is increasing worldwide. No large-scale study has previously compared the therapeutic management of this condition in different countries. OBJECTIVES: The purpose of this study was to determine the treatment preferences of dermatologists in Japan, the U.S.A. and the U.K., and investigate their relationship with certain factors pertaining to the physician and his practice. METHODS: A questionnaire was sent to all registered members of dermatological societies in Japan, the U.S.A. and the U.K. Responses were collated and statistical analysis performed using chi2, Mantel-Haenszel and Breslow heterogeneity tests. RESULTS: Three thousand six hundred and eighty-eight completed surveys were returned. U.S.A. and U.K. physicians were significantly more aggressive in prescribing systemic medications, such as steroids, antibiotics and immunosuppressants, compared with those in Japan. Japanese dermatologists also utilized topical steroids significantly less. The use of alternative remedies was highest in Japan. All three countries had a relatively high degree of optimism for topical immunosuppressants, but less so for other emerging therapies. CONCLUSIONS: Both similarities and differences in the therapy of AD exist in the three countries studied. Factors related to the physician, patient population and culture may influence these observations.

Does health habit counseling affect patient satisfaction?

BACKGROUND: Health behavior advice can potentially prevent a large burden of illness, but the acceptability of this advice to patients is not well understood. This study assessed whether physician discussion of behavioral risk factors decreases patient satisfaction with the outpatient visit. METHODS: In a cross-sectional study of 2,459 consecutive adult outpatient visits to 138 community family physicians in Northeast Ohio, the association of health habit counseling, measured by direct observation, with patient satisfaction, assessed by a modified subscale of the MOS 9-item visit rating scale, was calculated by logistic regression. RESULTS: In analyses controlling for patient mix, discussion of diet, exercise, alcohol and other substance use, sexually transmitted disease, and HIV prevention was not associated with patient satisfaction. Patients who were asked about their tobacco use or counseled about quitting were more likely to be very satisfied with the physician. CONCLUSIONS: Discussion of health behavior change, as practiced by community family physicians, is not associated with diminished patient satisfaction. In fact, tobacco use assessment and cessation counseling are associated with greater satisfaction.

Repeated BCG vaccination is more effective than a single dose in preventing diabetes in non-obese diabetic (NOD) mice.

Stimulation of the non-obese diabetic (NOD) mouse immune-system with a single bacillus Calmette-Guerin (BCG) vaccination can inhibit the development of diabetes. The optimal dose, and the time and number of vaccinations is still to be clarified. In this study we evaluated the protective effect of repeated BCG vaccinations on preventing diabetes in NOD mice. 17/32 (53%) of the control group, 8/31 (26%) of the single vaccine-treated (at age 35 days) mice, and 7/23 (30%) of the single vaccine-treated (at age 90 days) mice developed diabetes, and none of the repeated BCG vaccination (at age 35 & 90 days, n = 14) animals developed the disease, up to 250 days of age (p < 0.05, compared with controls and each of the single-vaccination groups). While the severity of insulitis was lower in repeatedly BCG-treated mice at age 120 days as compared with controls and single BCG-vaccination groups, we could not detect significant differences in the Intracellular adhesion molecule-1 (ICAM-1) expression between the various groups. There were no differences in weight gain and blood hematocrit between the different groups. Our report demonstrates that repeated BCG vaccination is safe and more effective than a single dose in preventing type I diabetes in NOD mice. This data should be considered in planning new human trials with BCG.

D-penicillamine-induced autoantibodies in a mouse model.

OBJECTIVE: We have previously shown that the administration of D-penicillamine (D-PEN) to patients with rheumatoid arthritis induces circulating insulin autoantibodies (INSAAB). In order to gain further insight into such immune responses, we measured a battery of circulating autoantibodies in 4 strains of mice receiving D-PEN: C57BL/KsJ, BALB/c, C3H/HeJ, and C57BL/6. These rodents groups differ in their degree of susceptibility to streptozotocin (STZ)-induced immune diabetes (SIMD), which is high in the first 2 strains, and mild and nil in the third and fourth, respectively. METHODS: Randomly assigned animals from each group were given a weekly subcutaneous (SC) injection of either D-PEN 1 mg, D-PEN 3 mg, or solvent (PBS) for a period of 4 weeks. Serum levels of antibodies to insulin, single stranded DNA (ssDNA), thyroglobulin, and cardiolipin were measured weekly. RESULTS: Only the C57BL/KsJ and C3H/HeJ mice reacted to D-PEN administration. When compared to the pre-treated and solvent-treated mice, D-PEN 1 mg, and to a lesser degree D-PEN 3 mg, induced elevation of antibodies to insulin and to ssDNA in C57/KsJ mice (p < 0.001), while only ssDNA antibodies were detected in the C3H/HeJ mice (p < 0.0001 for D-PEN 1 mg; p < 0.05 for D-PEN 3 mg). D-PEN had no effect on the level of antibodies to cardiolipin or to thyroglobulin in any of the mice. CONCLUSIONS: This study showed that D-PEN induces an antigen(s)-specific humoral response only in mice already inherently prone to autoimmunity. This model suggests that the activation of autoimmunity by environmental factors is probably facilitated by genetic background, and might partly explain the diversity of autoimmune manifestations in D-PEN-treated patients.

Bone turnover in cortical and trabecular bone in normal women and in women with osteoporosis.

UNLABELLED: This study is based on the assumption that is bone turnover, shown by the uptake of 99mTc-MDP, indicates a high rate of bone loss in patients with osteoporosis, it could potentially predict bone loss in patients at risk before significant bone loss has occurred. METHODS: Quantitative bone SPECT (QBS) using 99mTc-MDP, expressed as the %ID/cc x 10(-3), was performed in 71 women who had osteoporosis in the lumbar vertebrae, the femoral neck or both, and in 54 age-matched normal female controls. Of the women with osteoporosis, 42 had postmenopausal osteoporosis and 29 had primary hyperparathyroidism (HPT) and osteoporosis. RESULTS: QBS increased with age in the cortical bone and decreased in the trabecular bone of the normal women. Quantitative bone SPECT in the femoral neck was 3.18 +/- 1.20 and was 2.73 +/- 1.06 in the femoral shaft in 20 women with postmenopausal osteoporosis of the femoral neck. In 19 women with HPT and osteoporosis of the femoral neck, the QBS value in the femoral neck was 3.57 +/- 0.92 and in the femoral shaft 3.38 +/- 1.12. These values were also significantly higher for the femoral neck and for the femoral shaft than those of normals. Although QBS values were higher in the lumbar region in 39 women with postmenopausal osteoporosis (4.59 +/- 1.45) and in 27 women with HPT (4.30 +/- 1.52), as compared with the normal group (4.28 +/- 1.61), the difference was not statistically significant. CONCLUSION: This study shows that bone turnover is significantly higher in the cortical bone of women with osteoporosis than in normal women.

Low titer, competitive insulin autoantibodies are spontaneously produced in autoimmune diseases of the thyroid.

The occurrence of multiple endocrine autoimmunity with organ-specific autoantibodies is well known. In this study we evaluated the presence of competitive insulin autoantibodies (IAA) in immune and non-immune diseases of the thyroid, utilizing a sensitive and specific radiobinding assay. We studied 37 patients with Graves' disease, 44 patients with Hashimoto's thyroiditis, 11 patients with non-immune thyroid diseases and 30 normal controls. In 5/37 (13.5%), 7/44 (15.9%) patients with Graves' and Hashimoto's diseases, respectively, but in none of those with non-immune thyroid disease or of the controls, IAA levels exceeded our upper limit of normal range (50 nunits/ml) (P < 0.01). Positive IAA levels ranged between 50 and 123 nunits/ml with fluctuation of these levels over time. Islet cell antibodies were not detected in any of the patients and the controls in the study. No association was found between propylthiouracile treatment and level of IAA. In none of 10 IAA-positive patients was the early phase insulin secretion of the intravenous glucose tolerance test below 46 mu units/ml, and in 2 subjects repeated tests after 3 years showed conserved insulin secretion. In conclusion, our findings show that 15% of patients with autoimmune thyroid diseases, produce specific IAA which do not seem to reflect aggressive beta cell destruction.

Correlation between glucose disposal and amino acids levels in hyperthyroidism.

Insulin is known to decrease plasma levels of both glucose and amino acids. We have designed a study to examine whether in hyperthyroidism, where insulin sensitivity is changed, correlation between glucose disposal and amino acids levels is maintained. We studied 5 normal (N) and 5 hyperthyroid (HTD) subjects, and measured glucose disposal rate and serum levels of plasma amino acids before and during insulin infusion utilizing the euglycemic hyperinsulinemic clamp technique. Insulin was effective in decreasing the levels of all amino acids in the plasma of all subjects. The mean amino acid decrease in response to insulin infusion rate of 10 mu/kg/min was 35 +/- 3% in N and 50 +/- 3% in HTD. The half maximally effective dose of insulin on glucose disposal was 43 +/- 3 and 69 +/- 9 uU/ml in N and HTD respectively (p < 0.05). The half maximally effective dose of insulin on decreasing plasma amino acids was 37 +/- 7 and 75 +/- 5 uU/ml in N and HTD respectively (p < 0.01). The concentration of insulin giving a half maximal effect on serum amino acids correlated with the half-maximally effective dose on glucose disposal rate (r = 0.72, p < 0.01). The maximal effect on total amino acid levels correlated with maximal glucose disposal (r = 0.76, p < 0.001). Similar results were observed with branched chain amino acids. We conclude that in hyperthyroidism glucose disposal and decrease in amino acids levels are closely correlated as in healthy subjects. This also confirms the association between glucose disposal and amino acids levels in a variety of insulin sensitive and resistant states.

Frequent induction of insulin autoantibodies by D-penicillamine in patients with rheumatoid arthritis.

D-Penicillamine is a drug known to induce various immunological abnormalities. We used a competitive radiobinding assay, to evaluate the presence of insulin autoantibodies in 42 patients with rheumatoid arthritis (RA), under various treatment modalities. In 11/42 (26.2%) patients, the levels of insulin autoantibodies (range 59-1970 nU/ml) exceeded our upper limit of normal range (50 nU/ml). Nine of these 11 (81.8%) insulin autoantibodies positive patients had been treated with D-penicillamine. Out of 21 D-penicillamine treated patients, 9 (42.9%) were insulin autoantibodies positive (range 80 to 1970 nU/ml). An inverse correlation was found between the concentration of insulin autoantibodies and the time interval since the last drug administration, R = -0.58 (p < 0.05). No correlation was found between the autoantibodies levels and age, or duration of D-penicillamine treatment. In summary, elevated concentration of serum insulin autoantibodies are most probably induced by D-penicillamine therapy in patients with RA and tend to decrease after the drug withdrawal.

Effect of wheat germ agglutinin and concanavalin A on insulin binding and response by Madin-Darby canine kidney cells.

In Madin-Darby canine kidney (MDCK) cells, specific plasma membrane binding of [125I]insulin was undetectable. Correspondingly, neither insulin-stimulated incorporation of [14C]glucose into glycogen nor insulin-induced uptake of radiolabeled alpha-aminoisobutyrate ([ 3H]AIB) could be demonstrated. These results suggested that MDCK cells lack specific cell surface insulin receptors. To further examine this question intact MDCK cells were preincubated with antireceptor serum and subsequently labeled with [125I]protein A; however, insulin receptors were not detected. Control H4 hepatoma cells bound insulin, responded with increased glycogen synthesis and amino acid uptake, and possessed immunologically recognizable insulin receptor components. The insulin-associated response of stimulated [3H]AIB uptake was induced in MDCK cells by the insulinomimetic lectins concanavalin A (130-140% of basal value at concentrations of 10-40 micrograms/ml) and wheat germ agglutinin (140-160% of basal value at concentrations of 10-30 micrograms/ml). This stimulation was abolished by the respective lectin-specific monosaccharides D-mannose and N-acetyl-D-glucosamine. Together, these data indicate that the insulin-like activity of concanavalin A and wheat germ agglutinin can be elicited in MDCK cells even in the apparent absence of specific plasma membrane insulin-binding sites.

Difficult preoperative diagnosis of a patient with sclerosing splenic hemangioma.

We present a young asymptomatic woman with splenomegaly and a large isolated splenic mass demonstrated by ultrasonography, 99mTc sulfur colloid, and gallium scintigraphy studies. Computerized tomography (CT) and three-phase 99mTc-labeled red blood cell imaging suggested a malignant lesion. Repeated sonographically guided fine needle aspiration (FNA) obtained only blood, suggesting the possible vascular nature of the tumor. Splenectomy established the diagnosis of splenic hemangioma (SH) with marked sclerotic changes. We conclude from this case that 1) the sclerotic and cystic changes in the SH and the abdominal lymphadenopathy could explain why the three-phase red blood cell and CT scanning, respectively, suggested that the lesion was malignant rather than benign; 2) guided FNA of a splenic mass suspected to be hemangioma may be an additional safe and useful diagnostic procedure. Multiple aspirations yielding blood alone suggest hemangioma and may prevent an unnecessary operation. To the best of our knowledge, this is the first reported case in the literature of FNA of splenic hemangioma.

Digoxin-like immunoreactive factor(s) in human gonadotropin stimulated follicular fluid.

Plasma digoxin-like immunoreactive factor(s) (DLIF) have been reported in various pathophysiological conditions associated with volume expansion and linked to the regulation of blood volume and pressure. We hypothesized that DLIF might be present in rapidly expanding gonadotropin-stimulated ovarian follicles. The mean total and free DLIF concentrations in the follicles (n = 9) studied were 4925 nmol/L and 1885 nmol/L, respectively. These concentrations were substantially higher than the plasma total and free DLIF levels in these women: 1216 nmol/L and 158 nmol/L, respectively (p less than 0.0001). The plasma DLIF levels in the gonadotropin-treated women were comparable to those in term pregnant women, which are known to be higher than those in non-pregnant women. The ovary thus may be a source of DLIF in the plasma of gonadotropin-treated women, and DLIF may have a role in ovarian follicular fluid homeostasis.

Talcosis presenting as pulmonary infiltrates in an HIV-positive heroin addict.

A case of an HIV-positive young drug addict presenting with fever, respiratory distress, and pulmonary infiltrates is reported. Pulmonary talcosis was diagnosed by transbronchial biopsy. The differential diagnosis of pulmonary infiltrates in HIV-positive patients is reviewed and the predisposition of drug addicts to develop both HIV infection, as well as pulmonary talcosis, is discussed. Pulmonary talcosis must be considered in the differential diagnosis of pulmonary infiltrates of HIV-positive drug addicts.