Multifocal cutaneous alternariosis in a 70-year-old Kenyan renal transplant patient.

Alternaria species are a group of dematiaceous fungi that are ubiquitous in nature and are becoming an increasingly important cause of disease in immunocompromised patients. We present a case of a 70 year old renal transplant recipient with multiple areas of cutaneous Alternaria infections likely introduced during local trauma. Treatment has required a combination of systemic therapy and surgical excision. This case illustrates the importance of recognizing fungal infections with cutaneous manifestations, such as alternariosis, in immunosuppressed patients.

Visualization of Reinke's crystals in normal and cryptorchid testis.

Within the human testis, Reinke's crystals are found in Leydig cells but their nature and function are poorly understood. The aim of our study was to investigate the properties of Reinke's crystals in man with the normal morphology of the testis (control group) and infertile patients diagnosed with cryptorchidism. 20 biopsies from infertile patients and six biopsies from men with regular spermatogenesis (20-30 years.) were used. Sections of the testis tissue were stained with haematoxylin and eosin and a modified Masson's method. Specimens were observed by bright field, confocal and transmission electron microscopy (TEM). The number of Reinke's crystals in investigated groups was determined applying stereological methods. In both groups, Reinke's crystals were noted within the cytoplasm and nuclei of Leydig cells. Some "free" crystals were found within the interstitial space, outside Leydig cells. Confocal microscopy proved to be very useful in the assessment of the shape and 3D reconstruction of the crystal. TEM analysis confirmed a hexagonal form of the crystal, while crystallographic data on sections of 70-300 nm thickness provided a better insight into the organization of the crystal lattice. Stereological analysis revealed a significant increase in the number of crystals in cryptorchid testes when compared with controls. Increased number of crystals in cryptorchid specimens leads to the assumption that the prolonged exposure to higher (abdominal) temperature might stimulate enzymes involved in the synthesis of the proteins of the crystal. However, the exact molecular nature of the crystal lattice remains in both normal and cryptorchid testis obscure.

Management of imatinib-related exacerbation of psoriasis in a patient with a gastrointestinal stromal tumour.

A 62-year-old woman with a pre-existing psoriasis was treated with oral imatinib (400 mg/day) for a metastatic gastrointestinal stromal tumour. Within 4 weeks of starting therapy, she developed a guttate psoriasis flare. The eruption markedly improved within 2 weeks following cessation of imatinib. However, it recurred when imatinib was recommenced. She has been able to continue on imatinib (400 mg/day) with low-dose oral methotrexate (12.5 mg/week) controlling the psoriasis.

Perineural invasion of cutaneous squamous cell carcinoma and basal cell carcinoma: raising awareness and optimizing management.

BACKGROUND: Perineural invasion (PNI) by cutaneous squamous cell carcinoma (CSCC) and basal cell carcinoma (BCC) is an infrequent but not rare complication of traditionally low-morbidity skin cancers that can lead to catastrophic sequelae; 2.5% to 14% of CSCC and approximately 3% of BCC exhibit PNI. Tumors with PNI tend to be larger, have greater subclinical extension, have a higher rate of recurrence, and have a greater risk of metastases. Tumors with PNI may result in major neurologic deficits. OBJECTIVE: To review current recommendations for the management of PNI and to evaluate a treatment strategy involving excision using Mohs micrographic surgery (MMS) followed by adjunctive radiotherapy. MATERIALS AND METHODS: Cases of PNI treated with MMS and radiotherapy were reviewed for recurrence, disease-free follow-up, and adverse events. RESULTS: Twelve patients with incidental PNI treated with MMS and adjunctive radiotherapy are presented. After 3 to 32 months of follow-up, there had been no recurrences. Adverse events from radiotherapy were minor and self-limited. CONCLUSIONS: The use of adjunctive radiotherapy in these patients remains controversial. When managing superficial skin tumors with PNI, a multidisciplinary team including a cutaneous surgeon and a radiation oncologist familiar with PNI is recommended.

Physicians' interactions with third-party payers: is deception necessary?

Published reports indicate that physicians sometimes use deceptive tactics with third-party payers. Many physicians appear to be willing to deceive to secure care that they perceive as necessary, particularly when illnesses are severe and appeals procedures for care denials are burdensome. Physicians whose practices include larger numbers of Medicaid or managed care patients seem more willing to deceive third-party payers than are other physicians. The use of deception has important implications for physician professionalism, patient trust, and rational health policy development. If deception is as widespread as these studies suggest, there may be serious problems in the medical profession and the health care financing systems at the interface between physicians and third-party payers. Deception may be a symptom of a flawed system, in which physicians are asked to implement financing policies that conflict with their primary obligation to the patient.

Biogeochemical processes and microbial characteristics across groundwater-surface water boundaries of the Hanford Reach of the Columbia River.

Biogeochemical processes within riverbed hyporheic zones (HZ) can potentially impact the fate and transport of contaminants. We evaluated a modified freeze core technique for the collection of intact cobble-bed samples from the Columbia River HZ along a stretch of the Hanford Reach in Washington State and investigated microbiological and geochemical parameters of corresponding frozen and unfrozen samples. During three sampling periods (March, May, and November 2000), relatively high numbers of viable aerobic heterotrophic bacteria were recovered from both unfrozen (10(6)-10(7) cfu/g) and frozen samples (10(5)-10(6) cfu/g). Relatively large populations of sulfate-, nitrate-, and iron-reducing bacteria were present, and significant concentrations of acid-volatile sulfide were measured in some samples, indicating that anoxic regions exist within this zone. Cr(VI), a priority groundwater pollutant on adjacent U.S. Department of Energy lands, was probably removed from solution in HZ samples by a combination of microbial activity and chemical reduction, presumably via products of anaerobic microbial metabolism. These results suggest that biogeochemical processes in the Columbia River HZ may contribute to the natural attenuation of Cr(VI). Although freezing modestly diminished recovery of viable bacteria, freeze core techniques proved reliable for the collection of intact hyporheic sediments.