A cardiac computed tomography first strategy to evaluate chest pain in a rural setting: outcomes and cost implications.

INTRODUCTION: Chest pain continues to be a major burden on the healthcare system with more than eight million patients being evaluated in the emergency department (ED) setting annually at a cost of greater than 10 billion dollars. Missed chest pain diagnoses for ischemia are the leading cause of malpractice lawsuits for ED physicians. The use of cardiac computed tomography angiography (CCTA) to assess acute chest pain was adopted at the Chickasaw Nation Medical Center to attempt to accurately diagnose low to intermediate risk chest pain and potentially reduce the cost of chest pain evaluation to the system while still transferring appropriate high-risk patients. PATIENTS AND METHODS: Patients presenting to the ED with low to moderate risk chest pain were evaluated with at least two negative troponin levels, an ECG, and in most instances overnight observation followed by CCTA in the morning if eligible. High-risk patients were transported to a tertiary care facility with cardiac catheterization capabilities. Medical records were checked to determine if any adverse events had occurred during follow-up. Adverse events were defined as myocardial infarction, death, and/or revascularization. Mean follow-up was 28 months. RESULTS: Of the 368 patients studied, 29 patients were transferred due to findings of at least moderate obstructive disease. Of those 29 patients transferred, 11 patients underwent revascularization (10 underwent percutaneous coronary intervention and one underwent coronary artery bypass grafting). The average coronary artery calcium score for patients transferred was 96.1. The average coronary artery calcium score for patients undergoing revascularization was 174.6. Six patients had normal coronary arteries on catheterization. The remaining 12 patients had the moderate obstructive disease by catheterization that was not physiologically significant by either invasive fractional flow reserve or in two instances, negative stress perfusion testing. At 24 months, two patients had undergone revascularization and one patient had died suddenly. CONCLUSION: The cost savings associated with a CCTA first strategy to evaluate chest pain were ~$1 200 244.10. For a self-insured health system such as the Chickasaw Nation, these are very important cost savings.

Acroangiodermatitis of Mali and Stewart-Bluefarb syndrome.

Acroangiodermatitis (AAD), also known as pseudo-Kaposi sarcoma, is a rare benign vascular proliferation mainly of the extremities. It is characterized by violaceous patches or plaques resembling Kaposi sarcoma. The term pseudo-Kaposi sarcoma encompasses 2 variants of acroangiodermatitis: Mali type and Stewart-Bluefarb syndrome (SBS). Mali-type AAD is more common and is associated with chronic venous hypertension, while SBS is more rare and is associated with arteriovenous malformations and iatrogenic arteriovenous fistulae. We report 2 patients, representing each type of AAD.

Multinucleate cell angiohistiocytoma: Case report and literature review.

Multinucleate cell angiohistiocytoma is a rare, vascular, fibrohistiocytic proliferation that has a benign but progressive course. The clinical presentation is that of grouped red-purple papules and nodules characteristically located on the lower extremities in women. The histopathology shows a proliferation of narrow vessels within thickened collagen bundles associated with multinucleate giant cells. These lesions are probably reactive in nature, and several mechanisms of pathogenesis, including hormonal, have been proposed. Different modalities, including intense pulsed light and pulsed-dye laser, have been used for treatment of these lesions. We report a case of a 74-year-old Caucasian woman with long-standing multinucleate angiohistiocytoma on her bilateral thighs that eluded diagnosis for several years. Upon biopsy and histopathological analysis, the diagnosis was made. Treatment options were entertained, although ultimately not pursued by the patient. We report this case to increase clinical awareness of this rare disease and to contribute to the ongoing literature aimed to further characterize this condition.

Comparison of skin concentrations following topical versus oral corticosteroid treatment: reconsidering the treatment of common inflammatory dermatoses.

BACKGROUND: Topical corticosteroids are often considered to have greater safety and poorer efficacy than oral corticosteroids in treating psoriasis and atopic dermatitis. There are limited data for assessing relative efficacy of topical and systemic corticosteroids, however. The concentration of corticosteroid in skin, adjusted for the relative potency of the active compound, may be a predictor of clinical efficacy and can be estimated for both topical and oral administration. PURPOSE: To analyze the assumption that oral corticosteroid therapy should be more potent than topical therapy by comparing relative corticosteroid concentrations in the skin expected with topical versus systemic administration. METHODS: The estimated skin concentration of prednisone following oral dosing was calculated based on data showing 70-100% bioavailability and an even tissue distribution. Data on the concentration of corticosteroids found in skin after topical application were obtained from the literature. The relative potencies of corticosteroid molecules were then used to compare skin concentrations of corticosteroid following topical versus oral treatment. RESULTS: Data derived from the existing literature demonstrated that hydrocortisone 2.5% ointment, triamcinolone 0.1% ointment, and clobetasol 0.05% foam achieved effective skin concentrations greater than the effective concentration achieved by oral prednisone. Betamethasone 0.1% cream achieved effective concentrations in skin within the range created by oral prednisone. LIMITATIONS: This analysis was limited by the paucity of data regarding cutaneous concentrations of corticosteroids after topical application, and by the differing experimental designs utilized in the available studies. CONCLUSION: Most topical corticosteroids have the potential to achieve greater effective drug levels in the superficial layers of skin than those achieved with standard doses of oral prednisone. The apparently greater efficacy of oral corticosteroid therapy may be attributable, in part, to poor patient compliance with topical therapy. Systemic alterations in immune function following oral, but not topical, corticosteroid use may also play a role.

Do topical retinoids cause acne to "flare"?

BACKGROUND: Guidelines support this use of topical retinoids as a fundamental part of acne treatment regimens. However, existing dogma holds that topical retinoids may initially worsen acne. PURPOSE: To review the available data from clinical trials for evidence of initial worsening of acne with topical retinoids. METHODS: A PubMed and Google Internet search was performed for sources indicating or refuting worsening of acne with topical retinoids. RESULTS: No primary data from clinical trials were identified to support the dogma of acne worsening secondary to topical retinoids. Available data point to topical retinoids improving acne, even during the first couple weeks of treatment. CONCLUSION: It is unlikely that acne worsens or "flares" due to the initiation of topical retinoids. Some acne patients may have worsening of acne during the first week or two as part of the natural disease process.

Keratolytics for psoriasis: are they necessary?

It is a common belief that keratolytic agents are required to enhance the penetration of topical medications into thick psoriatic plaques. However, is this belief evidence-based?

The clinical value of histologic examination in shoulder arthroscopy.

BACKGROUND: The clinical value of histologic examination of tissues removed during shoulder arthroscopy has not been determined. The guidelines of the College of American Pathologists require routine histologic examination of all surgical specimens not specifically exempted by individual hospitals. Previous orthopaedic studies have examined the clinical value of these examinations in total hip and knee arthroplasty, lumbar discectomy, knee arthroscopy, and thumb arthroplasty. Those studies demonstrated that routine histologic examination rarely altered the diagnosis and increased the costs. This study examines the clinical value of histologic examination of shoulder arthroscopic specimens. We regard clinical value to include both diagnostic value and cost of the procedure. METHODS: Between 1989 and 2005, 2144 consecutive shoulder arthroscopies were performed by one surgeon. We retrospectively reviewed the pathology report from every procedure to determine whether the histologic diagnosis affected patient care. We then estimated the total cost of histologic examination in 2005 dollars. RESULTS: In all cases, the histologic examination confirmed the findings at arthroscopic surgery. In no case did the histologic findings alter patient care. In 2005 dollars, the total cost of reviewed histologic examinations is estimated to be $160,543. CONCLUSIONS: Histologic examination of surgical specimens from arthroscopic shoulder surgery does not alter patient care, and it increases costs. On the basis of this study, histologic examination in shoulder arthroscopy should be done at the discretion of the orthopaedic surgeon rather than being mandatory.

Self-assembled diisocyanide monolayer films on gold and palladium.

Self-assembled monolayers (SAMs) of the aromatic diisocyanides, 1,4-phenylenediisocyanide, 2,3,5,6-tetramethyl-1,4-phenylenediisocyanide, 4,4'-biphenyldiisocyanide, 3,3',5,5'-tetramethyl-4,4'-biphenyldiisocyanide, and 4,4' '-p-terphenyldiisocyanide, were prepared on gold and palladium surfaces. The SAMs were characterized by ellipsometry, polarization-modulated infrared reflection-absorption spectroscopy (PM-IRRAS), and grazing-angle attenuated total reflectance infrared spectroscopy (GATR). Based on the position of the metal-coordinated isocyanide stretching band, the SAMs on gold were found to bind in the terminal (eta(1)) geometry, while the SAMs on palladium prefer a different geometry which is possibly a triply bridging (mu(3)-eta(1)) geometry. A side-reaction of the unbound isocyanide in the SAM was identified as oxidation to an isocyanate group.