Meningeal carcinomatosis in undifferentiated nasopharyngeal carcinoma: a case report.

Meningeal carcinomatosis is the tumoral invasion of the leptomeninges. It is caused by the spread of malignant cells throughout the subarachnoid space, which produces signs and symptoms due to multifocal involvement. Cranial nerve symptoms are the most common focal findings. The diagnosis is usually made by imaging and/or cytology. Head and neck cancers are the cause of approximately 2% of all cases of meningeal carcinomatosis; in very rare cases, they are caused by a nasopharyngeal carcinoma. We report a case of meningeal carcinomatosis that was caused by a recurrence of undifferentiated nasopharyngeal carcinoma. The patient, a 60-year-old woman, experienced no focal neurologic symptoms and exhibited no radiologic evidence of meningeal involvement. We also review the literature on meningeal carcinomatosis secondary to nasopharyngeal carcinoma.

Disseminated superficial actinic porokeratosis.

Disseminated superficial actinic porokeratosis, which was described in 1966, is characterized by small, atrophic patches with distinctive keratin rims that occur on sun-exposed areas of the extremities, shoulders, and back. The diagnosis is based on the histopathologic finding of a cornoid lamella, absence of a granular layer, and often a thin epidermis. It is associated with exposure to ultraviolet radiation. Gene studies suggest a pathway defect in which several mutations in keratinocyte proliferation and differentiation lead to development of porokeratosis.

Histopathologic analysis of dermal lymphatic alterations in chronic venous insufficiency ulcers using D2-40.

BACKGROUND: Chronic venous insufficiency (CVI) ulcers represent a major medical problem worldwide. Current theories concerning the pathogenesis of CVI ulcers focus on abnormalities in the blood vascular system. Other abnormalities, such as chronic leg edema, may also play pathogenic roles in CVI ulcer development and further understanding of such alterations may lead to better treatments. OBJECTIVE: To gain insight into lymphatic abnormalities occurring in CVI, we compared dermal lymphatics in histologic sections from CVI ulcers and normal controls. METHODS: We compared global and architectural features of dermal lymphatics in D2-40-stained histologic sections from CVI ulcer tissue and from normal controls. D2-40 recognizes podoplanin, a transmembrane glycoprotein that is constitutively expressed in lymphatic endothelial cells, allowing us to distinguish dermal blood vessels from lymphatic vessels. RESULTS: Our analyses reveal that CVI ulcer specimens have more dermal lymphatic vessels per unit area than controls (5.71 vs 4.08 per mm(2), respectively; P = .0281); a higher percentage of lymphatic vessels with collapsed lumina compared with controls (30.5% vs 8.1%, respectively; P < .0001); and a higher percentage of competent lymphatic vessels displaying open inter-endothelial junctions compared with controls (5.7% vs 2.9%, respectively; P < .0369). LIMITATIONS: Our study is limited by its retrospective nature and relatively small sample size. CONCLUSIONS: Lymphatic vessels in CVI ulcer specimens display global and architectural differences compared with lymphatic vessels in control specimens. These findings further implicate lymphatic dysfunction in the pathogenesis of CVI ulcers and allow for the formulation of a hypothesis concerning lymphatic changes that may be tested in future studies.

Skin tightening of aging upper arms using an infrared light device.

BACKGROUND: Upper arm skin laxity is an important area of cosmetic concern. Recent studies using a noninvasive infrared device has demonstrated its efficacy in tightening skin in various body regions. The use of this device in upper arm loose skin has not been investigated. OBJECTIVES: To determine the safety and efficacy of an infrared device to treat upper arm laxity in aged skin. PATIENTS AND METHODS: Twenty women with mild to very loose aged upper arm skin underwent two treatments with an infrared device 1 month apart. Nineteen patients completed the study with a 3-month follow-up. Outcome measures included investigator and participant evaluations of skin laxity improvement, blinded photographic assessments of skin tightening, and differences in circumferences and spectrophotometric analysis of collagen content in the treated arms. Two patients participated in histological evaluations. RESULTS: The patient and investigator clinical assessments showed minimal improvement in skin laxity. There was a statistically significant decrease in arm circumference. Blinded photographic assessments and spectrophotometric analysis revealed no statistical improvement in skin laxity. The immediate post-treatment histological evaluations showed architectural disarray of dermal collagen and elastin. CONCLUSION: An infrared device is safe, well tolerated, and minimally effective in treating aged upper arm skin laxity.

Tumor necrosis factor-α in vitiligo: direct correlation between tissue levels and clinical parameters.

BACKGROUND: Experimental evidences have shown that tumor necrosis factor (TNF)-α may play a role in the pathogenesis of nonsegmental vitiligo, and successful cases of vitiligo treated with TNF-α inhibitors have been recently reported. MATERIALS AND METHODS: Two cases of refractory generalized vitiligo, which showed high tissue levels of TNF-α, were commenced anti-TNF-α antibody etanercept 50 mg weekly. A retrospective study, considering chart review and immunohistochemical staining for TNF-α, was then carried out on eight additional patients affected by untreated vitiligo. RESULTS: Etanercept achieved improvement of vitiligo in two patients at 6-month follow-up. Five out of eight specimens showed a strong cytoplasmic staining for TNF-α. Considering all 10 cases, patients with a strong TNF-α staining were characterized by a higher vitiligo disease activity score than patients with a weak staining. DISCUSSION: These findings, albeit limited in significance by the low number of cases and the retrospective nature of the study, confirm a probable role of TNF-α in the pathogenesis of vitiligo. The intensity of TNF-α staining in vitiligo lesions may be worth to be further studied as a biomarker for potentially successful anti-TNF-α treatment of nonsegmental vitiligo in cases refractory to conventional treatment.

Earlier stage at diagnosis and improved survival among Medicare HMO patients with breast cancer.

OBJECTIVE: We sought to evaluate differences in the stage at diagnosis and the survival of breast cancer patients enrolled in two different Medicare healthcare delivery systems: fee for service (FFS) and health maintenance organizations (HMO). METHODS: We used a linkage of two national databases, the Medicare database from the Centers for Medicare and Medicaid Services (CMS), and the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program database, to evaluate differences in demographic data, stage at diagnosis, and survival in patients with breast cancers over the period 1985-2001. RESULTS: Medicare patients enrolled in HMOs were diagnosed at an earlier stage of diagnosis than FFS patients. HMO patients diagnosed with breast cancer had improved survival, and these differences remained even after controlling for potential confounders. Specifically, breast cancer patients enrolled in HMOs had 9% increased probability of survival (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.88-0.93) than their counterparts enrolled in FFS. These findings persisted even when patients had a cancer diagnosis before their breast cancer. CONCLUSIONS: Improved survival among breast cancer patients in HMOs compared with FFS is likely due to a combination of factors, including but not limited to earlier stage at the time of diagnosis.

Increasing rates of melanoma among nonwhites in Florida compared with the United States.

OBJECTIVE: To compare melanoma trends within Florida with national melanoma trends from 1992 through 2004. An analysis of state and national melanoma trends is critical for the identification of high-risk regions of the country. DESIGN: Data from the Florida Cancer Data System (FCDS) and Surveillance, Epidemiology, and End Results (SEER) were evaluated to determine age-adjusted and race/ethnicity- and sex-specific invasive cutaneous melanoma incidence trends for 1992 through 2004 using joinpoint regression analysis. Standardized incidence rate ratios (SIRRs) were computed to compare Florida with the United States. PATIENTS: A population of 109 633 patients with invasive melanoma was evaluated: 73 206 (66.8%) from SEER and 36 427 (33.2%) from FCDS. MAIN OUTCOME MEASURES: Melanoma incidence and change in melanoma rates over time. RESULTS: The incidence of melanoma among male Hispanic patients residing in Florida was 20% higher than that of their male counterparts in the SEER catchment areas (SIRR, 1.2; 95% confidence interval [CI], 1.1-1.4). Conversely, the incidence of melanoma among female Hispanic patients residing in Florida was significantly lower than that in SEER (SIRR, 0.7; 95% CI, 0.7-0.8). Differences in melanoma incidence were identified in female non-Hispanic black (NHB) patients in Florida who had a 60% significantly higher incidence of melanoma compared with female NHB patients in SEER (SIRR, 1.6; 95% CI, 1.3-2.0). CONCLUSION: These findings suggest an emerging public health concern in race/ethnic subgroups that were previously understudied.

Differences in melanoma outcomes among Hispanic Medicare enrollees.

BACKGROUND: Hispanics are given the diagnosis of melanoma at later stages and have reduced survival. OBJECTIVE: We sought to evaluate the effect of Hispanic ethnicity and different health care delivery systems (fee-for-service [FFS] and health maintenance organizations) on melanoma stage at diagnosis and survival. METHODS: We studied a retrospective cohort of 40,633 patients, with at least 3 years of follow-up, who were given the diagnosis of incident melanoma from 1991 to 2002 and were 65 years or older using data from the Surveillance, Epidemiology, and End Results-Medicare linked database. The analytic sample consisted of 39,962 non-Hispanic whites (NHW) and 671 Hispanics. Logistic regression models examined the roles of the health care delivery system and race/ethnicity in stage at diagnosis and survival. RESULTS: For FFS patients, Hispanics were more likely to be given a diagnosis at an advanced stage (distant vs earlier stages [odds ratio {OR} = 2.07; 95% confidence interval CI = 1.36-3.16]; regional vs earlier stages [OR = 2.31; 95% CI = 1.75-3.03]) compared with NHW. Among Hispanic patients, those enrolled in health maintenance organizations were less likely to be given a diagnosis at later stage (regional vs earlier stages [OR = 0.50; 95% CI = 0.31-0.81]) than FFS patients; however, the earlier stage at diagnosis did not improve survival. For patients with a previous cancer before their melanoma diagnoses, NHW enrolled in health maintenance organizations from 1991 to 2002 were given a diagnosis at earlier stages compared with NHW FFS patients (OR = 0.72; 95% CI = 0.52-0.99); this was not found among Hispanics. LIMITATIONS: These results reflect findings in a Medicare-aged population and it is not clear if they are generalizable to younger patients. CONCLUSIONS: Differences in melanoma outcomes among different ethnic groups are, in part, dependent on the health care setting in which patients are enrolled.

Disparity in melanoma: a trend analysis of melanoma incidence and stage at diagnosis among whites, Hispanics, and blacks in Florida.

OBJECTIVE: To examine and compare the temporal trends in melanoma incidence and stage at diagnosis among whites, Hispanics, and blacks in Florida from 1990 to 2004. DESIGN: Cross-sectional and retrospective analysis. SETTING: Florida Cancer Data System. PATIENTS: Melanoma cases with known stage and race/ethnicity reported from 1990 to 2004. MAIN OUTCOME MEASURES: Age-adjusted melanoma incidence and stage at diagnosis. RESULTS: Of 41 072 cases of melanoma, 39 670 cases were reported for white non-Hispanics (WNHs), 1148 for white Hispanics (WHs), and 254 for blacks. Melanoma incidence rates increased by 3.0% per year among WNH men (P < .001), 3.6% among WNH women (P < .001), 3.4% among WH women (P = .01), and 0.9% among WH men (P = .52), while remaining relatively stable among black men and women. Both WHs and blacks had significantly more advanced melanoma at presentation: 18% of WH and 26% of black patients had either regional or distant-stage melanoma at diagnosis compared with 12% of WNH patients. The proportion of distant-stage melanoma diagnosed among WHs and blacks changed little from 1990 to 2004, compared with a steady decrease in the percentage of melanoma cases diagnosed at distant stage among WNHs (P < .001). Such differences in the time trends of the proportion of distant-stage melanoma remained after excluding in situ cases. CONCLUSIONS: The rising melanoma incidence among WNHs and WHs emphasizes the need for primary prevention. The persistence of disparity in melanoma stage at diagnosis among WHs, blacks, and WNHs warrants closer examination of secondary prevention efforts in minority groups.

Knowledge, attitudes, and behaviors of elementary school students regarding sun exposure and skin cancer.

The aim of this study was to assess baseline knowledge of skin cancer, sun protection practices, and perceptions of tanning among third through fifth grade elementary students in Florida. A total of 4,002 students in nineteen elementary schools in Palm Beach County, Florida were surveyed. SunSmart America curriculum pretest responses were the main outcome measures. Overall students' knowledge using a students' mean knowledge scale scores of skin cancer and sun protection were low (<40% of questions answered correctly) and was found to increase with increasing grade level (p < 0.01). Boys more frequently reported spending greater than 2 hours in the sun when compared with girls (p < 0.01). Girls, however, were more likely to try and get a tan most of the time or always when compared with boys (p = 0.02). Non-Hispanic White students (51.3%) more frequently reported use of SPF 15 or greater sunscreen "most of the time or always" compared with Hispanic (35.3%) and non-Hispanic Black (13.4%) students (p < 0.01). Elementary aged students in south Florida have limited knowledge about sun safety, despite spending considerable amount of time in the sun. Sun safe behavior is associated with gender and ethnicity. The findings provide empirical support for the need of a school-based educational intervention.

Acquiring allergen information from condom manufacturers: a questionnaire survey.

BACKGROUND: Allergic contact dermatitis from condoms is a problem that carries significant morbidity and that has been increasingly reported due to the use of condoms to prevent sexually transmitted diseases as well as for birth control. OBJECTIVE: The purpose of the study is to evaluate the process by which condom manufacturing companies divulge product allergen information to health care professionals. METHODS: An interviewer-administered telephone questionnaire eliciting the staff member's knowledge of condom allergens was utilized. Eligible respondents were condom manufacturers' service staff over 18 years of age. RESULTS: Complete surveys were obtained regarding 36 (85.7%) of the 42 subtypes of condoms. Telephoning was the primary (75%) method of obtaining allergen information. The majority (63.9%) of the information was obtained within minutes to hours of the initial contact. Nearly two-thirds of the interviews evaluated the condom manufacturers' service staff as good and effective in their knowledge base and in providing product information. CONCLUSION: The study determined that the extent of knowledge, helpfulness, and effectiveness of the customer service personnel in relaying product allergen information to clinicians were generally good. The study additionally generated a reference table outlining the common allergens in major manufactured condoms.

Knowledge of Surgery-Related Allergic Contact Dermatitis among Florida Dermatological Surgeons: A Pilot Study.

Objective. To assess knowledge base and practice habits of dermatological surgeons regarding surgery-related allergic contact dermatitis. Design. Cross-sectional study. Setting. The Florida Society of Dermatologic Surgery served as the study group. Participants. Cohort of dermatological surgeons. Measurements. An anonymous, close-ended survey instrument eliciting common surgical practices as well as allergic contact dermatitis knowledge. Results. Among the 45 respondents, 87 percent reported performing surgery more than 10 times per week and only 14 percent of respondents reported using latex-free gloves in their practice. Nearly two-thirds (66%) of respondents reported diagnosing allergic contact dermatitis either among themselves, their surgical staff, and/or patients. Surgeons were noted to use the TRUE Test((R)) to screen for adhesive allergy. While colophony can be found both in adhesive products and on the TRUE Test, the main adhesives found in perisurgical products, acrylates, cannot. Similarly, the TRUE Test does not screen for antiseptics, yet this group of respondents suspected antiseptics nearly one-fourth of the time and used the TRUE Test to screen for them. Lastly, six dermatological surgeons used the TRUE Test to screen for suture allergy. While only two used chromated cat gut (the TRUE Test screens for chromium), the other surgical components are not screened. Conclusion. Education among dermatological surgeons is needed regarding exposure to a potential allergen in the surgical setting and risk of developing allergic contact dermatitis.

Melanoma in Hispanic and black Americans.

BACKGROUND: Although age-adjusted incidence rates (per 100,000) for melanoma are lower among Hispanics and blacks (4.5 and 1.0, respectively) compared with white non-Hispanics (21.6), melanomas among minority populations in the United States are more likely to metastasize and have poorer outcomes. METHODS: A review of the literature was conducted on melanomas affecting Hispanic and black Americans. RESULTS: Because of the low index of suspicion in both the medical community and these ethnic populations, diagnosis is often delayed, resulting in advanced presentation and a poorer prognosis. CONCLUSIONS: More comprehensive medical training, expanded public educational campaigns, and increased awareness among patients of all skin types to perform self skin checks are recommended. Further studies elucidating the etiology and risk factors for melanoma among minority populations are warranted.

Cutaneous soft tissue sarcoma incidence patterns in the U.S. : an analysis of 12,114 cases.

BACKGROUND: Cutaneous soft tissue sarcomas (CSTS) are a heterogeneous group of mesenchymal neoplasms. To the authors' knowledge, no prior large, population-based study has focused on CSTS. METHODS: Surveillance, Epidemiology, and End Results (SEER) Program incidence and relative survival rates of CSTS were analyzed according to race, sex, and histologic type using the 2002 criteria of the World Health Organization classification. RESULTS: Among residents of the 13 SEER registries, 12,114 CSTS were diagnosed from 1992 through 2004. Overall age-adjusted CSTS incidence rates were highest among blacks (30.8 per 1,000,000 person-years) followed by whites (25 per 1,000,000 person-years), and American Indians/Alaska Natives (11.2 per 1,000,000 person-years) and were lowest among Asian/Pacific Islanders (7.7 per 1,000,000 person-years). Kaposi sarcoma (KS) accounted for 71.1% of cases, and the rates were similarly ranked. Dermatofibrosarcoma protuberans (DFSP) rates also were highest among blacks, whereas leiomyosarcoma (LS) and angiosarcoma (AS) rates were highest among whites. The rate ratio of men to women was 25.5 for KS, 4.7 for malignant fibrous histiocytoma (MFH), 3.7 for LS, 2.0 for AS, and 0.9 for DFSP. The 5-year relative survival rates were 99% for patients with DFSP, 89% for patients with MFH, 92% for patients with LS, and 45% for patients with AS. KS rates among men in the original 9 SEER registries increased more than 30-fold during the 1980s before they peaked around 1991 and subsequently declined rapidly because of human immunodeficiency virus-associated KS and highly active antiretroviral therapy. This KS pattern was evident not only among those ages 20 to 59 years but also among those ages 60 to 69 years. From 1978 through 2004, LS and AS rates among whites increased exponentially. CONCLUSIONS: CSTS rates varied markedly over time and by race, sex, and histologic type, supporting the notion that these histologic variants of CSTS areetiologically distinct.

Reported skin cancer screening of US adult workers.

BACKGROUND: Early detection of skin cancer by skin examination may reduce its associated morbidity and mortality, in particular for workers routinely exposed to sun. OBJECTIVES: We sought to describe the proportion of US workers reporting skin cancer screening examination in a representative sample of the US worker population in the National Health Interview Survey. METHODS: Report of skin cancer examination in the 2000 and 2005 National Health Interview Survey cancer control supplements were examined by a range of variables. RESULTS: Lifetime and 12-month reported clinical skin examination prevalence was 15% and 8%, respectively. Workers with elevated occupational exposure to ultraviolet light were less likely to have ever received a skin examination than the average US worker. Logistic regression analysis identified occupational category and age, sex, race, education level, health insurance, and sun-protective behavior as significant independent correlates of skin cancer examination. LIMITATIONS: A limitation is potential healthy worker effect and underestimation of skin cancer screening with self-reported data. CONCLUSIONS: Routine examination by primary care physicians frequently does not include a thorough skin examination. Physicians should be even more vigilant with patients at increased risk of excessive occupational sun exposure, as early detection of skin cancer by periodic skin examination decreases morbidity and can improve survival.

Predictors of skin cancer screening practice and attitudes in primary care.

BACKGROUND: Physician visits provide invaluable opportunities to screen patients for skin cancer, yielding earlier detection and improved survival. OBJECTIVE: We sought to assess frequency of skin cancer screening by full body skin examinations (FBSE) by primary care physicians, patient attitudes toward FBSE, and risk factors for cutaneous malignancy. METHODS: Questionnaires were distributed to patients at primary care and dermatology clinics. RESULTS: A total of 426 participants were surveyed. Overall, 20% of patients reported having undergone regular FBSE by their primary care physician. Sex, race, personal skin cancer history, and Fitzpatrick skin type were predictive of whether a FBSE was performed by a patient's primary care physician. Men were more likely to report having undergone a FBSE (22% vs 19%; P < .01); women were more likely to report feeling embarrassed by a FBSE (15% vs 4%; P < .01). LIMITATIONS: This study was conducted at a single site academic center. CONCLUSION: Although low rates of skin cancer screening are reported by patients, those at higher risk are being screened more frequently. Sex disparity exists, and as both male and female patients have a strong preference to undergo FBSE, unmet opportunities for skin cancer prevention should be maximized.

Pilot study of socioeconomic class, nutrition and birth defects in Spain.

Research has indicated that the appropriate intake of folic acid, a B vitamin, before and during early pregnancy has been shown to prevent 50-70% of neural-tube defects. Increased NTD incidence has long been reported to occur more frequently among women of lower socioeconomic (SES). Since consumption of the folate-rich Mediterranean diet in Spain does not vary by socio-economic status (SES), we hypothesized that there would be no social class effect on NTD occurrence. Using data from a Spanish hospital-based birth defects registry, we studied the risk of Neural Tube Defects (NTDs) in 980 cases and 774 controls between 1980 and 2003. Our analysis showed that the risk of NTDs did not vary by SES. This finding suggests that increased access to folate and nutrition education might benefit women of lower SES in the US.