Antimetabolites and cytotoxic drugs.

Mycophenolic mofetil, azathioprine, thioguanine, methotrexate, and cyclophosphamide were initially used for the treatment of malignancies. Because of their immunosuppressive activity, the range of diseases responsive to these medications has expanded to include various autoimmune-related diseases. Discussion includes a historical perspective of each medication, recent updates on responsive dermatologic conditions, dosages, monitoring guidelines, and medication expense.

Basal cell carcinoma in children: report of 3 cases.

BACKGROUND: The peak incidence of basal cell carcinoma occurs in the seventh decade of life and is rare in children. When found in the pediatric age group, basal cell carcinoma is usually associated with a genetic defect, such as basal cell nevus syndrome, xeroderma pigmentosum, or nevus sebaceus. In areas of intense UV radiation exposure, such as the southwestern United States, children may be at increased risk of developing this malignancy de novo. OBSERVATIONS: Three children (2 boys, aged 8 and 16 years, and an 11-year-old girl) from Tucson, Ariz, with isolated basal cell carcinoma unassociated with any other disease or syndrome are described. CONCLUSIONS: Basal cell carcinoma in children is probably the result of a combination of UV radiation exposure and genetic background. Early recognition in children can prevent extensive tissue destruction and excess scarring after excision. A higher index of suspicion for basal cell carcinoma may also aid in prompt diagnosis of a possible genetic disorder, such as basal cell nevus syndrome.

Pulse dosing of thioguanine in recalcitrant psoriasis.

BACKGROUND: Patients with severe psoriasis may be unresponsive to or unable to tolerate the adverse effects of traditional therapy. Thioguanine has been used to treat psoriasis, but experience is limited. Most previous studies have used daily therapy and have demonstrated significant hematologic abnormalities. OBJECTIVE: To reduce the adverse effects of traditional thioguanine therapy, our study patients were treated with thioguanine with a pulse-dosing schedule of 2 to 3 times per week. OBSERVATIONS: Marked improvement of recalcitrant psoriasis was noted in 10 (71%) of 14 patients receiving thioguanine therapy using a pulse-dosing schedule. Maintenance dosage ranged from 120 mg twice a week to 160 mg 3 times a week. Adverse effects were minimal. CONCLUSIONS: Thioguanine therapy is an effective treatment for recalcitrant psoriasis. A dosing schedule of 2 or 3 times per week is recommended to minimize the potential adverse effects. Routine laboratory follow-up is suggested to screen for potential adverse effects, with special attention to bone marrow suppression.

Diagnostic accuracy and image quality using a digital camera for teledermatology.

OBJECTIVE: The study was designed to evaluate the effectiveness of digital photography for dermatologic diagnoses and compare it with in-person diagnoses. MATERIALS AND METHODS: Patients referred for specialty consultations (n = 308) were recruited from a university dermatology clinic. Patients were examined in-person by one of three board-certified dermatologists who provided clinical diagnoses. Digital photos were obtained on all patients and were evaluated as computer images by a panel of dermatologists. RESULTS: There was 83% concordance between in-person versus digital photo diagnoses. Intradermatologist concordance averaged 84%, and interdermatologist concordance averaged 81%. Decision confidence was rated as "very definite" to "definite" 62% of the time. Concordance with biopsy results was achieved in 76% of the cases. Image sharpness and color quality were rated "good" to "excellent" 83% and 93% of the time, respectively. CONCLUSION: Digital photography for store-and-forward teledermatology produces high-quality images and diagnostic concordance rates that compare favorably with in-person clinical diagnoses.

Differences in plasminogen activator inhibitor 1 activity between blacks and whites may be diet related.

Two matched groups of healthy non-smoking male volunteers between 18 and 23 years old and with a body mass index of 19-24 kg/m2 were selected from urban whites (n = 15) and from rural Vendas (blacks; n = 17). Fasting venous blood samples were collected between 07.00 and 10.00 h, and a validated food frequency questionnaire was administered. The results showed highly significant differences in dietary patterns. Significant differences were observed with regard to serum cholesterol (p < 0.02), percentage high-density lipoprotein cholesterol (p < 0.02), calculated insulin sensitivity index (p < 0.04), and plasma fibrinogen levels (p < 0.03). Tissue plasminogen activator antigen did not differ significantly. The plasminogen activator inhibitor 1 activity was significantly lower (p < 0.0001) in the Vendas than in the whites. It is concluded that diet may be an important determinant of plasminogen activator inhibitor 1 activity.

Both fish oil and olive oil lowered plasma fibrinogen in women with high baseline fibrinogen levels.

This double-blind, cross-over study with olive oil as placebo, examined the effect of a daily dosage of 6 g fish oil on cardiovascular risk markers of 20 healthy young volunteers (10 men, 10 women). Serum lipids and lipoproteins, and plasma coagulation and fibrinolytic enzymes, including fibrinogen concentrations and plasminogen activator inhibitor-1 (PAI-1) activity were measured at baseline and after 6-week supplementation of either fish or olive oil. The results showed that fish oil had an independent lowering effect on triglycerides and coagulation factors Vc and VIIc. Both fish and olive oil significantly raised PAI-1 levels and lowered plasma factor Xc and fibrinogen levels in the women, who had higher initial levels than the men. Mean fibrinogen levels of the women were lowered from 3.23 +/- 0.98 to 2.64 +/- 0.55 g/l and from 3.19 +/- 0.72 to 2.66 +/- 0.49 g/l by fish and olive oil respectively. This study raises the question whether a particular fatty acid or group of fatty acids, or another constituent of the oil such as vitamin E may be responsible for the fibrinogen lowering effect.

Nutritional recommendations for individuals with diabetes mellitus.

The diabetic diet is fundamentally a healthy diet, high in complex carbohydrates, high in dietary fibre, low in fat. A nutritionally adequate, mixed diet is satisfactory for most people with diabetes and special foods or food supplements are not required. The dietary recommendations directed towards the diabetic population are essentially similar to those recommended by most authorities for the population as a whole. Education of diabetic patients and their families and also individualised diet and meal planning are essential components in the management of diabetes mellitus. Weight loss and subsequent maintenance of a desirable body weight should be achieved when necessary. The amount of carbohydrate should be liberalised, including a wide variety of fibre-rich complex carbohydrates. In some individuals modest amounts of sucrose taken at meal times are acceptable. Foods with lower glycaemic indices should be offered on trial to people with diabetes. Total fat intake, especially saturated fat, should be restricted. More research is needed before recommendations regarding eicosapentaenoic acid supplementation can be made. Protein intake should be restricted to the Recommended Daily Allowance except in groups at risk of negative nitrogen balance. A restriction in salt intake is advised. Alcoholic beverages and nutritive and non-nutritive sweeteners may be used, but in moderate amounts.

Egg intake does not change plasma lipoprotein and coagulation profiles.

The effect of the intake of 3-14 eggs/wk on biochemical risk markers of coronary heart disease (CHD) was examined in 70 young men who followed a high-fat diet. The study consisted of a run-in phase during which all subjects ate 3 eggs/wk for 2 mo and an experimental phase during which a reference group continued eating 3 eggs/wk and two experimental groups ate either 7 or 14 eggs/wk for 5 mo. The mean coefficients of variation in total plasma cholesterol (5.4-7.4%) were similar in all three groups and were larger than the mean changes of 0.2-5.6% in plasma cholesterol from baseline to end in the experimental groups. Except for increased lecithin-cholesterol acyltransferase activities and total serum protein concentrations, no significant differences in lipoproteins or coagulation factors occurred between groups. It seems that egg intake in this range did not influence CHD risk markers in these subjects. Recommendations to lower risk should probably concentrate on a reduction in fat and not cholesterol intake.

Occult basal-cell carcinoma within rhinophyma.

Rhinophyma, the end stage in the development of rosacea, is characterized by sebaceous hyperplasia, fibrosis, follicular plugging and telangiectasia. Although it is commonly considered a cosmetic problem, it can result in gross distortion of soft tissue and in airway obstruction. Previously, basal-cell carcinoma (BCC) has been reported in association with rhinophyma. We are reporting an additional case in which the patient had been delaying treatment because of the 'cosmetic nature' of this condition.

Influence of a habitual high egg intake on serum lipid levels in a rural coloured population.

The effect of a habitual high cholesterol intake on serum cholesterol and other lipid levels against the background of a moderate fat intake was investigated in 30 rural coloured volunteers (16 men, 14 women) working on an egg farm. Protein contributed approximately 11%, fat 31%, carbohydrate 58% (sucrose 21%) of energy intake. Daily cholesterol intake averaged 575 mg. In men, although not in women, cholesterol intake correlated negatively with serum cholesterol and low-density lipoprotein cholesterol levels, indicating that a high consumption of eggs in the study population did not prejudice lipid homeostasis. The population exhibited a high profile of coronary heart disease risk factors.

Spindle-cell and pleomorphic neoplasms of the skin. A clinicopathologic and immunohistochemical study of 30 cases, with emphasis on "atypical fibroxanthomas".

Atypical fibroxanthoma belongs to the family of spindle-cell and pleomorphic neoplasms of the skin. The lineage of differentiation of this tumor and the means whereby it can be diagnostically separated from other similar morphologic entities have been controversial. In order to address these issues, the authors studied 30 spindle-cell and/or pleomorphic cutaneous tumors, including atypical fibroxanthomas (AFXs), superficial malignant fibrous histiocytomas (MFHs), dermatofibrosarcoma protuberans (DFSPs), sarcomatoid squamous-cell carcinomas (SCCs), spindle-cell malignant melanomas (MMs), and leiomyosarcomas, (LMSs). These cases were analyzed using a panel of eight antibodies and the immunoperoxidase technique. AFXs were reactive for vimentin, alpha-1-antichymotrypsin (AACT), alpha-1-antitrypsin (AAT), and cathepsin-B (CB) but failed to display cytokeratin (CK), epithelial membrane antigen (EMA), S-100 protein, and desmin. MFHs and DFSPs exhibited immunophenotypic profiles that were nearly identical to that just described. In contrast, SCCs were typified by positivity for CK and EMA; MMs exhibited uniform reactivity for S-100 protein; and LMSs contained desmin in four of five cases. A surprising result was the expression of S-100 by LMSs. Also, all tumors displayed at least one of the three proteolytic enzymes assessed in this study (AAT, AACT, and CB), demonstrating the relative diagnostic nonspecificity of these determinants. It is concluded that AFXs are "fibrohistiocytic" neoplasms, with substantial morphologic and immunohistochemical similarity to MFHs. The immunohistochemical classification of spindle-cell and pleomorphic tumors of the skin necessitates the use of antibody panels to assess the presence of markers that are characteristic of each diagnostic group.

Serum cholesterol, lipoproteins, and plasma coagulation factors in South Africa blacks on a high-egg but low-fat intake.

Twenty-five rural South African black males who worked on an egg farm an average of 4.1 yr had a mean habitual cholesterol intake of 1240 mg/d with fat supplying only 20% of total energy. Although total serum cholesterol was slightly although significantly higher and serum triglycerides significantly lower than those for a control group, no disturbance was evoked in the distribution of cholesterol between HDL, LDL, and VLDL fractions. Coagulation factors were within the normal range, but the high egg consumer group had significantly higher plasma fibrinogen and factor IX levels with a shorter mean prothrombin and partial thromboplastin time, possibly indicative of a slight hypercoagulable state. Apparently rural blacks can handle a very high cholesterol intake without meaningful disturbance in serum lipid homeostasis.

Nutritional status of thoracic surgical patients. A prospective evaluation.

The nutritional status of 102 thoracic surgical patients was studied prospectively. Fifty patients showed combined or single abnormalities of the parameters studied. Seventy per cent of the patients with empyema were found to have abnormal nutritional values. Thirteen of 20 patients with oesophageal obstruction (malignant or benign) were also found to be malnourished or to have pathological nutritional parameter values. The diagnosis and correction of malnourishment in patients who are to undergo surgical procedures should be undertaken early.