Recruitment and enrollment for the simultaneous conduct of 2 randomized controlled trials for patients with subacute and chronic low back pain at a CAM research center.

OBJECTIVE: To describe recruitment and enrollment experiences of 2 low back pain (LBP) randomized controlled trials (RCTs). DESIGN: Descriptive report. SETTING: Chiropractic research center in the midwest United States that is not a fee-for-service clinic. PARTICIPANTS: Both trials enrolled participants with subacute or chronic LBP without neurologic signs who had not received spinal manipulative care during the previous month. For study 1 we screened 1940 potential participants to enroll 192 participants (89 women and 103 men), mean age 40.0 +/- 9.4 years (range, 21-54 years). For study 2 we screened 1849 potential participants to enroll 240 participants (105 women and 135 men) at least 55 years old (mean, 63.1 +/- 6.7 years). INTERVENTIONS: Study 1 randomly assigned participants to 2 weeks of 2 different chiropractic techniques or a wait list control group. Study 2 randomly assigned participants to 6 weeks of 2 different chiropractic techniques or medical care consisting of 3 provider visits for medications. OUTCOME MEASURES: Recruitment source costs and yield, and baseline characteristics of enrolled versus nonparticipants were recorded. RESULTS: We conducted 3789 telephone screens for both trials to enroll 432 (11%) participants, at a cost in excess of $156,000 for recruitment efforts. The cost per call for all callers averaged $41, ranging from $4 to $300 based on recruitment method; for enrolled participants, the cost per call was $361, ranging from $33 to $750. Direct mail efforts accounted for 62% of all callers, 57% for enrolled participants, and had the second lowest cost per call for recruitment efforts. CONCLUSIONS: It is important that complementary and alternative medicine (CAM) research can be successfully conducted at CAM institutions. However, the costs associated with recruitment efforts for studies conducted at CAM institutions may be higher than expected and many self-identified participants are users of the CAM therapy. Therefore, strategies for efficient recruitment methods and targeting nonusers of CAM therapies should be developed early for CAM trials.

Unilateral trachyonychia in a patient with reflex sympathetic dystrophy.

Reflex sympathetic dystrophy (RSD) is a poorly understood neurovascular disorder characterized by pain, altered sensation, motor disturbance, soft tissue changes, vasomotor changes, and autonomic changes that occurs after trauma to an extremity. Unilateral leukonychia, Beau's lines, nailfold swelling, and nail clubbing have been an observed sequela of RSD. We present a case of a unilateral atypical trachyonychia occurring in the setting of RSD after traumatic fracture of a digit.

Acquired ichthyosis.

Acquired ichthyosis (AI) is a nonhereditary cutaneous disorder characterized by dry, rough skin with prominent scaling that involves significant portions of the body. It has been associated with malignancies; autoimmune/inflammatory, metabolic, endocrine, and infectious diseases; and medication use. Most microscopic studies of AI exhibit hyperkeratosis with a reduced or absent granular layer. Because AI has been linked to a variety of conditions, the workup of a patient presenting with this finding can be complex. We present an update on AI to provide clinicians with direction regarding the assessment and treatment of patients presenting with AI. An algorithm for the evaluation of patients presenting with AI is provided.

Factors affecting prescription of ultra-high potency topical corticosteroids in skin disease: an analysis of US national practice data.

Of the topical preparations available, the ultra-high potency corticosteroids have an important role in treating psoriasis. However, the use of these agents in many other conditions and patient populations may not be appropriate. This study examines the prescribing patterns of Class I topical corticosteroids in patients with skin disease by analyzing data from the National Ambulatory Medical Care Survey (1990-2000). Of the nearly 718 million visits for skin disease, Class I topical corticosteroids were prescribed in nearly 3% of all skin disease-related visits, with prescription rates being highest in psoriasis (22%). The study found greater prescription rates of Class I topical steroids by dermatologists compared to non-dermatologists [Odds Ratio (OR) = 4.39 (95% CI: 2.15, 8.99)]. However, there were also a large number of questionable prescriptions for other conditions, which could be construed as misuse of these medications. Despite limitations and the potential dubious use seen here, Class I topical corticosteroid use is relatively commonplace. Education efforts and novel preparations of Class I agents will help to ensure the best possible care for patients suffering from significant skin diseases like psoriasis.

A 71-year-old man with spindle-cell neoplasm of unknown origin: a difficult-to-diagnose clear-cell sarcoma.

A patient initially presented in 1988 with a solitary axillary mass, diagnosed as a high-grade neuroendocrine spindle-cell neoplasm; there was no history of a primary cutaneous malignancy. After subsequent development of a pulmonary nodule in 2001 (14-years post initial diagnosis), the case was reviewed and the possibility of metastatic melanoma was raised. The histopathologic and immunohistochemical profile of this melanocytic neoplasm was diagnostic of clear cell sarcoma (CCS) of tendons and aponeuroses, although the differential diagnosis included malignant melanoma, follicular dendritic and interdigitating cell tumors, malignant peripheral nerve sheath tumor, and a category of so-called PEComas. It is the role of pathologists, particularly dermatopathologists, to distinguish CCS from malignant melanoma, and to alert the clinician, because proper diagnosis ultimately influences treatment. We discuss the immunophenotype, differential diagnosis, and molecular signatures of these neoplasms, and review the pertinent literature on these entities.