Shiitake dermatitis: a report of 3 cases and review of the literature.

Shiitake mushroom-induced toxicoderma, or shiitake dermatitis, is a widely recognized phenomenon in Japan, China, and Korea but only recently has been reported outside of Asia. Affected individuals develop a characteristic pattern of whiplike, linear, erythematous wheals within 1 to 2 days after consumption of raw or cooked shiitake mushrooms. Lentinan, a polysaccharide component of shiitake mushrooms with antitumor properties, is thought to instigate a toxic reaction, resulting in the appearance of a rash. Shiitake dermatitis is self-limited and typically resolves within days to weeks of its appearance.

Significant differences in nonmelanoma skin cancers of the upper and lower lip.

BACKGROUND: Squamous cell carcinomas (SCCs) generally have been reported to be more prevalent on the lips than basal cell carcinomas (BCCs), but in our experience, BCCs of the lips are common, particularly in women. OBJECTIVES: To determine the tumor characteristics of lip SCCs and BCCs, including tumor type, anatomic location, and size; and to identify the relationship between patient characteristics, including age and sex, and lip tumor characteristics. METHODS AND MATERIALS: Retrospective review of all BCCs and SCCs located on the lip treated between January 1995 and October 2010. RESULTS: Of 470 lip nonmelanoma skin cancers (NMSCs) identified, 71.4% were BCCs, and 28.6% were SCCs. Lower lip tumors were predominantly SCCs (79.8%, p < .01), whereas upper lip tumors were predominantly BCCs (85.7%, p < .01). Patients with lower lip tumors were significantly older (68.8 vs. 64.7, p = .02) and were largely male (70.8%, p < .01). Patients with SCCs were mostly male (62.2%, p = .02), whereas those with BCCs were predominantly female (68.8%, p < .01). Subgroup analysis showed that upper lip tumors were 98.1% cutaneous or more than 50% cutaneous, whereas 56.3% of lower lip tumors were mucosal or more than 50% mucosal; 87.1% of mucosal tumors were SCCs, whereas 83.6% of cutaneous tumors were BCCs (p < .01). Seventy-one percent of patients with mucosal tumors were men, whereas 67% of patients with cutaneous only tumors were women (p < .01). CONCLUSION: These data provide evidence of significant differences in patient and tumor characteristics between NMSCs of the upper and lower lips.

In vitro and in vivo characterization of a novel liposomal butorphanol formulation for treatment of pruritus.

As yet no transdermal topical formulations have been developed for the treatment of chronic itch. We developed a formulation containing 2 mg butorphanol tartrate in 100 microl purified water encapsulated into multilamellar phospholipid vesicles. Drug permeation experiments were studied with Franz diffusion chambers using human skin in vitro and on rat skin in vivo. Histological analysis of rat skins was performed to evaluate skin irritation of the formulation in vivo. Physical properties showed stable formulation with desirable viscosity. In vitro dermal penetration rate data suggest that there was significant permeation at time-points 2 h and 4 h, and a steady state was achieved afterwards to 24 h. Maximal plasma butorphanol concentration was noted at 2 h and steady state was achieved at 8 h. Visual skin assessment as well as histological analysis of excised rat skin did not demonstrate any evidence of inflammation and irritation. In vitro and in vivo analysis demonstrated release of a consistent amount of butorphanol in a sustained manner for 24 h. This liposomal transdermal delivery formulation could serve as a method to deliver butorphanol for patients with chronic pruritus.

Systematic selection bias: a cause of dramatic errors in the inference of treatment effectiveness.

Our understanding of the world around us is derived from our observations. The accuracy of our inferences depends on the representativeness of those observations. Selection bias limits the accuracy of our inferences. Systematic selection bias occurs when the particular outcome observed caused the observation; this type of bias can lead to dramatic errors in inference. We describe examples of selection bias, provide a mathematical formulation of the systematic selection bias phenomenon, and discuss how biased observations may affect people's impressions of important issues in dermatology.

Cutaneous blood flow in dermatomyositis and its association with disease severity.

BACKGROUND: Several studies using nailfold capillary microscopes have demonstrated capillary changes in patients with dermatomyositis (DM); however, no previous study has examined cutaneous blood flow in this disease. PURPOSE: To determine cutaneous blood flow in involved and non-involved skin surfaces of patients with DM and to assess possible correlation with clinical measures of disease severity. METHODS: Using a Laser Doppler perfusion imager, cutaneous blood flow was measured at six targeted sites of involved and apparently non-involved skin of 13 DM patients and the corresponding non-involved sites of 13 healthy controls. Overall disease severity of DM patients was determined by physician's global assessment (PGA), creatinine phosphokinase (CPK) levels, medical research council (MRC) scores, and the DM skin severity index (DSSI). RESULTS: Skin blood flow was significantly elevated in involved vs. non-involved skin of DM patients at all anatomic sites measured: periungual (P=0.001), knuckle (P=0.001), elbow (P=0.013), periorbital (P=0.015), chest (P=0.028), and back (P=0.001). Blood flow was also higher in apparently non-involved skin of DM patients vs. skin of healthy controls at all anatomic sites, although statistical significance was not achieved. A significant negative correlation was observed between the DSSI and blood flow in involved skin of the chest (P=0.003), back (P=0.002), and knuckle (P=0.026). CONCLUSION: DM is associated with significantly increased cutaneous blood flow, even at sites where no erythema is evident. This suggests significant involvement of the skin vasculature in this disease process.

Skin barrier structure and function and their relationship to pruritus in end-stage renal disease.

BACKGROUND: The relationship between dry skin and uraemic pruritus remains controversial. In addition, there is a lack of published data describing the structure and function of the stratum corneum (SC) in end-stage renal disease (ESRD). The purpose of the present study was to assess the function and structure of the skin barrier in patients with ESRD and to correlate any abnormalities with uraemic pruritus. METHODS: Thirty-eight subjects participated in the study; 20 with ESRD and 18 healthy controls. Subjects underwent evaluation of SC integrity and permeability barrier recovery, SC surface pH, pruritus and dry skin. The content of glycerol, an important endogenous humectant, was assessed in D-squame tape strips from seven patients with ESRD. Skin biopsies from six of these patients were examined by electron microscopy using ruthenium tetroxide (Ru04)-post-fixation. RESULTS: Although SC integrity was impaired in ESRD patients (P = 0.001), there were no significant differences in permeability barrier recovery rates between ESRD subjects and controls. However, there was a high significant negative correlation between SC glycerol content and dry skin in the arms of ESRD subjects (r = -0.866, P = 0.01). Yet, there was no consistent correlation between pruritus and either dry skin, SC integrity, glycerol content or surface pH. Electron microscopy revealed no significant ultra-structural abnormalities, with particular reference to the lipid bi-layer. CONCLUSIONS: SC integrity, but not permeability barrier recovery, is impaired in dialysis patients. Although dry skin in ESRD is associated with reduced SC glycerol levels, the ultra-structure appears to be unaffected.

Obesity and the skin: skin physiology and skin manifestations of obesity.

UNLABELLED: Obesity is widely recognized as an epidemic in the Western world; however, the impact of obesity on the skin has received minimal attention. The purpose of this article is to highlight the association between obesity and dermatologic conditions. We review the impact of obesity on the skin, including skin physiology, skin manifestations of obesity, and dermatologic diseases aggravated by obesity. Obesity is responsible for changes in skin barrier function, sebaceous glands and sebum production, sweat glands, lymphatics, collagen structure and function, wound healing, microcirculation and macrocirculation, and subcutaneous fat. Moreover, obesity is implicated in a wide spectrum of dermatologic diseases, including acanthosis nigricans, acrochordons, keratosis pilaris, hyperandrogenism and hirsutism, striae distensae, adiposis dolorosa, and fat redistribution, lymphedema, chronic venous insufficiency, plantar hyperkeratosis, cellulitis, skin infections, hidradenitis suppurativa, psoriasis, insulin resistance syndrome, and tophaceous gout. We review the clinical features, evidence for association with obesity, and management of these various dermatoses and highlight the profound impact of obesity in clinical dermatology. LEARNING OBJECTIVE: After completing this learning activity, participants should be aware of obesity-associated changes in skin physiology, skin manifestations of obesity, and dermatologic diseases aggravated by obesity, and be able to formulate a pathophysiology-based treatment strategy for obesity-associated dermatoses.

Mohs surgery for the treatment of melanoma in situ: a review.

BACKGROUND: Controversy exists in the literature regarding the use of Mohs surgery for the treatment of melanoma in situ (MIS). Mohs surgery provides the advantage of complete margin assessment; however, variations in surgical and laboratory techniques employed, make comparison of outcomes difficult. OBJECTIVE: To review the current literature regarding Mohs surgery for treatment of MIS and to evaluate treatment options. METHODS: We review the literature regarding traditional excision margins for MIS, the proportion of biopsy-proven MIS lesions that prove to have an invasive component, and the efficacy of Mohs surgery for MIS. RESULTS: Many authors report a need for surgical margins larger than the recommended 5 mm, particularly with MIS arising in sun-exposed areas. Further, a review of the literature reveals that nearly one-quarter of biopsy-proven MIS lesions are found to contain invasive melanoma after complete surgical removal and pathologic examination. Substantial evidence supports the value of complete margin assessment in the treatment of MIS, particularly in the head and neck region. CONCLUSION: Complete surgical excision with careful margin assessment is required to adequately treat MIS lesions, particularly given the high rate of invasive melanoma in lesions initially thought to be MIS. Mohs surgery remains the treatment of choice for all clinically ill-defined MIS.

Are itch and chronic pain associated in adults? Results of a large population survey in Norway.

BACKGROUND: Few large-scale epidemiological studies have been performed on the prevalence of itch. Itch and pain are common and complex symptoms which contribute to the burden of disease. Although there is antagonistic interaction between itch and pain, there are also many similarities in their pathophysiology. OBJECTIVE: To investigate possible associations between chronic itch and chronic pain in a large population. METHODS: The design was cross-sectional. 18,770 adults completed a self-administered questionnaire addressing sociodemographic factors, psychosocial factors and self-reported health including chronic itch and chronic pain. RESULTS: Individuals reporting pain and itch were more likely to be women (80 and 60%, respectively, compared to 55% in the total sample), had a lower income (49 and 37% compared to 32%), were more likely to be depressed (36 and 20% compared to 11%) and reported poorer well-being (74 and 34% compared to 25%). In an adjusted logistic regression, chronic pain was strongly associated with chronic itch (OR = 1.79, 95% CI = 1.43-2.24). CONCLUSION: This study demonstrates the association of chronic itch and chronic pain and points out the need of further studies that focus on both symptoms in dermatological diseases.

Study of psychological stress, sebum production and acne vulgaris in adolescents.

Sebum production is thought to play a major role in acne vulgaris in adolescents. Psychological stress may exacerbate acne; however, it is not known whether the perceived association between stress and acne exacerbation is due to increased sebum production. The aims of this study were to determine: (i) if psychological stress in adolescents is associated with increased sebum production; and (ii) if stress is associated with increased acne severity independent of, or in conjunction with, increased sebum production. Ninety-four secondary school students in Singapore (mean age 14.9 years) were enrolled in this prospective cohort study. During a high stress condition (prior to mid-year examinations) and a low stress condition (during the summer holidays), the following were evaluated: (i) self-reported stress level using the Perceived Stress Scale; (ii) sebum level at baseline and at 1 h; and (iii) acne severity. The prevalence of self-reported acne in this study population was high (95% in males and 92% in females). Most subjects had mild to moderate acne. Sebum measurements did not differ significantly between the high stress and low stress conditions. For the study population as a whole, we observed a statistically significant positive correlation (r=0.23, p=0.029) between stress levels and severity of acne papulopustulosa. In adolescents, psychological stress does not appear to affect the quantity of sebum production. The study suggests a significant association between stress and severity of acne papulopustulosa, especially in males. Increased acne severity associated with stress may result from factors other than sebum quantity.

Treating itch in psoriasis.

Itch is an important, but underestimated symptom in psoriasis. Many therapies are available for pruritus; however, few are effective for psoriatic itch. Antipruritic therapies that are potentially effective in psoriasis include coal tar products, topical corticosteroids, topical salicylates, menthol and pramoxine, capsaicin, phototherapy, vitamin D analogs, topical immunomodulators, methotrexate, oral mirtazapine, and biologics. Using these therapies can benefit psoriasis patients in the outpatient clinical setting.

Butorphanol for treatment of intractable pruritus.

Severe chronic itch and intractable pruritus are encountered frequently by dermatologists. Recent data suggest that generalized pruritus may result from an imbalance between the mu and kappa opioid systems, and kappa-agonists have been shown to inhibit pruritus in both animals and human beings. These findings led us to use butorphanol, a commercially available kappa-opioid agonist and mu-opioid antagonist. We present a case series of 5 patients with intractable pruritus associated with inflammatory skin diseases or systemic diseases who demonstrated rapid and marked improvement when treated with intranasal butorphanol. Because of the small, open-label nature of this study, butorphanol should be investigated further in a larger, randomized controlled trial.

Patient expectations regarding eye care: development and results of the Eye Care Expectations Survey (ECES).

OBJECTIVE: To develop an instrument (the Eye Care Expectations Survey [ECES]) that can identify and quantify the expectations of patients visiting eye care providers. METHODS: A total of 202 patients attending 4 ophthalmology practices affiliated with Duke University Eye Center enrolled in the study. All participants completed the pilot version of the ECES, which was developed through a review of the expectations literature and a multicondition focus group process. Factor analysis of patients' responses was used to identify the performance characteristics of the ECES. RESULTS: Factor analysis yielded factors that describe 4 distinct types of expectations: patient involvement in eye care, interpersonal manner, information about diagnosis and prognosis, and communication and clinical competence. These 4 factors explained 89% of the total variance. The factor analysis identified a subset of 27 questions (of the original 37) to represent the 4 factors. Estimates of internal consistency and test-retest reproducibility indicate that the ECES is reliable. In addition, tests of association with clinical variables support the construct validity of the survey. The psychometric properties of the ECES were influenced by the severity of the underlying eye condition as well as other demographic and clinical variables, including the patient's rating of his or her own vision, best corrected visual acuity, sex, education, race, and household income. CONCLUSIONS: Based on this cross-sectional study, the 27-item ECES appears to be a useful tool for better understanding patients' expectations regarding eye care.

Patient expectations for medical and surgical care: a review of the literature and applications to ophthalmology.

Over the past several decades, emphasis on patient-centered care, the dramatic growth of refractive surgery in the United States, and increasing competition in the eye care marketplace have made patient expectations increasingly important in the field of ophthalmology. Patient-centered care recognizes the obligation to understand and meet patient's expectations. Despite increasing patient expectations for refractive surgery and eye care in general, however, there has been limited research on patient expectations within the field of ophthalmology. The vast majority of existing research on patients' expectations has focused on expectations of primary care physicians. Because ophthalmologists are involved in both surgical and medical care, it is important to expand the consideration of patient expectations beyond the traditional primary care setting. Using elements of the taxonomy developed by Kravitz (Kravitz RL: Patients' expectations for medical care: an expanded formulation based on review of the literature. Med Care Res Rev 53:3-27, 1996), this article reviews the existing literature on patient expectations and draws attention to the limited research in specialty and surgical fields. This article has the following objectives: 1) provide a context for understanding what patient expectations are, 2) review the different ways that patient expectations are measured, 3) illustrate the content of patient expectations from empirical research, 4) outline potential determinants of patient expectations, and 5) discuss the role of patient expectations in ophthalmology.

Parents' expectations regarding their children's eye care: interview results.

PURPOSE: To determine a relevant set of concerns that parents express as expectations regarding their children's eye care. DESIGN: Qualitative, cross-sectional, pilot study. METHODS: A total of 48 interviews were conducted with parents of pediatric ophthalmology patients at Duke University Eye Center and the McGovern Davidson Children's Health Center at Duke University to elicit parents' expectations regarding their children's eye care. Interviews were audiotaped, transcribed, and coded for parent expectations. RESULTS: Content analysis of transcripts from the 48 interviews yielded 35 different expectation areas for eye care, which were further classified into six groups: (1) Communication, (2) Interpersonal Manner, (3) Doctor's Skill, (4) Examination and Testing, (5) Logistics, and (6) Other. The six expectation areas most frequently identified by parents as the single "most important" expectation were the following: (1) Clinical Competence, (2) Interaction with Child, (3) Education/Training, (4) Explanation in Clear Language, (5) Information about Diagnosis, and (6) Personal Connection. CONCLUSIONS: Parents of pediatric ophthalmology patients expressed expectation areas in the Communication group more frequently than any other group. However, when asked to identify their single most important expectation area, more than half of parents identified Clinical Competence.

Patient expectations regarding eye care: focus group results.

BACKGROUND: Increasing emphasis on patient-centered care and other recent developments should make patient expectations increasingly important in ophthalmology. Motivated by the pivotal role of patient expectations in quality-of-care assessments and by the limited knowledge about patients' expectations regarding eye care, we initiated a pilot study using focus groups to determine a relevant set of concerns that patients express as expectations. METHODS: A total of 6 focus groups were conducted with patients at Duke University Eye Center (Durham, NC). Focus groups ranged in size from 4 to 10 people. The average group size was 6. RESULTS: Content analysis of transcripts from the 6 focus groups yielded 22 areas of expectations for eye care, which were classified into 5 categories: communication, interpersonal manner, physician's skill, logistics, and other. The 6 areas that appeared to be of greatest importance to focus group participants were the following: (1) honesty, (2) information about diagnosis and prognosis, (3) explanation in clear language, (4) ophthalmologist's experience and reputation, (5) empathy, and (6) listening and addressing concerns. CONCLUSIONS: In general, ophthalmology patients in the focus groups emphasized expectations related to communication and interpersonal manner. In contrast to previous studies with primary care patients, however, ophthalmology patients expressed few expectations for technical interventions, such as medication prescriptions, physical examination, or diagnostic testing.

Development of a patient satisfaction survey for outpatient care: a brief report.

Patient satisfaction has become a significant component of health care outcomes and an increasingly important component of quality assessment. Selecting the appropriate methods to measure patient satisfaction is a critical challenge for health care managers, yet, there is limited knowledge of the methods used to develop patient satisfaction instruments. In this brief report, we provide insights into the development of a patient satisfaction instrument for outpatient care at the Duke Private Diagnostic Clinic (PDC). We surveyed the 12 medical directors and asked them to rate 15 concept areas for inclusion in an outpatient satisfaction survey. We then constructed a patient satisfaction survey by drawing selected subscales from the publicly available PSQ-18 (Patient Satisfaction Questionnaire) and CAHPS (Consumer Assessment of Health Plans) surveys to address the seven highest rated concept areas: 1) general/overall satisfaction; 2) courteousness of office staff; 3) courteousness of physicians; 4) doctor/patient communication; 5) professionalism; 6) ease and time to get appointment; and 7) technical quality of care.

Patient satisfaction instruments used at academic medical centers: results of a survey.

As physicians and health administrators increasingly incorporate patients' perspectives into health care, patient satisfaction has become a significant health care outcome. However, there is limited knowledge regarding the patient satisfaction instruments being used by leading academic medical centers. The objective of this study was to determine the types of patient satisfaction instruments used by leading academic medical centers. We conducted a telephone survey of 16 leading academic medical centers across the United States to determine the types of patient satisfaction instruments used at each institution for outpatient and inpatient care. Among the institutions surveyed, a significantly higher proportion used internally developed surveys for satisfaction measurement among outpatients than for satisfaction measurement among inpatients. Although much attention has been focused on patient satisfaction in recent years, there is little standardization of the patient satisfaction instruments currently being used at the academic medical centers surveyed, particularly for outpatient care. This lack of standardization limits opportunities for benchmarking of patient satisfaction data among peer institutions and may limit efforts to improve care.