Psoriasis: an opportunity to identify cardiovascular risk.

Psoriasis is highly prevalent and is associated with skin-associated complaints as well as arthritis, depression and a lower quality of life. Recently, it has been demonstrated that not only do patients with psoriasis have an increased prevalence of cardiovascular risk factors, but an increased risk of myocardial infarction, and for those with severe disease, increased mortality. Dermatologists and other health professionals need to be cognizant of this association and ensure that cardiovascular risk factors are evaluated and treated appropriately in those patients with psoriasis. We review the association between psoriasis, atherosclerosis and inflammation, as well as some treatable cardiovascular risk factors that may prove beneficial in reducing a patient's cardiovascular risk.

Thrombosis: new culprits in an old disorder.

Venous thrombosis is a cause of considerable morbidity and mortality. Over the past several years, several new causes of thrombophilia have been identified and have dramatically altered the approach to patients presenting with thrombosis. Newly described abnormalities associated with thrombophilia include the syndrome of activated Protein C resistance (APCR), the prothrombin 20210A mutation, hyperhomocysteinemia, and elevated levels of coagulation factors VIII and XI. Clinicians can now frequently determine causes of thromboses that have previously been deemed idiopathic. Though the risk factors for VTE are becoming better defined, the cost-effective approach to diagnosis and therapeutic implications are not entirely clear at this point.

Fatal rhabdomyolysis caused by lipid-lowering therapy.

Treatment of hypercholesterolemia has been shown to reduce mortality in patients with coronary artery disease. Patients with severe lipid abnormalities may require high-dose statin therapy, at times used in combination with additional agents. We report a case of fatal rhabdomyolysis caused by the combination of simvastatin and gemfibrozil. Clinicians should be aware of risk factors for rhabdomyolysis, which include underlying renal insufficiency, high-dose statin therapy, and combination therapy with a fibrate.

Cutaneous leishmaniasis in an Italian woman: case report.

Leishmaniasis is a sandfly-borne disease caused by a protozoan. The typical lesion of cutaneous leishmaniasis first appears as an erythematous papule at the site of inoculation, increases slowly in size, develops raised borders, and eventually ulcerates. The pentavalent antimony compounds continue to be a mainstay of therapy. We describe an Italian patient with an enlarging facial plaque that was found to be caused by leishmania and discuss the toxicity associated with therapy.

Dermatology in primary care: Prevalence and patient disposition.

BACKGROUND: Cutaneous disease is commonly encountered in primary care. The frequency of patients presenting to primary care physicians with skin disease and their eventual disposition is not well studied. OBJECTIVE: The purpose of this study was to determine the prevalence of patients seen with skin disease in a primary care setting and the likelihood of their referral to a dermatologist. The impact the primary care provider had on the quality of skin care was also examined. METHODS: A retrospective chart review was performed of patients seen during a 2-year period at a general medicine clinic within the University of Miami and upon referral to a University of Miami dermatology office. Data were obtained on the prevalence of skin disease, dispositions of referral, diagnoses made, and procedures performed. RESULTS: During a 2-year period, 36.5% of patients who presented to their primary care physician had at least one skin problem. Of 208 patients with skin disease, in 58.7% (122/208) it was their chief complaint. A wide range of diagnoses were made by the primary care physician, with a limited number of diagnostic procedures performed. Of the 37.5% of patients referred to a dermatologist, 68% were referred on initial evaluation. Diagnoses made by the primary care physician were concordant with that made by the dermatologists 57% of the time. CONCLUSION: Patients frequently see their primary care physician for skin disease. A large percentage are referred to dermatologists, often for a biopsy of a suspect lesion, to confirm a suspected diagnosis, or to establish a diagnosis of lesions of unknown origin.

Interpretation of cutaneous biopsy specimens: choice of pathologist by primary care practitioners.

BACKGROUND: Primary care providers (PCPs) have limited training in recognizing common skin disorders, and additional emphasis may be placed on laboratory evaluation, including skin biopsies. METHODS: Primary care providers in Miami, Fla, were surveyed regarding skin biopsy and excision practices and histologic interpretation. They then participated in an examination, using 20 high-quality color photographs of common dermatologic disorders. RESULTS: Of the 80 PCPs who participated, 42% currently do skin biopsies and consult general pathologists for interpretation. Another 20% of PCPs intend to do biopsies within the next 5 years. Only 33% prefer to have a dermatopathologist interpret histopathology. We found no correlation between PCPs' scores on diagnostic testing and whether they do skin biopsies. CONCLUSION: Nearly all PCPs doing skin biopsies in our study sample use general pathologists to interpret histopathology. The limited training in clinical dermatology of both PCPs and general pathologists may result in compromised clinical-pathologic correlation.

An update on hypercoagulable disorders.

Venous thrombosis is a cause of considerable morbidity and is often responsible for chronic venous disorders that frequently lead to visits to dermatologists and others involved in wound healing. Over the past several years, many new causes of thrombophilia have been identified and have dramatically altered the approach to patients presenting with thrombosis. Newly described abnormalities associated with thrombophilia include the syndrome of activated protein C resistance, the prothrombin 20210A mutation, hyperhomocysteinemia, and elevated levels of coagulation factors VIII and XI. Clinicians can now frequently determine causes of thromboses that have previously been deemed idiopathic.

The primary care provider and the care of skin disease: the patient's perspective.

OBJECTIVE: To ascertain the patient's perspective on dermatologic care provided by primary care providers (PCPs) or dermatologists. DESIGN: Cross-sectional survey of patients drawn from primary care and dermatology clinics. SETTING: Academic Veterans Affairs medical center. PATIENTS: Convenience sample of patients in either a primary care or a dermatology clinic. INTERVENTION: Survey questionnaire. MAIN OUTCOME MEASURES: Patients' confidence in having their skin problems cared for by PCPs and dermatologists and satisfaction with previous care rendered. RESULTS: A total of 137 patients in the primary care clinic (group 1) and 100 patients in the dermatology clinic (group 2) participated. Patients (N = 237) expressed confidence in their PCP's ability to treat rashes (62%), diagnose skin cancer (65%), perform skin biopsies (60%), "freeze" lesions with liquid nitrogen (50%), and perform cutaneous surgery (46%). Group 2 patients were significantly less likely to have confidence in their PCP than group 1 patients for all measures other than the use of liquid nitrogen. High levels of confidence were expressed in a dermatologist's ability for all 5 measures: 92%, 91%, 92%, 83%, and 85%, respectively. Patients were more confident in dermatologists' abilities to perform these procedures compared with PCPs (P<.001 for all comparisons). Of patients previously treated for skin disorders, there was a high rate of satisfaction with the treatment rendered by PCPs (81% for group 1 and 75% for group 2) and by dermatologists (92% for group 1 and 90% for group 2). However, patient satisfaction was higher for dermatology vs primary care for the treatment of skin disease (P<.001). Direct access to dermatologists was preferred. CONCLUSIONS: Although patients have confidence in their PCP to care for their skin disease, they have greater confidence in the care provided by dermatologists. Among patients previously treated for skin disease, satisfaction was higher with care rendered by dermatologists vs PCPs. Most patients prefer direct access to dermatologists should they develop a skin problem.

Sports supplements. Can dietary additives boost athletic performance and potential?

Nutritional sports supplements, many of which are endorsed by professional athletes, are increasing in popularity among casual and adolescent sports enthusiasts, bodybuilders, and weight lifters. Because many people consider nutritional additives to be "natural" and therefore "safe," patients may not consider the possible effects of those substances when taken in high doses or in combination with medications. Drs Rubinstein and Federman present an interesting overview of several sports supplements and examine the consequences and caveats of their use, as well as the reasons for their popularity.

Pyoderma gangrenosum and myelodysplastic syndrome.

Pyoderma gangrenosum (PG) is a painful, often rapidly progressive, ulcerating skin disorder frequently associated with systemic diseases. We report the case of a patient with PG and an anemia. A bone marrow biopsy showed changes consistent with one of the myelodysplastic syndromes, refractory anemia with ringed sideroblasts. Patients with PG and anemia should have bone marrow biopsy if no cause of anemia is readily apparent.

Acne vulgaris: pathogenesis and therapeutic approach.

AUDIENCE: This activity is designed for primary care providers, internists, and general audiences. GOAL: To provide the reader with a basic understanding of the pathogenesis of acne vulgaris and the rationale behind several treatment options. Clinicians should be aware of treatment strategies for various subtypes of acne vulgaris. OBJECTIVES: 1. To describe the emotional and financial impact of acne. 2. To describe the differential diagnosis of acne vulgaris. 3. To discuss acne's pathogenesis. 4. To provide information on topical therapy for the treatment of acne vulgaris. 5. To discuss oral therapy for the treatment of acne vulgaris.

Recalcitrant pyoderma gangrenosum treated with thalidomide.

Pyoderma gangrenosum is a painful, noninfectious, ulcerating skin disorder often associated with systemic disease. Thalidomide has been used to treat many inflammatory dermatologic conditions and has been reintroduced in the United States to treat immune-modulated diseases such as pyoderma gangrenosum. The patient described, a 47-year-old man, had histologically confirmed pyoderma gangrenosum that did not respond to treatment with several courses of methylprednisolone. The ulcer healed with 10 weeks of oral thalidomide administration.

Fatal bladder cancer and dermatomyositis.

Dermatomyositis is an uncommon inflammatory myopathy accompanied by characteristic cutaneous findings. Adult-onset dermatomyositis is often associated with internal malignancy. We report a case of dermatomyositis associated with an aggressive and fatal case of transitional cell carcinoma of the bladder.

The primary care physician and the treatment of patients with skin disorders.

Scientific advances have altered the nature of primary care medicine. Primary care providers are increasingly asked to care for a broad spectrum of common maladies, including cutaneous disease. We review studies that have compared primary care physicians with dermatologists with respect to the diagnosis and treatment of skin disorders. Though primary care providers play a crucial role in the delivery of health care, the judicious and appropriate use of dermatology consultation should be encouraged.

Informed consent for PSA screening: does it happen?

CONTEXT: Screening for prostate cancer with serum prostate-specific antigen (PSA) is controversial. Ideally, patients should be aware of the potential benefits and risks related to testing. PURPOSE: To assess whether patients remembered having PSA screening and to determine whether they recalled having a discussion with their primary care provider about the pros and cons of such testing. METHODS: A questionnaire was sent to patients who had PSA screening ordered by a primary care practitioner during a 2-month period at a university-affiliated Veterans Affairs medical center. Approximately 3 months after the PSA test was done, patients were asked about their baseline health as well as their knowledge of and attitudes toward screening with PSA and treatment for prostate cancer. RESULTS: The overall response rate was 197 out of 421 (46%) patients. Among 173 eligible respondents without prostate cancer, 53 (31%) were unaware that their physician had ordered a PSA test. Among the 120 patients who were aware of receiving the test, only 56 (47%) recalled having a discussion with their primary care provider about the risks and benefits of screening. Support for the test was more common among patients who recalled having PSA screening than those who did not recall having the test (91% vs. 70%, respectively; P = 0.003). CONCLUSIONS: Patients who have PSA screening often are unable to recall relevant facts about the test and may have no knowledge of its associated risks and benefits. The role and effectiveness of obtaining verbal informed consent for PSA screening should be re-evaluated.

Skin cancer screening in primary care: prevalence and barriers.

BACKGROUND: Skin cancer incidence is increasing, but whether primary care providers routinely screen for skin cancer is not known. OBJECTIVE: We assessed whether primary care practitioners are performing skin cancer screening within the context of primary care and whether barriers exist that might act as impediments to the implementation of this practice. METHODS: A total of 465 primary care providers belonging to their respective county medical societies in either New Haven County, Connecticut, or Miami-Dade County, Florida were randomly selected and surveyed by mailed questionnaire regarding their skin cancer screening practices. RESULTS: Only 31% of responding physicians reported performing skin cancer screening on all of their adult patients. Of those not performing skin cancer screening on all adult patients, only 31% report performing screening on high-risk patients. Almost half of physicians reported that they do not perform skin cancer screening. We found that physicians' lack of confidence in identifying suspect lesions was a common barrier. Fear of patient embarrassment, inadequate lighting, or lack of studies demonstrating mortality benefits were not frequent deterrents. Furthermore, there was no statistical difference in screening rates between the more northern latitude and the more southern latitude. CONCLUSION: Skin cancer screening is not being performed within the context of primary care visits. Barriers exist that may impede skin cancer screening.

Comparison of dermatologic diagnoses by primary care practitioners and dermatologists. A review of the literature.

BACKGROUND: Cost-containment efforts in the United States have led to a greater emphasis on health care delivery by primary care physicians as opposed to specialists, who are assumed to be more costly. With this approach, it is incumbent on the primary care physician to be able to accurately diagnose and treat common maladies, including skin disease. OBJECTIVE: To ascertain whether differences in performance were detectable between groups of physicians when presented with color slides or high-quality transparencies. DESIGN: We performed a critical review of published studies. RESULTS: Overall, dermatologists (93% correct) performed better than nondermatologists (52% correct) (P < .001). No difference was appreciable between dermatology residents (91% correct) and practicing dermatologists (96% correct) or between internal medicine residents (45% correct) and family practice residents (48% correct). In addition, family medicine attending physicians (70% correct) performed better than internal medicine attending physicians (52% correct) (P < .001). CONCLUSION: Primary care physicians should receive more training in the diagnosis of skin disease.