Dermatologists and allergists have far more experience and use more complex treatment regimens in the treatment of atopic dermatitis than other physicians.

BACKGROUND: Atopic dermatitis (AD) is a prevalent skin condition, especially in the pediatric population. Whereas it has been shown that dermatologists prefer using more intensive therapy for AD than generalists, actual drug utilization has not been quantified. OBJECTIVE: The purpose of this study is to characterize visits for and treatment of AD in the office-based setting. METHODS: National Ambulatory Medical Care Survey data from 1990 to 1997 was analyzed to determine the use of topical corticosteroids (including their relative potencies), oral antibiotics, and oral antihistamines in the treatment of AD. RESULTS: There were an estimated 900,000 outpatient visits per year for AD. If in some visits to generalists the diagnosis for AD was miscoded as contact dermatitis, there may have been as many as 3 million outpatient visits per year for AD. Topical corticosteroids were used in 67% of visits with a mean potency rank of 4.5 (4.3, 4.8 95% CI). Dermatologists saw 48% of all visits for AD (63 yearly visits/physician) and allergists saw 10% of visits (30 yearly visits/physician). Other physicians saw from 0.1 to 2 yearly visits per physician. Dermatologists were the most likely to use topical corticosteroids (81% of visits) and high-potency corticosteroid agents (22% of visits). Dermatologists and allergists were the only physicians to prescribe ultrahigh-potent corticosteroid agents (12% and 9% of visits, respectively) and were more likely than other physicians to use multiple-agent regimens (21% and 27% of visits treated with a corticosteroid agent, respectively). CONCLUSIONS: Dermatologists and allergists have more expertise in the management of AD than other physicians, as suggested by their higher per capita visits and greater use of complex topical corticosteroid regimens.

Allergists and dermatologists have far more expertise in caring for patients with urticaria than other specialists.

BACKGROUND: Urticaria is a common disease for which numerous treatments have been described, yet there is little information about what agents are commonly used to treat urticaria. There may be differences in the way in which urticaria is treated by different medical specialties. OBJECTIVE: The purpose of this study was to characterize the visits and treatments of urticaria in office-based practices. METHODS: National Ambulatory Medical Care Survey data from 1990 to 1997 were analyzed to determine patient populations, medications used, and physician specialties for visits of urticaria. RESULTS: Women accounted for 69% of all patient visits, but an equal gender distribution was observed in patients 18 years of age and younger. There was a bimodal age distribution with peak visits in patients aged birth to 9 years and 30 to 40 years. H(1) antihistamines and systemic corticosteroids were used in 56% and 14% of visits, respectively. Other medications reported as useful in the treatment of urticaria were used in 12% of visits. Allergists and dermatologists had a mean of 47 and 37 visits per physician per year, respectively, compared with all other physicians who averaged fewer than 10 visits per physician per year. Allergists were the least likely to use a corticosteroid agent (6% of visits), whereas internists were the most likely (29% of visits). Dermatology and allergy recorded a relatively large percentage of visits for urticaria that were referred for their condition by other physicians (49% and 25% of visits, respectively). CONCLUSION: We observed a bimodal utilization curve for age and urticaria not previously described. H(1) antihistamines remain the mainstay in treatment of urticaria, whereas the low use of systemic corticosteroids likely reflects physicians' understanding of their secondary function in the treatment of urticaria.

Overexpression of the Candida albicans ALA1 gene in Saccharomyces cerevisiae results in aggregation following attachment of yeast cells to extracellular matrix proteins, adherence properties similar to those of Candida albicans.

Candida albicans maintains a commensal relationship with human hosts, probably by adhering to mucosal tissue in a variety of physiological conditions. We show that adherence due to the C. albicans gene ALA1 when transformed into Saccharomyces cerevisiae, is comprised of two sequential steps. Initially, C. albicans rapidly attaches to extracellular matrix (ECM) protein-coated magnetic beads in small numbers (the attachment phase). This is followed by a relatively slower step in which cell-to-cell interactions predominate (the aggregation phase). Neither of these phases is observed in S. cerevisiae. However, expression of the C. albicans ALA1 gene from a low-copy vector causes S. cerevisiae transformants to attach to ECM-coated magnetic beads without appreciable aggregation. Expression of ALA1 from a high-copy vector results in both attachment and aggregation. Moreover, transcriptional fusion of ALA1 with the galactose-inducible promoters GALS, GALL, and GAL1, allowing for low, moderate, and high levels of inducible transcription, respectively, causes attachment and aggregation that correlates with the strength of the GAL promoter. The adherence of C. albicans and S. cerevisiae overexpressing ALA1 to a number of protein ligands occurs over a broad pH range, is resistant to shear forces generated by vortexing, and is unaffected by the presence of sugars, high salt levels, free ligands, or detergents. Adherence is, however, inhibited by agents that disrupt hydrogen bonds. The similarities in the adherence and aggregation properties of C. albicans and S. cerevisiae overexpressing ALA1 suggest a role in adherence and aggregation for ALA1 and ALA1-like genes in C. albicans.

Developing organization of mental verbs and theory of mind in middle childhood: evidence from extensions.

The purpose of the study was to assess developments in the theory of mind suggested by changes in the organization of cognitive verb extensions during the elementary school years. Adults and 3rd- and 5th-grade children were provided with a set of mental activity scenarios and were asked to select the best verbs from a list of cognitive verbs that might apply to each scenario. Changes in organization were assessed by examining overlapping uses of cognitive verbs in different contexts. There were 3 major changes with development: (a) the understanding of the role of memory in input functions increased, (b) the interrelatedness of memory- and comprehension-related verbs increased, and (c) the importance of cognitive certainty and uncertainty engaged by constructive processing verbs increased. Together, these findings suggest that a constructivist theory of mind develops in later childhood.

Multiple noncontiguous spine fractures.

The data from a prospective study of 508 spine injuries were reviewed to determine the incidence of multiple noncontiguous spine fractures. All patients were examined at admission and at 1 and 2 years postinjury. This series identified 77 (15.2%) multilevel fractures. Motor vehicle accidents were the primary cause of these fractures. The incidence of neurologic injury was not significantly different between multiple noncontiguous and single fractures. Failure to use seat belts and ejection from the vehicle were the main factors associated with multiple noncontiguous spine injuries. Seven major fracture patterns were identified, which accounted for 60% of these injuries. The prognosis for multilevel spine fractures was not significantly worse that that for single-level injuries.

Vinblastine, bleomycin and cisplatin for recurrent or metastatic squamous cell carcinoma of the head and neck.

Forty-two patients with recurrent or metastatic squamous cell carcinoma of the head and neck were treated with vinblastine, bleomycin, and cisplatin. All patients had received prior surgery, radiation or chemotherapy and all had measurable disease. Forty-five percent of the patients responded with a median duration of response of eight months and median survival of nine months. Six patients (14%) were complete responders and had a median duration of response of 12 months and median survival of 24+ months. Thirteen patients (31%) were partial responders and had a median duration of response of seven months and survival of 13 months. Toxicity was mild with nausea and vomiting occurring in all patients after cisplatin. There were two cases of bleomycin-induced pulmonary fibrosis and two cases of mild renal insufficiency (creatinine clearance level, 45 cc/min). This regimen compares favorably with other published regimens for advanced head and neck cancer.

Hypothyroidism and wound healing: occurrence after head and neck radiation and surgery.

A retrospective five-year review of patients treated for cancer of the larynx disclosed a high prevalence of hypothyroidism after combined therapy. A total of 29 patients were studied. Seven (24%) of the 29 patients had hypothyroidism develop in the posttreatment period (zero to two years). Two (22%) of the nine patients treated with a combination of surgery and radiation had hypothyroidism develop. An additional ten patients treated with radiation alone remained clinically euthyroid, and no thyroid function tests were performed. Of the five patients who became hypothyroid after treatment with a combination of surgery and radiation, two had fistulae develop that were resistant to intensive local care. They closed promptly after treatment of the hypothyroidism. Of the two patients who had hypothyroidism develop after surgery alone, one had fistulae develop that were resistant to local cae, but responsive to thyroid hormone. These patients should have thyroid function tests done in the early postoperative period, and those found to be hypothyroid should be treated promptly.

Combination chemotherapy with vinblastine, bleomycin, and cis-diamminedichloroplatinum (II) in squamous cell carcinoma of the head and neck.

Forty-five patients with advanced squamous cell carcinoma of the head and neck, 23 of whom had received no prior therapy, were given the combination of vinblastine, 4 mg/m2 intravenously (IV) on Day 1; bleomycin, 15 mg/day intramuscularly on Days 1-7; and cis-diamminedichloroplatinum (II), 60 mg/m2 with mannitol diuresis on Day 8. The regimen was repeated at three-week intervals, for a maximum of three cycles. Among the 23 patients without prior surgery or radiation, there were 5 complete responses and 12 partial responses, a 74% response rate; whereas, among the 22 with prior therapy, there were 2 complete responses and 8 partial responses, a response rate of 45%. Nineteen of 23 previously untreated patients were subsequently given radiation, 1 had surgery, and 1 had surgery plus radiation. Twelve of these 19 patients are currently free of disease, with a median duration of ten months from initial response. Four of the 22 previously treated patients received radiation and 2, surgery; 4 of these 6 patients are without evidence of disease. Renal dysfunction with elevation of serum creatinine occurred in 5 patients, a leukocyte count of less than 3,000/mm3 in 3, a platelet count of less than 100,000/mm3 in 2, skin changes in 11, hearing loss in 1, and both peripheral neuropathy and pulmonary changes in 1 patient. This combination of agents has substantial activity in untreated patients and may be useful as initial therapy in advanced head and neck malignancies by diminishing the incidence of local recurrence and distant metastasis.

Recurrent adenoid cystic carcinoma of the trachea: intraluminal radiotherapy.

Malignant neoplasms of the trachea are rare lesions, of which adenoid cystic carcinoma constitutes 30%. A case of extensive tumor recurrent after primary radiotherapy is presented. Surgical resection and radioisotope implantation were impossible. A method was devised for placement of intraluminal iridium 192 by casting six small hollow plastic tubes to the outer circumference of a Silastic endotracheal tube. This was an easy, safe, and effective method of delivering radiation to the trachea while sparing other vital structures and organs. Excellent tumor response and palliation were achieved. The literature is reviewed and the problems in diagnosis of this tumor are discussed. A comprehensive plan for early diagnosis is presented. All current methods of treatment are discussed, and the need for aggressive surgical management is stressed.

Cocaine use by the otolaryngologist: a survey.

The unique characteristics of cocaine--anesthesia and vasoconstriction--make it a valuable nasal anesthetic which is a safe topical anesthetic when used properly. The safe dose limit for cocaine used topically in the nose is surely greater than 200 mg, as evidenced by 826 otolaryngologists using greater than 200 mg in their daily practice without ever having experienced a cocaine reaction. Cocaine reactions are not simply dose-dependent, as evidenced by reactions occurring with as little as 10 mg. Fatalities secondary to topical application of cocaine to the nasal mucous membranes are exceedingly rare; only 15 fatalities have been seen in the entire clinical practices of the 2,434 physicians responding in this survey. Establishing 200 mg as the safe limit for cocaine in our literature, althugh it is not based on experimental evidence, is haphazard and carries far-reaching medicolegal implication to 48% of otolaryngologists who use greater than 200 mg of cocaine. A controlled scientific study to elucidate experimental data regarding the toxicity of cocaine in clinically useful doses is urgently needed.

Luetic hearing loss.

Luetic hearing loss has been noted with increasing frequency in recent years. Four cases of luetic hearing loss seen at Walter Reed General Hospital from 1974 to 1975 are presented and discussed. Symptoms and pathology of luetic involvement of the inner ear are also presented. Serum FTA-ABS and TPI, in addition to VDRL, must be routinely obtained during the workup of hearing loss. CSF FTA-ABS should be obtained if serum FTA-ABS and TPI are positive. Reversibility may be dependent on early detection of luetic hearing loss and treatment with high doses of antibiotics and steroids.

Metabolism of intranasally applied cocaine.

Surprisingly little is known about the metabolism and toxicity of cocaine in man. In this study serum obtained following nasal surgery was assayed for benzoylecgonine (the major metabolite of cocaine) by radioimmunoassay. It was found that cocaine was rapidly hydrolyzed in the serum. Benzoylecgonine was detectable in the serum at 15 minutes. The peak blood level of the metabolite appeared at 4.5 hours with a peak concentrations of 872.9 ng/ml. The half time clearance of the metabolite from the serum was 5.5 hours. A discussion of variables which must be considered in deriving, by a scientific method, a maximum safe clinical dose is presented.