Nonmelanoma skin cancers in association with seborrheic keratoses. Clinicopathologic correlations.

BACKGROUND: Seborrheic keratoses (SKs) can be seen in association with cancers. OBJECTIVE: Our study was designed to demonstrate the occurrence of concomitant SKs and nonmelanoma skin cancers, as well as to correlate their histological types and clinical locations. The study was not intended to be an epidemiologic survey. METHODS: We prospectively collected 108 completely excised SKs, examined them microscopically, categorized them, and correlated the clinical site, histological type, and determined the incidence of concomitant malignancy. RESULTS: Of the 108 SKs studied, 71 were acanthotic, 27 hyperkeratotic, and 10 reticulated. The incidence of associated nonmelanoma cancers was 4.6%. All malignancies were squamous cell carcinomas and were on sun-exposed skin. Three of the five malignancies arose in conjunction with reticulated SKs. CONCLUSIONS: The incidence of nonmelanoma skin cancer in association with SKs may be greater than previously reported, particularly in SKs situated on photo damaged skin and of the reticulated type. SKs that have undergone recent growth or other clinical change should be biopsied and all SKs that are removed should be examined histologically.

Disseminated Mycobacterium scrofulaceum infection: a potentially treatable complication of AIDS.

Disseminated Mycobacterium scrofulaceum infection has rarely been reported (only 8 cases to date), and no case of infection associated with AIDS has been reported in detail. We report a case of disseminated M. scrofulaceum infection in an AIDS patient that presented as chronic ulcerative and nodular skin lesions with probable cavitary lung involvement. We discuss reported cases of dissminated M. scrofulaceum infection and features of human immunodeficiency virus (HIV)-associated disease due to mycobacteria other than tuberculosis. Although our patient died before susceptibility testing could be completed, the M. scrofulaceum isolate was found to be susceptible to clarithromycin, ethambutol, and clofazimine. Physicians who evaluate skin lesions in HIV-infected persons should perform appropriate mycobacterial studies and search for disseminated disease. Drug susceptibility testing for mycobacteria other than tuberculosis is not yet standardized, but the broth dilution method, currently being studied in clinical trials of treatment for Mycobacterium avium complex, may be superior to older methods. After the possibility of Mycobacterium tuberculosis infection has been excluded, physicians should consider administering initial empirical therapy with two or more drugs, including a newer macrolide, to AIDS patients with disseminated mycobacterial disease.

Unusual presentation of a third ventricular cyst in a patient with basal cell nevus syndrome.

Patients with basil cell nevus syndrome often have neurologic manifestations that occasionally cause complications. I report a case of a third ventricular cyst causing unusual symptoms in a 16-year-old boy. The discussion includes a review of the various neurologic signs and symptoms in this syndrome.

Lofgren's syndrome.

Lofgren's syndrome consists of a triad of erythema nodosum, bilateral hilar adenopathy, and arthritis and heralds the acute onset of sarcoidosis. A single symptom may be misdiagnosed and mistreated by an unsuspecting physician. We present a case of Lofgren's syndrome that was initially believed to be cellulitis. We briefly review the course and treatment of Lofgren's syndrome.

The clinical spectrum of mid-dermal elastolysis and the role of UV light in its pathogenesis.

BACKGROUND: We observed four patients with mid-dermal elastolysis (MDE) that was either precipitated or aggravated by UV light (UVL) exposure or was primarily confined to areas of UVL exposure. OBJECTIVE: Our purpose was to report four cases of MDE occurring after significant UVL exposure and to demonstrate why we suspect that MDE in some instances may be photoinduced or photoaggravated. We also wish to demonstrate the varied clinical presentation of this disorder. METHODS: Because all our patients had MDE involving skin exposed to UVL, biopsies were performed on clinically uninvolved sun-exposed and sun-protected skin in one patient to elucidate further the role of UVL in this process. RESULTS: On routine histopathologic examination we found that uninvolved sun-exposed skin but not sun-protected skin demonstrated early MDE. Ultrastructural examination revealed a spectrum of elastic fiber changes in involved and clinically uninvolved sun-exposed skin. Phagocytosis of elastic fibers was not present. CONCLUSION: We conclude that UVL exposure was a major causative or aggravating factor of MDE in our patients and that the clinical appearance of this disorder is variable.

Comparison of paragraph comprehension test scores with reading versus listening-reading and multiple-choice versus nominal recall administration techniques: justification for the bypass approach.

Eight groups of learning disabled children (N = 100), categorized by the clinical Lexical Paradigm as good readers or poor readers, were individually administered the Gilmore Oral Reading Test, Form D, by one of four input/retrieval methods: (1) the standardized method of administration in which the child reads each paragraph aloud and then answers five questions relating to the paragraph [read/recall method]; (2) the child reads each paragraph aloud and then for each question selects the correct answer from among three choices read by the examiner [read/choice method]; (3) the examiner reads each paragraph aloud and reads each of the five questions to the child to answer [listen/recall method]; and (4) the examiner reads each paragraph aloud and then for each question reads three multiple-choice answers from which the child selects the correct answer [listen/choice method]. The major difference in scores was between the groups tested by the recall versus the orally read multiple-choice methods. This study indicated that poor readers who listened to the material and were tested by orally read multiple-choice format could perform as well as good readers. The performance of good readers was not affected by listening or by the method of testing. The multiple-choice testing improved the performance of poor readers independent of the input method. This supports the arguments made previously that a "bypass approach" to education of poor readers in which testing is accomplished using an orally read multiple-choice format can enhance the child's school performance on reading-related tasks. Using a listening while reading input method may further enhance performance.

Comparison of nominal recall (standard) and multiple-choice methods for administration of WISC-R information subtest: a preliminary study indicating a learning effect of multiple-choice testing.

The Wechsler Intelligence Scale for Children--Revised (WISC--R) Information subtest was administered to learning disabled children using two methods of administration, the standard (recall) method and a multiple-choice format. Those children who were tested first with the multiple-choice format and subsequently with the standard format did better on the standard format than expected. This preliminary study suggests a learning effect of such multiple-choice testing and the desirability of further research being undertaken.

Depression, learning disability, and school behavior problems.

It is possible that recurrent depression (primary affective illness) is the most significant variable related to school problems of a behavioral nature in children manifesting developmental specific learning disabilities. The association of school problems and depression was investigated at a private school for children with developmental specific learning disabilities. These children were of normal intelligence and were free of primary conduct or thought disturbances. Prior to entering school, 95% of the students fulfilled criteria for developmental specific learning disabilities and 64% for depression with or without hyperactivity. Students manifesting no diagnosable behavioral condition prior to entrance continued to be relatively free of behavioral problems during their stay at school. Students with both depression and hyperactivity showed the most problematic behavior followed by students with depression without hyperactivity.

One surgeon's ten-year experience with abdominal aortic aneurysm surgery in smaller community hospitals.

The results of one surgeon's 10-year experience with surgical treatment of abdominal aortic aneurysms are reviewed. There were 64 elective operations, eight operations on expanding aneurysms, and 19 procedures done for frank rupture. The mortality rate was 4.2% for the nonruptured aneurysm group compared with 36.8% for those patients with rupture. It may be suggested from this study that surgical treatment of abdominal aortic aneurysms can be done safely in low volume in smaller community hospitals and that such surgery need not be regionalized to larger institutions.

Treatment of experimental frostbite with intra-arterial sympathetic blocking drugs.

A number of experimental and clinical studies have shown that early regional surgical sympathectomy decreases tissue loss following frostbite, presumably by relieving vasospasm and increasing blood flow. This study was performed to determine if a decrease in tissue loss following a standard cold injury could be obtained following a regional "medical sympathectomy" achieved by the intra-arterial administration of sympathetic blocking drugs. A standard cold injury was produced in rabbits and the animals were divided into nine treatment groups. Various treatment modalities were evaluated, including rapid rewarming, intra-arterial reserpine and tolazoline, and intravenous low molecular weight dextran. In the slowly rewarmed animals, the usual clinic situation, the regional intra-arterial administration of reserpine and tolazoline significantly reduced tissue loss, equalling the results obtained in the rapidly rewarmed group. These results indicate that the early achievement of a regional "medical sympathectomy" may be of benefit in reducing tissue loss following frostbite in patients, especially in those in whom rapid rewarming cannot be performed.

The diagnosis and treatment of Raynaud's phenomenon.

Twenty-five patients with Raynaud's phenomenon, including 20 with associated diseases and five with primary Raynaud's disease, were evaluated with sequential determinations of digital temperature recovery time after cold exposure and magnification hand arteriography before and after cold exposure and before and after intra-arterial reserpine. A variety of immunologic screening tests were performed, and the clinical response to oral guanethidine of phenoxybenzamine was determined. Temperature recovery time was prolonged in all but two patients with Raynaud's phenomenon before treatment. Arteriography revealed luminal obstruction of variable degree in all but two patients with Raynaud's phenomenon but not in those with Raynaud's disease. Radiographic vasospasm was noted in all patients. Patients with Raynaud's symptoms had a markedly greater vasospastic response to cold exposure than did three control patients without Raynaud's symptoms. Arteriography 48 hours after intra-arterial reserpine repeat revealed decreased vasospasm and a decreased vasospastic response to cold in most patients. A variety of serum protein and serologic aberrations were detected, with only eight patients being free of immunologic abnormalities, Nineteen patients were treated with guanethidine alone, three with guanethidine-phenoxybenzamine combination, and one with phenoxybenzamine alone. Good or excellent clinical results were noted in 19 of the 23 patients treated, with an average follow-up to date of 12 months.

Axillary-axillary artery bypass for the correction of subclavian artery occlusive disease.

Numerous procedures have been proposed for the correction of symptomatic subclavian artery occlusive disease, none of which have been uniformly accepted by vascular surgeons. During the past 21 months we have successfully treated six patients with symptomatic subclavian artery occlusive disease by the construction of an axillary-axillary artery bypass. There were three complications in this small series, a wound hematoma, a case of median nerve parasthesias, and a late graft thrombosis, possibly caused by external pressure on the graft. These complications have not caused any serious morbidity. All patients have been followed to the present time, all have experienced symptomatic improvement and none has developed any symptoms of donor arm ischemia. Axillary-axillary artery bypass is currently our procedure of choice for the correction of symptomatic subclavian artery occlusive disease because of its effectiveness, absence of serious morbidity and ease of performance.