Developing tomorrow's integrated community health systems: a leadership challenge for public health and primary care.

As the nation's health system moves away from earlier models to one grounded in population health and market-based systems of care, new challenges arise for public health professionals, primary care practitioners, health plan and institutional managers, and community leaders. Among the challenges are the need to develop creative concepts of organization and accountability and to assure that dynamic, system-oriented structures support the new kind of leadership that is required. Developing tomorrow's integrated community health systems will challenge the leadership skills and integrative abilities of public health professionals, primary care practitioners, and managers. These leaders and their new organizations must, in turn, assume increased accountability for improving community health.

Diagnosing and treating congenital melanocytic nevus simulating malignant melanoma.

Many cases reported as malignant melanomas arising in benign congenital melanocytic nevi in the neonatal period have not shown evidence of metastases after several years of follow-up. These lesions were probably pathologically misdiagnosed, thus creating a controversy regarding the precise incidence. This article describes the case of an infant with a giant melanocytic nevus simulating malignant melanoma to illustrate the proper criteria for diagnosis of this condition so extensive and unnecessary therapy procedures can be avoided.

Mohs micrographic surgery.

Mohs micrographic surgery has been highly successful in treating skin cancers that grow in a contiguous manner. The technique requires removal of involved tissue in thin layers and histographic mapping to pinpoint residual tumor. This process is repeated until all of the tumor is resected. This allows 100 percent of all margins to be examined and is very tissue conservative, attributing to its unsurpassed cure rates and excellent cosmetic results. Since it is done as an outpatient procedure under local anesthetic, it also is safe and efficient.

Histiocytosis X and acute monocytic leukemia. Biologic illustration of the monocyte phagocytic system.

The concept of a mononuclear phagocytic system consisting of a continuum of cells arising from the bone marrow monoblast and terminating in the mature tissue macrophage is being actively investigated. The presentation of documented acute monocytic leukemia 18 months following the confirmed diagnosis of histiocytosis X in a 39-year-old man strongly supports the concept of the mononuclear phagocytic system lineage.

Continuous ambulatory peritoneal dialysis for psoriasis. A report of four cases.

Four patients with psoriasis were treated with continuous ambulatory peritoneal dialysis (CAPD). Two were being treated for renal failure; the other two had normal renal function and were being treated exclusively for psoriasis. With CAPD at a rate of three to four exchanges per day, the psoriasis cleared completely in the two patients with renal failure and improved in the other two. In the patients without renal failure, low-flow peritoneal dialysis (one exchange per day) seemed to be of some value in maintaining remission but was ineffective in treating more active disease. Long-term therapy (greater than or equal to 12 weeks) with three or four daily exchanges may be needed for initial complete remission, and continuous treatment may be needed to prevent relapse. Thus, CAPD shows promise for the study of psoriasis and may be a last-resort treatment for severe, disabling cases.

Pseudouremic pruritus: a scabies epidemic in a dialysis unit.

A scabies epidemic was studied in a university hospital dialysis unit. Itching in patients was initially attributed to uremic pruritus, and diagnosis of the epidemic was delayed until cases occurred among the staff. Sixteen cases (seven patients and nine staff) were identified by survey questionnaire and dermatologic examination. Application of 1% lindane lotion (Kwell, Reed and Carnrick, Piscataway, NJ) to all patients dialyzed in the unit and the entire staff eradicated the epidemic. A dialysis unit-associated nosocomial scabies epidemic has not been reported before and may mimic uremic pruritus in dialysis patients.

Scanning electron microscopic evaluation of tinea versicolor. Effects of treatment with miconazole nitrate and clotrimazole.

A study of tinea versicolor organisms was conducted in one patient by scanning electron microscopy. Morphologic changes in the organisms during treatment with topical clotrimazole and miconazole nitrate consisted of initial wrinkling of the surface, followed by fragmentation. These changes may have reflected cell wall alterations resulting from inhibited ergosterol synthesis induced by both treatment agents. The two drugs were effective in eliminating the organisms.

Personality development and familial dysautonomia.

The study sought to establish baselines for personality and frequency of psychopathology in familial dysautonomia (FD). Fifty FD patients, aged 6 to 28 years, served as subjects. FD subjects in all age ranges manifest neurotic patterns, but show no greater incidence of more severe pathology than is found in the general population. the arrested psychologic development seen in FD is described, together with the phenomenon of periodic lapses in judgment. The organic impairment of cognitive functions is discussed. Recommendations for treatment are proposed.

Intellectual development and familial dysautonomia.

The study examined adaptive trends in cognitive development among individuals with familial dysautonomia and sought to establish new base rates of intelligence for the dysautonomic population. Fifty-two subjects, aged 6 to 28 years, were administered the Wechsler scales of intelligence. The results indicate that there is less cognitive impairment than previous research would suggest, and that more dysautonomic children are capable of adjusting to standard school programs than was heretofore thought possible. Specific deficits seen in this population are discussed along with a rationale for deleting the term retarded where most of these individuals are concerned.

Lymphangioma circumscriptum. A case with deep lymphatic involvement.

Lymphangioma circumscriptum is a rare disorder that is localized to the skin. To our knowledge, involvement of deeper lymphatic structures has been reported on only two prior occasions. Our patient had typical lymphangioma circumscriptum of her inner thigh, which was associated with deep lymphatic involvement and enlargement of the extremity. We report this case to alert others to this disease entity.

Sign of Leser-Trélat.

We report a case of squamous cell carcinoma of the lung associated with the sudden appearance of seborrheic keratosis and acquired ichthyosis. We conclude that the sign of Leser-Trélat is a rare cutaneous manifestation of internal malignant disease.

Dapsone motor neuropathy--an axonal disease.

Dapsone produces a potentially reversible toxic neuropathy, with its primary effect on the soma and axons of motor neurons as opposed to myelin. There is very little evidence to suggest involvement of sensory axons in most cases; if present, it would appear minimal. A "dying back" of motor axons is postulated to produce the clinical features of primarily distal weakness and wasting. Recovery appears to occur via axon regeneration and peripheral sprouting. The sporadic occurrence of this neuropathy may be due to slow acetylation of dapsone in some patients.