Public health policy: maternal substance use and child health.

Maternal substance use and abuse is a public health issue. Much of what researchers have discovered in this field has been achieved through support of funds appropriated by Congress to the Public Health Service agencies and institutes whose mandates include stimulating and supporting this research in the scientific community. In this same vein the research institutes have a responsibility for disseminating new knowledge and encouraging its application in real-life settings. Individual freedom, social justice and public health relationships need to be carefully weighed by the architects of public policy. We elect those architects through our system of citizen participation in government. However, how to effectively incorporate the relevance of what has been learned about harmful effects of substance abuse into policy that will enable society to deal with emerging maternal and child health issues remains unresolved. Health-policy-relevant issues, as they impact the lives and well-being of our children, including the increasing number who are children of drug-abusing parents, are too important for politicians to ignore and too complex for health professionals to resolve alone. Participation by the research community in policy development is critical. It is clear that a policy of preventive intervention will need widespread public support. It will need to be feasible, effective and affordable in relation to other public demands. Society will ultimately need to make choices among those options that can be implemented and sustained in a political climate characterized by conflicting values.

Scurvy. A case caused by peculiar dietary habits.

A 9-year-old girl had the insidious development of lethargy, gingival erosions, and follicular hyperkeratosis with perifollicular hemorrhage. A dietary history disclosed that she consumed only one kind of sandwich and beverage and took no other foods. A skin biopsy specimen was consistent with the diagnosis of scurvy, and marked improvement occurred with ascorbic acid therapy. Although it is an uncommon disorder in the United States, scurvy may occur in persons with prolonged and peculiar dietary habits.

Arachidonic acid metabolites in cutaneous carcinomas. Evidence suggesting that elevated levels of prostaglandins in basal cell carcinomas are associated with an aggressive growth pattern.

There is evidence suggesting a role of eicosanoids in the growth of certain tumors. In this study, tissue samples were collected from basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) of the skin. Both BCCs and SCCs contained more prostaglandin E2 and F2 alpha (PGE2 and PGF2 alpha) than normal epidermis. In vitro incubation of tumor samples with arachidonic acid also resulted in PGE2 and PGF2 alpha formation. Basal cell carcinomas exhibiting a histologically aggressive growth pattern contained higher levels of prostaglandins than those with a nonaggressive growth pattern, both in vivo and after in vitro incubation. Lipoxygenase products (12- and 15-hydroxyeicosatetraenoic acid) were present in smaller amounts than cyclo-oxygenase products (PGE2 and PGF2 alpha) in vivo. Compared with normal epidermis, SCCs and, particularly, BCCs produced smaller amounts of 12-hydroxyeicosatetraenoic acid during in vitro incubation with arachidonic acid. The levels of lipoxygenase products were not related to the tumor growth pattern. These results indicate that excessive prostaglandin levels in BCCs may be associated with an aggressive growth pattern.

Methotrexate and etretinate as concurrent therapies in severe psoriasis.

A patient with pustular psoriasis, which was inadequately controlled by high-dose methotrexate and potent topical corticosteroid therapy, was treated with oral methotrexate and the aromatic retinoid etretinate. The patient's psoriasis improved with sustained maximal etretinate therapy and continued high-dose methotrexate therapy. Subsequently, the methotrexate dose was tapered and used of this drug was discontinued. Previously unattainable success in controlling the psoriasis was achieved with continued etretinate treatment. There were no recognizable adverse effects from concurrent therapy. As the methotrexate dose was tapered, the patient noted increased psoriatic arthritic pain, unrelieved at maximal etretinate levels, but improved with indomethacin treatment. Combination therapy with methotrexate and etretinate may be useful in the treatment of severe psoriasis by providing a controlled transition from methotrexate to etretinate therapy alone.

Characterization of the humoral immune response to bovine collagen implants.

The use of bovine collagen implants (BCIs) for the correction of dermal contour deformities is becoming widespread. A small percentage of patients receiving treatment with BCIs suffer adverse reactions that appear to be of an immune nature. Circulating antibodies to BCIs are found in all patients suffering adverse treatment reactions and in small numbers of normal individuals and BCI-treated patients not suffering adverse reactions. These antibodies are always IgG, although quite often IgA is also present. The anti-BCI antibodies are quite stable, suffering virtually no loss of activity after storage at room temperature for 54 days. Immunoblotting studies indicate that no singular component of the BCI collagen is the prime antigenic component; multiple regions of the collagen molecule are recognized by patients' antibodies.

The association of HLA and immune responses to bovine collagen implants.

The HLA type of patients with various kinds of immune reactions to bovine collagen implants were evaluated to determine a possible genetic basis for such responses. All patients suffering adverse clinical reactions to bovine collagen implants were lacking the HLA-DR4 antigen. All patients who received multiple bovine collagen injections without having adverse clinical reactions were lacking HLA-B5 and HLA-DR5 and had a significantly increased incidence of HLA-DR4. Combinations of histocompatibility antigens may influence immune response to bovine collagen implants.

Continuing education needs as perceived by dietetic practitioners.

Educational needs of dietitians were identified by 232 practitioners in Ohio by means of a self-administered questionnaire. Three major knowledge areas--managerial science, nutritional care science, and behavioral, communicative, and socio-cultural science--were covered in 109 questions. The respondents perceived a need for more professional knowledge than for behavioral, communicative, and socio-cultural sciences. Greater need was expressed for skills in technical and human ability than for skills in conceptual ability, and generally for nutritional knowledge rather than application. The findings could form the basis for continuing education programs.

Chiseling of exposed bone to stimulate granulation tissue after Mohs surgery.

Extensive Mohs surgery for carcinomas of the forehead and scalp occasionally requires the removal of periosteum. The exposed bone presents a wound management problem. One method, if healing by secondary intention is a viable option, is to chisel bone to stimulate granulation tissue and promote healing. A case is presented that describes this procedure in an elderly patient.

Topical application of nonsteroidal anti-inflammatory drugs prevents vehicle-induced improvement of psoriasis.

In a double-blind fashion, we compared the effect of topical application of 1% indomethacin cream or 1% meclofenamate cream with the effect of vehicle therapy alone in thirty patients with psoriasis. After 4 weeks' treatment of bilaterally symmetric psoriatic plaques, the indomethacin-treated sides were worse than the vehicle-treated sides in fourteen of twenty patients (p less than 0.01); the meclofenamate-treated sides were worse than the vehicle-treated sides in seven of ten patients (p less than 0.05). We suspect that the nonsteroidal anti-inflammatory drugs contributed to the maintenance of our patients' psoriasis by altering the arachidonic acid transformation cascade.

Topical therapy of alopecia areata with squaric acid dibutylester.

The efficacy of the topical allergen squaric acid dibutylester (SADBE) was investigated in the treatment of twenty-six patients with alopecia areata or alopecia totalis. The patients had their disease for a mean duration of 8.3 years (range, 3 months to 27 years). Sensitization was attempted with 2% SADBE in acetone. Five individuals could not be sensitized. The twenty-one sensitized patients were treated with topical applications of 0.001% to 1.0% SADBE in acetone adjusted to produce and maintain dermatitis for an average of 21 weeks. Eleven (52%) had excellent responses consisting of complete regrowth in six and cosmetically acceptable regrowth in five. The average treatment time for regrowth was 11 weeks (range, 5-20 weeks). Ten (48%) had no clinical response after an average of 19 weeks of therapy (range, 4-42 weeks). Topical SADBE is an effective therapy for some patients with long-standing alopecia areata.

Immune responses to bovine collagen implants. Significance of pretreatment serology.

Bovine collagen implants are in widespread use for the correction of soft tissue deficiencies. A small portion of the population responds adversely to these implants, evidenced by either positive skin tests or treatment site reactions. Antibodies against bovine collagen implants have been detected in the sera of virtually all patients with adverse treatment reactions and in small percentages of untreated individuals and treated individuals without adverse reactions. In this study we examined the levels of anti-bovine collagen implant antibodies in 150 individuals prior to bovine collagen implant therapy and then monitored these patients for adverse reactions to skin tests and bovine collagen implant treatments. Statistical analyses were performed to determine the value of pretreatment serology in predicting positive skin tests or adverse reactions. It was determined that individuals with greatly elevated levels (greater than 2 standard deviations [SDs] above the mean reactivity of pretreatment sera) of anti-bovine collagen implant antibodies prior to treatment were approximately sixfold more likely to suffer adverse reactions than patients with no elevation of antibodies prior to treatment.

Topical minoxidil for hair regrowth.

Minoxidil, a potent peripheral vasodilator used orally for refractory hypertension, has produced hypertrichosis. To determine the efficacy and safety of 1% or 5% topical minoxidil for the stimulation of scalp hair regrowth, we studied fifteen normotensive patients, five with androgenic alopecia and ten with alopecia areata diagnosed clinically and by biopsy, for 12 months. Three of five patients with androgenic alopecia using 5% minoxidil for 12 months noted hair regrowth, ranging from minimally observable hair to an appreciable restoration of larger, pigmented, terminal hair in one patient. Among the patients with androgenic alopecia, regrowth response corresponded to the serum minoxidil blood levels. None of the patients with alopecia areata receiving either 1% or 5% minoxidil noted hair regrowth despite comparable minoxidil blood levels. Improved local absorption of topical minoxidil solution may promote hair regrowth in androgenic alopecia.