An independent comparison of terbinafine and itraconazole in the treatment of toenail onychomycosis.

BACKGROUND: Previously, sponsored publications have shown that either terbinafine or itraconazole (pulse regimen) are effective for patients with toenail onychomycosis. However, independent comparative studies are lacking. OBJECTIVES: To objectively compare treatment with terbinafine and itraconazole in patients with toenail onychomycosis. METHODS: The effectiveness of terbinafine (250 mg/day 3 months) versus itraconazole pulse regimen (400 mg/day for the first week of each month, for three cycles) was retrospectively evaluated in patients with toenail onychomycosis using mycological tests and subjective outcome measures. Statistical analyses were performed using one-way analyses of variance (ANOVA) for continuous variables and Fisher exact tests for categorical variables. RESULTS: Included in the study were 117 patients (74 patients treated by terbinafine and 43 patients treated with itraconazole). Patients were examined at an average period of 20 months after the end of therapy. Mycological cure was observed in 70.6% and 62.8% of the patients who were treated by terbinafine or itraconazole, respectively (not statistically significant). Mean visual analogue scale assessment of treatment outcome was 79.9 mm (SD 24.7 mm) and 65.2 mm (SD 34.6 mm) for patients treated by terbinafine or itraconazole, respectively (p=0.008). When the results were stratified according to age and gender, it was observed that the advantage of terbinafine versus itraconazole retained statistical significance only for patients who were 55 years old and above, or females. CONCLUSIONS: Mycological cure proportions were not statistically significant between patients treated by terbinafine or itraconazole for toenail onychomycosis. However, better subjective outcome measures indicated an advantage for terbinafine over itraconazole, noticeable in females and patients 55 years old and above.

Association of Ureaplasma urealyticum colonization in male urethra and Condyloma acuminatum.

BACKGROUND: The frequent coexistence of two or more sexually transmitted diseases in one patient has been reported in non-dermatological literature, mostly in languages other than English. Identification of Ureaplasma urealyticum, Chlamydia trachomatis and Mycoplasma hominis in men with other STDs is important, since these bacteria have been implicated in a variety of diseases such as non-gonococcal urethritis, premature rupture of fetal membranes, and infertility in female sexual partners of these patients. OBJECTIVE: To assess the frequency of concomitant STD, particularly urethral colonization of U. urealyticum, C. trachomatis and M. hominis, in men consulting for suspected STD-related symptoms. METHODS: All patients attending our dermatology clinic for STD-related symptoms during a 12 month period in 1996-97 underwent systematic clinical and laboratory screening for syphilis, gonorrhea, NGU, prostatitis, genital herpes simplex infection, Condyloma acuminatum, urethral carriage of U. urealyticum, C. trachomatis and M. hominis, as well as serological screening for HIV, and hepatitis B and C infections. RESULTS: A total of 169 men with STD-related symptoms were enrolled in the study. The following clinical diagnoses were established: NGU in 109 men, C. acuminatum in 40, genital herpes simplex in 10, prostatitis in 7, latent syphilis in 6, primary syphilis in 1, and Behcet's disease in 1. No clinical evidence of STD was found in 13 patients. Of the 169 patients, 39 (23%) had two or more concomitant STDs, of whom 27 (69%) had C. acuminatum associated with one or more of the urethral pathogens. A positive U. urealyticum culture was found in 67.5% (27/40) of the men with C. acuminatum as compared to 42% (40/96) among the patients with NGU who did not have C. acuminatum (P = 0.004, chi 2 test). Conversely, the prevalence of C. acuminatum among patients positive for U. urealyticum was significantly higher than the prevalence among those who were negative--27/75 (36%) vs. 13/94 (14%), P < 0.0009, chi 2 test. About half of the U. urealyticum-positive patients with C. acuminatum had no clinical signs or symptoms of urethritis. CONCLUSION: Our findings suggest that patients with C. acuminatum should be assessed for U. urealyticum carriage and, when identified, their sexual contacts should be actively sought and treated.

Perimyocarditis. Report on an unusual cause.

A 29-year-old man had a febrile illness accompanied by chest pain and tachycardia. The ECG suggested either myocarditis or acute ischemia. Heart muscle enzymes were normal, the peripheral blood count showed absolute and relative lymphocytosis, and an echocardiogram disclosed a small pericardial effusion. After defervescence, splenomegaly was noted and the SGPT level was elevated to four times normal. There was a greater than fourfold rise in titer of IgM antibodies to cytomegalovirus. This is only the second report in detail of perimyocarditis caused by cytomegalovirus mononucleosis. An interesting aspect of the case was an afebrile prodrome that lasted for more than one week, during which prostration, palpitations, and breathlessness on exertion were present and the sole physical finding was tachycardia.

[Vasculitis with cutaneous necrosis induced by oral contraceptive].

Multiple ulcerated and necrotic lesions developed in a 29-year-old woman. Response to treatment during the next few months was minimal. The most plausible explanation was drug-induced vasculitis caused by contraceptive pills (Microgynon: levonorgestrel 0.15 mg and ethinyl oestradiol 0.03 mg). The diagnosis of vasculitis was confirmed by histopathological and immunofluorescent studies. Urticarial manifestations had developed into necrotizing inflammation and the lesions only began to heal after discontinuation of the pills. Contraceptive pills are not included among the drugs causing necrotizing vasculitis, and to the best of our knowledge, this is the first report. Although contraceptive pills are commonly implicated in the induction of erythema nodusom or vasculitis, such a severe reaction with necrosis is rare.

PIP: Oral contraceptives (OCs) have been implicated as a major cause of mostly mild vascular diseases; cutaneous necroses are rare. A 29-year old married female developed vasculitis following administration of (OCs). The disease which developed her knees, progressed into cutaneous ulcerative necrosis that was impervious to therapy. She had stopped taking OCs a month before. The presence of staphylococci and streptococci were detected in the ulcer cultures. A slight improvement of the ulcers occurred following treatment with cephalosporins. 1 week after treatment ceased she returned with new ulcers. She had resumed taking OCs and had taken 5 pills at once to make up for 5 omitted days. 2 days later new ulcers appeared, and the existing ones became aggravated. Histology showed an inflammatory reaction rich in leukocytes, monocytes, and eosinophils, and endothelial edema of vessels with fibrin deposition. In some places, partial obstruction of the blood vessels was observed. Partial involvement of the subcutaneous fat was also observed. Improvement occurred 1 month later following discontinuation of OCs.

[Primary dermatology--who is the gate keeper?].

For several years health funds in Israel have allowed patients to see dermatologists, gynecologists, orthopedic surgeons and ENT specialists without being referred by their primary care physician. There is heated debate about whether this practice is justified and if it is cost effective. Is it better medicine for the patient? What are the roles of the primary care physician and of the primary dermatologist in the care of skin diseases? What do patients want? We examined the practices of 4 dermatology clinics and discuss the issues involved.

[Cutaneous leishmaniasis: incidental outbreak in a new endemic area?].

In the autumn of '94 we saw 32 patients with cutaneous leishmaniasis from a newly populated areas south of Yerucham. Yerucham had never previously been reported as a focus of leishmaniasis. Ongoing construction in the town and the health hazards that resulted may play a part in this new situation. There are a number of ways of controlling and preventing outbreaks leishmaniasis. They include elimination of the vector, Phlebotomus and its host, the gerbils as well as their food supply, "maloach" bushes, other health hazards and vaccination of the population. Patients were treated according to the severity of disease. It is still too early to determine whether our efforts to limit the spread of the outbreak have been successful.

The prevalence of pain complaints in a general population in Israel and its implications for utilization of health services.

OBJECTIVE: To determine the prevalence of pain complaints, specifically of chronic widespread pain, in the general population; and to explore the utilization of health services by various pain groups. METHODS: Cross sectional population survey of 2210 adults in the southern part of Israel, who were classified into 5 pain groups: no pain, transient pain, chronic regional pain, chronic widespread pain, and other. Participants were interviewed about pain patterns and utilization of health services. RESULTS: Forty-four percent reported pain on the day of the interview. The prevalence of chronic widespread pain in the study population was 9.9%, 14% in women and 3% in men (p<0.01). The prevalence in the Israeli adult population was estimated after adjusting for sex and age as 10.2%. The prevalence of any chronic pain (regional or widespread) increased with age. The prevalence of chronic widespread pain was significantly higher in women than in men across all age groups (p<0.01). Persons with chronic widespread pain reported most frequent visits to their physicians (10.8 visits/year) and most frequent use of antiinflammatory and analgesic drugs. They were more frequently referred to specialists and tended to be hospitalized slightly more often. CONCLUSION: In the general population in Israel, widespread pain is common, and its prevalence is comparable with reports from USA, UK, and Canada.

Davener's dermatosis: a variant of friction hypermelanosis.

BACKGROUND: As part of our clinical experience we encountered a group of patients from a specific population with a similar peculiar pigmentation over the lower dorsal spine. OBJECTIVE: We investigated these patients to see whether we could determine a common origin. METHODS: Patients meeting the inclusion criteria underwent detailed history and complete physical examination; biopsy specimens from 3 patients were studied. RESULTS: All 13 patients were full-time male students at Orthodox Jewish Talmudic seminaries (Yeshivas). The lesion consisted of an elongated, vertical, midline, hyperpigmented patch with indistinct borders, which was distributed along the skin overlying the bony protuberances of the inferior thoracic and lumbar vertebrae. It was often unrecognized by the patients. Mean body mass index was lower than that for the general population. Histologic study showed a marked diffuse hyperkeratosis and hyperplastic epidermis with diffuse hyperpigmentation. We attributed the phenomenon to friction from the rigid backrests against the cutaneous surface of the lower back generated by the characteristic swaying activity that traditionally accompanies Torah study or "davening" (praying) and termed it Davener's dermatosis. CONCLUSION: We believe this phenomenon represents a new form of benign friction hypermelanosis. This report highlights the importance of a thorough history in patients presenting with pigmented lesions.

Experiences of stigmatization play a role in mediating the impact of disease severity on quality of life in psoriasis patients.

BACKGROUND: Psoriasis may have a severe impact on patients' quality of life (QOL) in several ways, an impact mediated by the mental or physical difficulties they have to deal with during the course of the disease and the various treatment regimens. In addition, psoriatic patients often suffer from experiences of stigmatization (EOS) related to the disease. OBJECTIVES: This study was designed to test the hypotheses that psoriasis patients report higher levels of stigmatization than a comparison group, and that their EOS play a role in mediating the impact of the severity of psoriasis on their QOL. METHODS: One hundred patients with psoriasis (study group) and 100 patients with mixed skin problems (comparison group) were matched according to age, sex and education. All subjects answered questionnaires on EOS and QOL. A dermatologist diagnosed the diseases and measured severity scores. The Psoriasis Area and Severity Index score was used for psoriasis and a linear severity score for the comparison patients. The mediating effect of EOS was analysed using structural equation modelling (SEM). SEM is a multivariate statistical method used to examine the consistency of a theory relating one group of variables (termed a 'latent construct') to another: in the present study, the relationship between EOS and QOL. RESULTS: Psoriatic patients were found to report significantly higher levels of EOS related to the disease, compared with the comparison group. No significant differences were found regarding QOL or severity of disease. Clinical severity of psoriasis was found to correlate negatively with QOL in psoriasis patients. EOS were found to have a complete mediating effect for the severity of disease on the QOL in patients with psoriasis. This result was not found among the comparison group patients. CONCLUSIONS: The results of this study indicate that psoriasis patients experience higher levels of stigmatization than do other dermatological patients, and that these EOS mediate the association between disease severity and patients' reported low levels of QOL. Treatment of psoriatic patients should consider these results and should include tools for psychosocial intervention.

Cys 618 Arg mutation in the RET proto-oncogene associated with familial medullary thyroid carcinoma and maternally transmitted Hirschsprung's disease suggesting a role for imprinting.

The multiple endocrine neoplasia type 2 (MEN2) syndromes and Hirschsprung's disease (HSCR) are inherited neurocristopathies characterized by medullary thyroid carcinoma (MTC), pheochromocytoma, parathyroid disease, and gastrointestinal neuromatosis. Mutations in the RET proto-oncogene are the underlying cause of the MEN2 syndromes and some cases of HSCR. In this report, we show that Cys 618 Arg mutation cosegregates with familial MTC and HSCR in two Moroccan Jewish families in which no involvement of pheochromocytoma or parathyroidism was observed. A single haplotype shared by chromosomes bearing the Cys 618 Arg mutation in both families strongly suggests a founder effect for this mutation. We have observed in our and in several other previously reported families, an excess of maternal over paternal mutated RET alleles in offsprings affected by HSCR. We suggest that parental imprinting may play a role in the ethiology of HSCR caused by mutations in the RET protooncogene.