Inpatient teledermatology improves diagnostic accuracy and management of erythroderma in hospitalized patients.

With the onset of the COVID-19 pandemic, healthcare providers have made increasing use of inpatient teledermatology; however, few studies have analysed the impact of teledermatology on patient outcomes. In this study, we investigated the diagnostic concordance between the primary team and teledermatologist, and we analysed the impact of this technology on the diagnosis and management of erythroderma, a condition with high morbidity and mortality. Overall, out of 2987 inpatient teledermatology encounters reviewed, we found 33 cases of erythroderma, and, of these, 78.8% had a change in diagnosis after teledermatology consult, 81.8% were recommended biopsy and all patients had a change in topical/systemic therapy. We hope to promote further study of the efficacy of teledermatology as it may begin to address large gaps in dermatological access to care particularly in regional and community hospitals.

Derivation of a human equivalent concentration for n-butanol using a physiologically based pharmacokinetic model for n-butyl acetate and metabolites n-butanol and n-butyric acid.

The metabolic series approach for risk assessment uses a dosimetry-based analysis to develop toxicity information for a group of metabolically linked compounds using pharmacokinetic (PK) data for each compound and toxicity data for the parent compound. The metabolic series approach for n-butyl acetate and its subsequent metabolites, n-butanol and n-butyric acid (the butyl series), was first demonstrated using a provisional physiologically based pharmacokinetic (PBPK) model for the butyl series. The objective of this work was to complete development of the PBPK model for the butyl series. Rats were administered test compounds by iv bolus dose, iv infusion, or by inhalation in a recirculating closed chamber. Hepatic, vascular, and extravascular metabolic constants for metabolism were estimated by fitting the model to the blood time course data from these experiments. The respiratory bioavailability of n-butyl acetate (100% of alveolar ventilation) and n-butanol (50% of alveolar ventilation) was estimated from closed chamber inhalation studies and measured ventilation rates. The resulting butyl series PBPK model successfully reproduces the blood time course of these compounds following iv administration and inhalation exposure to n-butyl acetate and n-butanol in rats and arterial blood n-butanol kinetics following inhalation exposure to n-butanol in humans. These validated inhalation route models can be used to support species and dose-route extrapolations required for risk assessment of butyl series family of compounds. Human equivalent concentrations of 169 ppm and 1066 ppm n-butanol corresponding to the rat n-butyl acetate NOAELs of 500 and 3000 ppm were derived using the models.

Metabolism and disposition of hydroquinone in Fischer 344 rats after oral or dermal administration.

Studies were conducted to determine the absorption, tissue distribution, excretion, and metabolism of 14C-hydroquinone (HQ) in male and female rats following single oral, repeated oral, or 24-h dermal administration. The concentration of parent compound in blood was also determined following a single 50-mg/kg gavage administration. Absorption into the blood was rapid after oral dosing; the maximum concentration of parent compound was attained within 20 min after dosing, and the maximum concentration of total 14C was attained within 30 min. Parent compound represented 1% of total 14C in blood, indicative of extensive first-pass metabolism. Excretion was primarily via the urine within the first 8h of gavage. Typically, 87-94% of the 14C was excreted in urine. Dermal application of 14C-HQ (20 microCi) as a 5.4% aqueous solution resulted in near background levels of 14C in blood; the maximum mean blood concentration was 0.65 microg HQ equivalents/g in females and not quantifiable in males. The majority (61-71%) of the 14C was recovered from the skin surface by washing at 24 h. HQ was extensively metabolized following oral dosing with typically <3% of the dose excreted as parent compound. The major urinary metabolites of HQ were glucuronide and O-sulfate conjugates, which represented 45-53% and 19-33%, respectively, of an oral dose. A <5% metabolite was identified as a mercapturic acid conjugate of HQ.

The relationship of ischemia-reperfusion injury of transplanted lung and the up-regulation of major histocompatibility complex II on host peripheral lymphocytes.

OBJECTIVES: This study was designed to examine the relationship between ex vivo preservation time of the transplanted lung and the extent of injury and to relate this to the severity of rejection with and without allogenicity. METHODS: Single lung transplantation was performed on two groups of domestic swine. Group A (n = 7) and group B (n = 6) had ex vivo preservation times of 4 and 15 hours, respectively, at 4 degrees C hypothermia. Group C (n = 6) underwent 2 hours of warm ischemia via dissection and isolation of the left lung with ligation of its bronchial artery and crossclamping of the left pulmonary artery, vein, and bronchus without explantation. Assessment measures included lung function, antioxidant enzyme activities in the plasma and lung tissue, levels of inflammatory mediators in the recipient plasma, and quantification of major histocompatibility complex II HLA-DR-beta on host peripheral lymphocytes. RESULTS: All groups demonstrated increases in interleukin-10, lung weight, and HLA-DR-1beta expression and decreases in lung-tissue antioxidant enzyme activities, gas exchange, and lung compliance. There was a strong positive correlation between ex vivo preservation time and the expression of HLA-DR-beta and a negative correlation between ischemic time and lung-tissue superoxide dismutase. CONCLUSIONS: These results suggest that the intensity of the host immunogenic response is related to the severity of ischemia-reperfusion injury and is independent of tissue incompatibility and/or the type of ischemic insult. We conclude that the extension of ex vivo preservation time may predispose the transplanted lung to more severe rejection.

Effect of crystalloid administration on oxygen extraction in endotoxemic pigs.

We asked whether crystalloid administration improves tissue oxygen extraction in endotoxicosis. Four groups of anesthetized pigs (n = 8/group) received either normal saline infusion or no saline and either endotoxin or no endotoxin. We measured whole body (WB) and gut oxygen delivery and consumption during hemorrhage to determine the critical oxygen extraction ratio (ERO2 crit). Just after onset of ischemia (critical oxygen delivery rate), gut was removed for determination of area fraction of interstitial edema and capillary hematocrit. Radiolabeled microspheres were used to determine erythrocyte transit time for the gut. Endotoxin decreased WB ERO2 crit (0.82 +/- 0.06 to 0.55 +/- 0.08, P < 0.05) and gut ERO2 crit (0.77 +/- 0.07 to 0.52 +/- 0.06, P < 0.05). Unexpectedly, saline administration also decreased WB ERO2 crit (0.82 +/- 0.06 to 0.62 +/- 0.08, P < 0.05) and gut ERO2 crit (0.77 +/- 0.07 to 0.67 +/- 0.06, P < 0.05) in nonendotoxin pigs. Saline administration increased the area fraction of interstitial space (P < 0.05) and resulted in arterial hemodilution (P < 0.05) but not capillary hemodilution (P > 0.05). Saline increased the relative dispersion of erythrocyte transit times from 0.33 +/- 0.08 to 0.72 +/- 0.53 (P < 0.05). Thus saline administration impairs tissue oxygen extraction possibly by increasing interstitial edema or increasing heterogeneity of microvascular erythrocyte transit times.

Family approach for estimating reference concentrations/doses for series of related organic chemicals.

The family approach for related compounds can be used to evaluate hazard and estimate reference concentrations/doses using internal dose metrics for a group (family) of metabolically related compounds. This approach is based upon a simple four-step framework for organizing and evaluating toxicity data: 1) exposure, 2) tissue dosimetry, 3) mode of action, and 4) response. Expansion of the traditional exposure-response analysis has been increasingly incorporated into regulatory guidance for chemical risk assessment. The family approach represents an advancement in the planning and use of toxicity testing that is intended to facilitate the maximal use of toxicity data. The result is a methodology that makes toxicity testing and the development of acceptable exposure limits as efficient and effective as possible. An example is provided using butyl acetate and its metabolites (butanol, butyraldehyde, and butyrate), widely used chemicals produced synthetically by the industrial oxo process. A template pharmacokinetic model has been developed that comprises submodels for each compound linked in series. This preliminary model is being used to coordinately plan toxicity studies, pharmacokinetic studies, and analyses to obtain reference concentrations/doses. Implementation of the family approach using pharmacokinetic modeling to obtain tissue dose metrics is described and its applications are evaluated.

The role of platelet-activating factor in regional myocardial ischemia-reperfusion injury.

BACKGROUND: This swine model was designed to elucidate the role of platelet-activating factor in regional myocardial ischemia-reperfusion injury. METHODS: In groups 1 and 2 (n = 12 each), the left anterior descending coronary artery was ligated for 60 minutes to induce regional myocardial ischemia followed by 6 hours of reperfusion. Group 1 received the platelet-activating factor antagonist TCV-309 before ischemia, whereas group 2 did not. Group 3 (n = 3) had a sham operation. RESULTS: Animals in group 2 exhibited significant (p < 0.05) hemodynamic instability and myocardial depression during the reperfusion period. Despite preventive measures, 7 of the 12 animals experienced severe dysrhythmias in the form of atrial and ventricular fibrillation leading to cardiac arrest. In contrast, animals in group 1 in whom the effects of platelet-activating factor were blocked by the specific platelet-activating factor receptor antagonist TCV-309 were hemodynamically stable and had significantly (p < 0.05) better myocardial function. This significant difference in global myocardial function between the groups was observed in the presence of similar morphologic findings and regional myocardial function. CONCLUSIONS: These results suggest that platelet-activating factor has a definite influence on global myocardial dysfunction associated with regional myocardial ischemia-reperfusion injury.

Right outflow tract obstruction by a pedunculated neurofibroma: case report and literature review.

Right outflow tract obstruction due to neurofibroma is rare, with only four cases identified in the world literature. Obstruction due to a pedunculated neurofibroma has never been reported. A 36-year-old woman with no known heart disease presenting with dyspnea, palpitations and chest pain was shown on echocardiogram to have a mobile right ventricular mass. Cardiac catheterization revealed normal coronary arteries and right ventricular outflow tract obstruction by a pedunculated mass, which was surgically removed and histologically proven to be a benign neurofibroma. Following surgery the patient's symptoms disappeared, with no recurrence three years postoperatively.

Therapeutic potential of platelet-activating factor antagonism in the management of myocardial infarction.

BACKGROUND: Antagonists of platelet-activating factor (PAF) reduce myocardial postischemia reperfusion injury when given before the onset of ischemia. However, the effects of PAF antagonists when administered at a clinically modelled time (during ischemia but before reperfusion) are controversial. Moreover, the extended survival (eight day) and the characteristics of scar formation after treatment with PAF antagonists have not been investigated. OBJECTIVES: To determine the therapeutic potential of PAF antagonist TCV-309 for the treatment of regional myocardial ischemia-reperfusion injury; and to determine the effects of TCV-309 on cardiovascular recovery, evolution of scar formation and survival eight days after a myocardial infarction treated with reperfusion. ANIMALS AND METHODS: Swine underwent regional myocardial ischemia for 60 mins by ligation of the left anterior descending coronary artery, followed by reperfusion for eight days. The treated group (n=7) received PAF antagonist TCV-309 (0.1 mg/kg) 45 mins after ligation; the untreated group (n=7) received vehicle only. RESULTS: Untreated animals experienced significantly (P<0.001) lower systemic arterial blood pressure during the reperfusion period than animals treated with TCV-309. Furthermore, untreated animals required significantly more (P<0.01) antiarrhythmic and inotropic support. Only two of seven animals in the untreated group survived, which was significantly different (P<0.05) from the six of seven treated animals that survived for eight days. Morphometric analyses did not show differences between groups in the characteristics of scar formation following reperfusion for eight days. CONCLUSIONS: PAF antagonist TCV-309 improves survival and reduces cardiovascular dysfunctions associated with regional myocardial ischemia reperfusion injury when administered at a clinically modelled time.

Lack of nephrotoxicity and renal cell proliferation following subchronic dermal application of a hydroquinone cream.

Hydroquinone (HQ) is used in over-the-counter formulations of skin-lightening creams sold in the United States and European Union. HQ was introduced into these formulations to provide a safe and effective alternative to mercury and other less effective ingredients. Recent studies involving subchronic oral exposure of male F344 rats to HQ have shown nephrotoxicity and renal tubule cell proliferation (English et al., 1994), while chronic exposures of male F344 rats were reported to cause renal cell adenomas (NTP, 1989). Previous subchronic dermal toxicity studies (CTFA, 1986; NTP, 1989) with HQ failed to detect nephrotoxicity; however, these studies were not specifically designed to assess renal structure and function. More sensitive endpoints were used in the present subchronic study to address concerns over potential toxicity from repeated dermal exposure to HQ. Male and female F344 rats were given topical applications with 0, 2.0, 3.5, or 5.0% HQ in an oil-in-water emulsion cream for 13 wk (5 days/wk). Body weights, feed consumption and water consumption were monitored, and animals were observed for clinical signs of toxicity and dermal irritation. Blood taken at termination was analysed for haematological and clinical chemistry effects. Erythema, which abated when exposure stopped, was the only dermatological effect seen at the HQ-cream application sites. Cell proliferation in the kidneys was evaluated after 3, 6 and 13 wk of treatment using bromodeoxyuridine (BrdU) labelling, but no changes indicative of sustained cell proliferation were seen. The renal histopathological lesions noted after oral exposure to HQ were not present after dermal exposure. Thus, topical exposure to HQ does not result in the renal toxicity observed in previous studies with F344 rats given HQ orally.

Recurrence of intravenous talc granulomatosis following single lung transplantation.

Advanced pulmonary disease is an unusual consequence of the intravenous injection of oral medications, usually developing over a period of several years. A number of patients with this condition have undergone lung transplantation for respiratory failure. However, a history of drug abuse is often considered to be a contraindication to transplantation in the context of limited donor resources. A patient with pulmonary talc granulomatosis secondary to intravenous methylphenidate injection who underwent successful lung transplantation and subsequently presented with recurrence of the underlying disease in the transplanted lung 18 months after transplantation is reported.

Localized and systemic scleroderma.

Scleroderma is a broad term encompassing both localized and systemic sclerosis. Localized scleroderma is a cutaneous limited fibrosis that manifests as plaque morphea, generalized morphea, linear scleroderma, and deep morphea. Systemic scleroderma (sclerosis) can manifest as either limited or diffuse disease. Limited systemic sclerosis is typically preceded by Raynaud's phenomenon, involves cutaneous sclerosis distal to the elbows, with gastrointestinal and pulmonary fibrosis, and anticentromere antibody positivity. Diffuse systemic scleroderma is characterized by simultaneous Raynaud's phenomenon, cutaneous skin involvement proximal to the elbow with gastrointestinal, pulmonary, renal and cardiac fibrosis, and positive serology for antitopoisomerase and anti-RNAP III antibodies. This article discusses the classification, epidemiology, pathogenesis, clinical manifestations, treatment, and prognosis of the scleroderma.

A systems-in-transition paradigm for healthy communities.

WHO is generating a new approach to public health in many nations. In Canada the new public health has stimulated important innovations such as the Health Promotion Framework in Achieving Health For All and the Canadian Healthy Communities Project. There is a need, however, for a political theory of social organization and change to facilitate social and political analysis of communities. This article proposes a paradigm which organizes community using a structural-functional approach linked with process components addressing community change through development, stress and conflict. A new definition of a healthy community is proffered using the language of the model. The emerging political role of community health practitioners in the new public health is described.

Evaluation of an advertising method for a university family practice center.

Advertising by physicians has become accepted by the public and is practically mandatory in today's competitive marketplace. This study evaluated the feasibility and effectiveness of a specific method of advertising a university family practice center by using fliers targeted to nearby neighborhoods. The fliers were inexpensive handbills describing the center's location and services, distributed to 23,000 households. Six months after distribution of the fliers, a randomized survey of 100 of these households was conducted to determine the fliers' success at increasing consumers' awareness of the center's location and altering consumers' attitudes and behavior concerning using the center's services. In 27% of the households, someone recalled receiving the flier. Half of these still had the fliers in their possession. Two thirds of those who remembered it thought the flier made them consider using the center, and half had called or visited the center. The results show that this technique was effective.

Cutaneous larva migrans complicated by erythema multiforme.

Cutaneous larva migrans is an intensely pruritic serpiginous eruption caused by the dog or cat hookworm. Often, the disease is self-limiting and no other significant pathology develops; however, a significant localized inflammatory response to the nematode is extremely common. We present a case of cutaneous larva migrans in which a systemic inflammatory process ensued that was characteristic of erythema multiforme. We discuss possible mechanisms of this complication and review the literature.

Cutaneous hyperpigmentation and polyglandular autoimmune syndrome type II.

Primary adrenal insufficiency (Addison's disease) may initially present with cutaneous hyperpigmentation. Addison's disease, when associated with autoimmune thyroid disease and/or insulin-dependent diabetes mellitus, is referred to as polyglandular autoimmune syndrome type II. We present the case of a patient who initially was diagnosed as having Grave's disease and eventually Addison's disease due to persistent cutaneous hyperpigmentation, fatigue, weight loss, hypotension, hyponatremia, peripheral eosinophilia, and positive results of a synthetic corticotropin stimulation test. Addison's disease, polyglandular autoimmune syndrome type II, and cutaneous hyperpigmentation are reviewed.

A man with nevoid hyperkeratosis of the areola.

Nevoid hyperkeratosis of the nipple and areola is a unique clinical entity and a diagnosis of exclusion. The patient presenting with nipple/areolar hyperkeratosis must be examined carefully for other underlying cutaneous diseases such as epidermal nevi, ichthyosis, acanthosis nigricans, Darier's disease, cutaneous T-cell lymphoma, and other chronic skin dermatitides that may be responsible for the changes. If no other clinical findings are evident, the diagnosis can be made. Although the disorder is more common in women of childbearing age, men may show nevoid changes after estrogen therapy or idiopathically. The use of topical 12 percent lactic acid lotion (Lac-Hydrin) resolves the skin changes over a six-month period.

Effective treatment of localized Darier's disease with adapalene 0.1% gel.

Darier's disease is an autosomal dominant disorder of keratinization that can produce unique clinical manifestations. Oral and topical retinoid products have been the mainstay therapy for this population, but local as well as systemic side effects often limit their effectiveness. A case of localized Darier's disease is presented that responded promptly and with no side effects to the topical application of adapalene 0.1% gel. A review of treatments for Darier's disease is presented.

Mees' lines in a patient with multiple parasitic infections.

Mees' lines, or transverse striate leukonychia, are classically associated with arsenic poisoning, but have been described in other cases of acute or chronic illness. Their pathogenesis is thought to be a disruption of nail plate keratinization secondary to systemic stress. Mees' lines are observed in a patient with helminthic and amebic infections and no history of arsenic exposure. This case demonstrates another clinical setting in which Mees' lines can appear, providing further evidence that Mees' lines may chronicle systemic disease.

Hepatitis C and porphyria cutanea tarda.

Porphyria cutanea tarda (PCT) is a clinical manifestation of decreased uroporphyrinogen decarboxylase (UPD) activity. Multiple endogenous and exogenous factors have been implicated in inducing PCT in genetically predisposed patients. The most recent is the RNA virus hepatitis C (HCV), which is transmitted via blood exposure. The mechanism of action in HCV-induced PCT is unknown but produces the same clinical, laboratory, and histopathologic changes seen in other forms of sporadic PCT. Therefore, patients presenting with PCT clinically should be tested serologically for antibodies against HCV and patients with HCV should be monitored for signs and symptoms of PCT.