Association of dementia in patients with benign paroxysmal positional vertigo.

OBJECTIVE: We conducted a cohort study to investigate whether benign paroxysmal positional vertigo (BPPV) is correlated with an increased risk of dementia. METHODS: We established a case cohort comprising 7818 patients aged over 20 years who were diagnosed with BPPV from 2000 to 2010. In addition, we formed a control cohort by randomly selecting 31,272 people without BPPV and matched them with the BPPV patients according to gender, age, and index year. Cox proportional hazard regressions were performed to compute the hazard ratio (HR) of dementia after we adjusted for demographic characteristics and comorbidity. RESULTS: The prevalence of comorbidity was higher among patients with BPPV than among those without BPPV. In addition, patients with BPPV exhibited a 1.24-fold (95% confidence interval, CI 1.09-1.40; P < 0.001) higher risk of dementia than those without BPPV after we adjusted for age, gender, and comorbidity. An analysis stratified according to demographic factors revealed that women with BPPV exhibited a 1.36-fold (95% CI 1.16-1.59; P < 0.001) higher risk of dementia. Patients with BPPV aged over 65 years exhibited a significantly higher risk of dementia (adjusted HR: 1.26; 95% CI 1.10-1.43; P < 0.001) than those without BPPV. CONCLUSIONS: Patients with BPPV exhibited a higher risk of dementia than those without BPPV.

Bacteremia caused by Brevundimonas species at a tertiary care hospital in Taiwan, 2000-2010.

We investigated clinical and microbiological characteristics of 30 patients with Brevundimonas bacteremia treated at a tertiary care hospital in Taiwan during 2000-2010. All the 30 bacteria isolates were confirmed to the species level by 16S rRNA sequencing analysis. Minimum inhibitory concentrations (MICs) of 11 antimicrobial agents against these isolates were determined by the agar dilution method. Seventeen (57%) patients had underlying malignancy, 12 (40%) had undergone central catheter placement, and 13 (43%) had received chemotherapy within the previous three months. Eight (27%) patients had community-acquired bacteremia and the remaining 22 patients (73%) had healthcare-associated bacteremia. The overall 14-day and 30-day mortality rates were 13% and 17%, respectively. Among the 30 isolates, B. vesicularis constituted most commonly (n = 22, 63%), followed by B. nasdae (n = 5) and B. diminuta (n = 3). All isolates were susceptible to piperacillin-tazobactam and amikacin, while all were resistant to ciprofloxacin and colistin. Tigecycline (MICs at which 90% of isolates are inhibited [MIC(90)] was 0.12 mg/L) and doripenem (MIC(90) of 1 mg/L) both possessed good in vitro activities. In conclusions, Brevundimonas should be considered a pathogen that can cause bacteremia in immunocompromised hosts. Piperacillin-tazobactam, amikacin, doripenem, and tigecycline exhibit good in vitro activities against these ciprofloxacin- and colistin-resistant Brevundimonas species.

Positive culture for Klebsiella pneumoniae in relevant sputum samples as a predictor of rapidly fatal outcome in septic patients at medical intensive care units.

Sixty-five patients with main diagnosis of sepsis, who were directly admitted to the emergency department (ED) and had fatal outcomes after transfer to the medical intensive care units (MICU), were included. Patients who died within 48 hours of MICU transfer were defined as having rapidly fatal outcomes (RFO). The following clinical variables, including diagnosis of infection source; results of blood, sputum, and urine cultures; management for sepsis in the ED and MICU and survival time, were analyzed. There were 30 (46%) patients with RFO. The median survival time in the RFO group was 22.6 hours in MICU. Klebsiella pneumoniae was the most common pathogen isolated from blood (7/65, 10.7%) and relevant sputum samples (7/45, 15.5% ). Multivariate analysis revealed that age, gender and positive sputum culture for K. pneumoniae (hazard ratio, 11.898, p < 0.001) were independently associated with RFO in septic patients. The median survival times for patients with positive and negative K. pneumoniae sputum culture were 17 hours and 66.8 hours (p < 0.001, by the log rank test), respectively. This study found that positive sputum culture of K. pneumoniae was an important independent predictive factor of RFO in septic patients admitted to the MICU.

Incidence and trend of herpes progenitalis. A 15-year population study.

A population-based epidemiologic study of herpes progenitalis was conducted in residents of Rochester, Minnesota, for the 15-year period 1965 through 1979. Three hundred ninety-two patients (129 males, 263 females) were identified. The average annual incidence rate of herpes progenitalis was 50 per 100,000 population. A continuous increase in incidence was demonstrated throughout the study period (P less than 0.0005, trend test). In 1979, the incidence peaked at 128 per 100,000 population. The median age at onset was 24 years, and more than 80% of the patients were 18 to 36 years of age. Females predominated by 1.5:1 (P less than 0.001) and were, on the average, 4 years younger than the male patients. Although 15 pregnancies in the series were affected by herpes progenitalis, no neonatal herpes was noted, nor was the number of unfavorable outcomes of pregnancy unusual. No invasive or in situ genital carcinoma developed in patients after 1,544 person-years of follow-up.

Neonatal herpes: incidence, prevention, and consequences.

The incidence, prevention (by cesarean section), and severe consequences (particularly mortality) of neonatal herpes were appraised. The incidence rate of neonatal herpes should be around one in every 15,000 deliveries with a range of one in 7,500 to 30,000 deliveries. Cesarean section for pregnancies exposed to herpes simplex virus fails to prevent newborns from acquiring neonatal herpes. The mortality rate of herpes patients could be around 25% if a better reporting and diagnostic system were available.

Bowen's disease (squamous cell carcinoma in situ) as a skin marker for internal malignancy: a case-control study.

Bowen's disease has been viewed as a skin marker for internal malignancy by dermatologists for decades. If substantiated, it certainly would help in early detection of an occult malignancy. We conducted a matched case-control study to evaluate the significance of this link. Ninety patients with Bowen's disease diagnosed between 1972 and 1986 were selected for study. These patients were matched by age, sex, race, and date of biopsy for diagnosis (or treatment) to 90 other patients chosen as controls. Six patients in the Bowen's disease group and three patients in the control group had internal malignancy during the period after the date of biopsy or treatment (P greater than 0.4). The present study cannot substantiate the claim that Bowen's disease is a skin marker for internal malignancy.

Squamous cell carcinoma. A population-based incidence study in Rochester, Minn.

The records linkage resources of the Rochester Epidemiology Program Project were used to identify 169 incident cases of invasive squamous cell carcinoma of the skin in the population of Rochester, Minn, between 1976 and 1984. The overall age-standardized incidence was 38.8/100,000 persons (63.1 in men; 22.5 in women). Metastasis occurred in 3.6%, and during an average of 3.8 years of follow-up, recurrence was seen in 3.6% while subsequent new lesions occurred in 12%. The demographics and course of patients with squamous cell carcinoma were different from either those of Bowen's disease or basal cell carcinoma in these population-based data.

The diagnostic yield of histologic examination of seborrheic keratoses.

OBJECTIVE: To examine the diagnostic yield in submitting clinically diagnosed seborrheic keratoses for routine microscopic examination. DESIGN: Retrospective examination of preoperative and postoperative diagnoses based on information provided by the clinician on the laboratory worksheet and the subsequent histopathologic diagnosis. SETTING: A regional nonhospital-based dermatopathology laboratory with specimens submitted by physicians (dermatologists and nondermatologists) practicing in a 4-state midwestern region of the United States. PATIENT MATERIAL: A total of 5592 cutaneous pathology reports were reviewed. Specimens submitted with a preoperative clinical diagnosis of seborrheic keratosis, with or without a modifier, were examined. A comparison group with the clinical diagnosis of melanocytic nevus was reviewed. MAIN OUTCOME MEASUREMENT: Preoperative clinical diagnoses were compared with the microscopic diagnoses. RESULTS: Of 577 specimens clinically diagnosed and submitted as seborrheic keratoses, 37 (6.4%) were histologically diagnosed as malignant tumors. The rate of malignant tumors increased when clinical information suggested findings beyond the classic clinical presentation, such as irritation, or when a malignant tumor was considered in the differential diagnosis. Two lesions that histologically proved to be melanomas were in this group. Comparison of the seborrheic keratosis group with the nevus group showed that seborrheic keratoses were more likely to be malignant tumors than were melanocytic nevi. Clinically diagnosed seborrheic keratoses submitted by dermatologists were more likely than clinically diagnosed melanocytic nevi to be melanomas. CONCLUSIONS: Our data suggest that there were differences in the rate of malignant tumors between dermatologists and nondermatologists and that clinically diagnosed, surgically removed seborrheic keratoses are more likely than clinically diagnosed, surgically removed melanocytic nevi to be malignant tumors.

The utility of submitting fibroepithelial polyps for histological examination.

BACKGROUND: The fibroepithelial polyp (FEP) is a common cutaneous lesion that is often removed for medical or cosmetic reasons. We examined the utility of submitting clinically diagnosed FEPs for routine microscopic examination. DESIGN: We reviewed 11500 consecutive cutaneous pathology reports. Materials submitted with the clinical diagnosis of FEP or a synonym were reviewed and the histopathologic slides were examined. A comparison group of specimens submitted with the clinical diagnosis of melanocytic nevus was reviewed. SETTING: The biopsy reports were generated at a regional non-hospital-based dermatopathology laboratory providing service to physicians (dermatologists and nondermatologists) practicing ambulatory medicine predominantly within a 4-state region (Ind, Ky, Tenn, and WVa). RESULTS: Of 1335 clinical specimens submitted as FEPs, there were 5 malignant tumors. In the comparison group of 697 clinically diagnosed melanocytic nevi, there were 6 malignant tumors. In comparison with clinically diagnosed melanocytic nevi, the likelihood that a lesion clinically diagnosed as FEP would be a malignant tumor on histological examination is very low (relative risk, 0.4). None of the lesions clinically diagnosed as FEPs by dermatologists proved to be malignant. CONCLUSIONS: Our data suggest there is an extremely low prevalence of malignancy in lesions clinically diagnosed as FEPs. We conclude that cutaneous lesions diagnosed as typical FEPs by dermatologists need not be submitted for microscopic examination.

Condyloma acuminatum in Rochester, Minn., 1950-1978. I. Epidemiology and clinical features.

From 1950 through 1978, condyloma acuminatum was diagnosed in 746 residents of Rochester, Minn (246 male and 500 female subjects). With the number of cases increasing almost every year until 1975, the mean annual incidence rate reached 106.5 per 100,000 population in the period 1975 through 1978, apparently the highest reported to date. Among age groups, the rate was highest in the 20- through 24-year-old group. Female patients contracted the infection at a higher rate and at a younger age than male patients. Anal condyloma occurred in one third of the male subjects studied and recurrent condyloma in 30% of the male subjects. More female than male patients had lesions at multiple locations.

Condyloma acuminatum in Rochester, Minn, 1950-1978. II. Anaplasias and unfavorable outcomes.

A total of 746 patients residing in Rochester, Minn, received the diagnosis of condyloma acuminatum between 1950 and 1978. Anaplasia was present in six and subsequently developed in 36 patients during follow-up examination in 42 patients (one male and 41 female). One had invasive squamous cell carcinoma (vulva), six had severe dysplasias, 21 had moderate to mild dysplasias, and 14 had carcinomas in situ (CIS), of which 11 were cervical. In the female patients, 37 of the anaplasias were cervical and the other four were vulval or vaginal. The 11 cervical CIS amounted to 3.8 times the expected number of 2.9, based on an earlier study of cervical cancer incidence in the community. The risk of cervical CIS developing among patients with condyloma is significantly higher than expected. Neither laryngeal papilloma nor other unfavorable outcomes substantially affected the conceptus of 51 pregnancies in women with concurrent condyloma. There appears to be an association between condyloma and genital malignant neoplasms and a relationship of condyloma with sexually transmitted disease and warts.

Keratoacanthoma in Kauai, Hawaii. The first documented incidence in a defined population.

BACKGROUND AND DESIGN: A prospective 5-year population-based incidence study was conducted on the island of Kauai, Hawaii, from 1983 through 1987 to investigate the frequency of keratoacanthoma in white residents. RESULTS: A total of 53 residents, 36 men and 17 women, were identified with an initial episode of keratoacanthoma during the 5-year study. The average annual incidence rate per 100,000 Kauai residents, standardized to the US white population, was 144 for men and 73 for women, with a combined rate of 104. The average patient age was 63.5 years. The limbs, particularly the hands and arms, were the most common anatomic site, with the trunk second. Only one patient developed a new subsequent keratoacanthoma, and no recurrent lesions were observed. Three patients had two keratoacanthomas when they first presented, and 13 patients had concurrent skin cancer. Sixty percent (32) of our patients developed skin cancer at one time or another. CONCLUSIONS: We report the first population-based keratoacanthoma incidence rates documented in the United States, which are almost equal to those of squamous cell carcinoma. Keratoacanthoma also shares many common epidemiological features with squamous cell carcinoma, such as increasing incidence in progressively older age groups.

Reliability testing of the dermatology index of disease severity (DIDS). An index for staging the severity of cutaneous inflammatory disease.

OBJECTIVES: To describe a new severity of illness index for inflammatory skin disease called the Dermatology Index of Disease Severity (DIDS), and to show its preliminary use and reliability in staging disease in patients with psoriasis and dermatitis. DESIGN: Interobserver rating study using the DIDS with as many as 10 observers independently rating the same patient at a single point in time. SETTING: Ambulatory care clinics at an academic medical center with patients from various socioeconomic backgrounds. PATIENTS: Thirty-four patients with psoriasis and 15 patients with dermatitis were included in the study. MAIN OUTCOME MEASURES: The severity of illness for each patient was rated as 1 of 5 stages: 0, no evidence of clinical disease; I, limited disease; II, mild disease; III, moderate disease; and IV, severe disease. The degree of interobserver concordance was measured by the Cohen kappa statistic. RESULTS: All 5 stages were represented in the study of patients with psoriasis. The overall kappa statistic was 0.76, which is defined as substantial interobserver concordance. The use of the instrument in dermatitis showed good consensus in staging, where the kappa statistic was 0.41. CONCLUSION: We introduce an easy and efficient instrument for staging the severity of illness in inflammatory cutaneous diseases. The reliability of the DIDS is demonstrated in patients with psoriasis and in patients with dermatitis.

EMG power spectrum analysis of first dorsal interosseous muscle in pianists.

PURPOSE: Long-term piano training may induce potential biochemical and structural adaptations in hand intrinsic muscles or alter the motor strategy in the nervous systems. METHODS: This study investigated, by electromyography (EMG) and strain gauge, whether this pedagogical training is aerobic or anaerobic by nature. Changes in EMG power spectrum during incremental isometric muscle contractions before and after a sustained, fatiguing muscular performance were studied in the first dorsal interosseous muscle (FDI) of 13 female pianists and 15 sedentary controls. The maximal voluntary contraction (MVC) force of the FDI and the time needed to induce fatigue were also measured. RESULTS: During fatigue, the median frequency (MF) shifted toward the low frequencies in both groups. The MF of 50% and 25%MVC subsequent to fatigue were significantly lower than those before fatigue in the control group (104.0 +/- 45.5 Hz vs 116.7 +/- 41.4 Hz at 50%, P < 0.05; 114.7 +/- 43.4 Hz vs 123.3 +/- 46.7 Hz at 25%, P < 0.05). There were no significant MF changes within the pianists before and after fatigue. The root mean squares (RMS) of 50%, 25%, and 10%MVC of control subjects after fatigue were significantly higher than those before fatigue, but not in pianists. There was no difference in MF and RMS between the two groups at any level of %MVC before or after fatigue, but the pianists tended to show higher MF at each level of %MVC. Although the MVC was similar in both groups, the pianists, however, needed a much longer time to induce fatigue than controls (14.3 +/- 5.8 min vs 5.8 +/- 3.3 min, P < 0.005). CONCLUSIONS: These observations are discussed in terms of the training-induced metabolic adaptations, the changes in the strategy of motor unit recruitment, and the possibility of differences in muscle fiber composition. This study indicates that piano training should not be classified as power training, rather as endurance training. Such findings may also provide information about fine motor training for athletes and other professionals.

Current therapy of cutaneous melanoma.

Melanoma is a growing public health problem. Optimal care of the melanoma patient is multidisciplinary, but plastic surgeons and other surgical specialties play a central role in the management of these patients. Although surgery remains the mainstay of therapy for melanoma, several recent clinical studies have helped to clarify the biology of the disease and have changed the patterns of care for patients with melanoma. The advent of lymphatic mapping for interrogation of regional lymph nodes and interferon as the first effective postsurgical adjuvant therapy have had a major impact on the care of melanoma in the United States and elsewhere. This article will review the current clinical approach and therapy for cutaneous melanoma. The diagnosis, prognostic variables, staging evaluation, current surgical and medical treatment, and follow-up guidelines for patients with all stages of melanoma are reviewed. Recent studies, controversies, and directions of future investigational therapies will be discussed.

0.05 percent betamethasone dipropionate in optimized cream vehicle for psoriasis.

A multicenter open clinical evaluation of 0.05 percent betamethasone dipropionate in optimized cream vehicle for the treatment of psoriatic lesions was conducted to investigate its efficacy. There were 348 patients with moderate to severe psoriasis who completed the three-week clinical trial. Three hundred and ten patients used the cream twice a day and another 38 patients used it once a day. All patients responded well to treatment. Significant improvement was observed at all follow-up visits on days 8, 15, and 21 (p less than 0.001) for measures of erythema, induration, and scaling of lesions. The response was equally impressive whether the patient's psoriatic status prior to the treatment was stable or worsening, involved more than 50 percent of the skin surface or less, or had lasted more than ten years or less. The response of psoriasis to once-a-day application of cream was as good as that seen with twice-a-day application. Side effects, noted in a small percentage of patients, were burning, dry skin, and pruritus. We conclude that the cream is a safe and highly effective treatment for psoriasis. The once-a-day application is probably adequate for control of psoriasis.

Concurrent infection with sporotrichosis and blastomycosis: an unusual case.

Two facial nodules and a pulmonary infiltrate occurred in a twenty-one-year-old man. Tissue cultures from one of the facial lesions showed both Sporothrix schenckii and Blastomyces dermatitidis. Cultures from lung biopsy tissue grew B. dermatitidis. This is the first known reported case of sporotrichosis and blastomycosis occurring concurrently in the same cutaneous lesion.

Severe eczema in a patient with DiGeorge's syndrome.

We describe a patient with DiGeorge's syndrome who had severe, intractable eczema. The causes and exact nature of the eczema and DiGeorge's syndrome remain to be elucidated.