Intraocular pressure increases with fenoldopam, but not nitroprusside, in hypertensive humans.

Fenoldopam mesylate stimulates adenyl cyclase in porcine ocular trabecular meshwork and raises intraocular pressure in humans. To clarify whether this results from direct activation of the dopamine-1 receptor or indirectly from baroreflex sympathetic stimulation after blood pressure reduction, intraocular pressure was measured in 14 patients with accelerated/malignant hypertension, randomized between intravenous fenoldopam or sodium nitroprusside. Intraocular pressure was measured with a Perkins tonometer, before and at the twentieth minute of each dose increment. In seven patients with a mean blood pressure of 232/131 mm Hg treated with fenoldopam, intraocular pressure increased in a dose-dependent fashion, from 16 +/- 1 to 20 +/- 2 mm Hg (p less than 0.005). In contrast, seven patients with a mean blood pressure of 225/134 mm Hg treated with sodium nitroprusside exhibited no change in intraocular pressure (15 +/- 1 versus 14 +/- 1 mm Hg) despite similar blood pressure reduction. Increases in heart rate were not significantly different. Rates of urinary excretion of norepinephrine plus epinephrine increased significantly relative to baseline (p less than 0.05) but were not different between groups. These data suggest that the increase in intraocular pressure with fenoldopam results from specific activation of the dopamine-1 receptor and is not caused by baroreflex sympathetic stimulation. Because dopamine-1 receptors may modulate intraocular pressure, dopamine-1 receptor blockers might be useful therapy for glaucoma.

Disseminated intravascular coagulation and purpura fulminans in a patient with Candida sepsis. Biopsy of purpura fulminans as an aid to diagnosis of systemic Candida infection.

Disseminated intravascular coagulation and purpura fulminans developed in association with septicemia and meningitis due to Candida tropicalis in an 18-year-old female immunosuppressed renal allograft recipient. Although systemic Candida infection was initially suspected, blood cultures showed no growth of this organism until after its identification in the dermis of a skin biopsy specimen obtained from the site of purpura fulminans. This case illustrates the association between Candida sepsis and purpura fulminans, and demonstrates the usefulness of skin biopsy of purpura fulminans in the early diagnosis of Candida sepsis.

Systemic candidiasis: cutaneous manifestations in low birth weight infants.

The cutaneous manifestations of 18 infants treated for systemic candidiasis during a 3 3/4-year period were examined. Eight infants, with a mean birth weight of 712 +/- 161 g, had a diffuse burn-like dermatitis, usually within the first three days of life. Candida pseudohyphae were identifiable on skin scrapings. A history of a maternal cerclage or intrauterine device complicated by chorioamnionitis was common. A delay in diagnosis or therapy resulted in mortality, whereas promptly treated infants survived. Nine additional infants had monilial diaper rashes, which spread to the trunk and extremities in four infants. These infants were older at the onset of the dermatitis, and all survived the systemic infection. Systemic candidiasis without any cutaneous involvement developed in only one infant. Candidiasis should be more frequently considered, and prompt systemic therapy should be instituted when cutaneous candidiasis occurs within the first few days of life in infants who weigh less than 1,500 g.

Attitudes of teenagers toward sun exposure and sunscreen use.

A survey of 220 adolescents attending a multiphysician pediatric office in Virginia was conducted to determine the frequency with which they used sunscreens. Eighty-one percent of the teenagers in the study stated that they spent most weekends in the sun; however, only 9% always used sunscreen, while 33% never did. Factors found to be associated with increased sunscreen use included female sex (odds ratio = 4.5, P less than .0001), having a best friend who routinely used sunscreen (odds ratio = 3.0, P less than .001), having parents who insisted on sunscreen use when the teenagers were children (odds ratio = 3.0, P = .006), and knowing that the maximum time for safe exposure to the sun is short (odds ratio = 6.2, P less than .0001). Adolescents with a history of skin cancer in the family were not more likely to use sunscreens than other teenagers. Thirty-three percent of the girls and 16% of the boys older than 15 years of age reported that they had visited a tanning salon at least once. This survey substantiates poor compliance with sunscreen use by teenagers despite increasing evidence of the dangers of excessive sun exposure.

A histologic comparison of congenital and acquired nevomelanocytic nevi.

A reliable microscopic differentiation of nevomelanocytic nevi (NMNs) as congenital or acquired would be useful in defining a histogenic relationship between cutaneous melanoma and congenital NMN. In order to delineate histologic differences between congenital NMN and acquired NMN, a standardized assessment was conducted blindly, using a sample of consecutive surgical specimens of NMN submitted to a children's hospital pathology file. Despite significant histologic differences between congenital NMN and acquired NMN, the lack of a reliable prevalence rate for the proportion of congenital NMNs among all NMN specimens submitted for pathologic examination precludes a precise estimate of predictive value for diagnosing a given NMN as congenital or acquired based on histologic features alone. The results of this study can be used neither to support nor to refute a histologic association between cutaneous melanoma and congenital NMN.

State of the art: therapeutic controversies in severe acute asthma.

This is a transcript of the 1999 SAEM State-of-the-Art session on "Therapeutic Controversies in Severe Acute Asthma," presented at the 1999 SAEM annual meeting in Boston. The aim of this session was to address some of the current controversies in the management of acute asthma exacerbations, a major issue in emergency medicine. Despite many recent advances in asthma management, morbidity and mortality remain high. While many of us have strong feelings on how asthma patients should be treated, many of our assertions are not based on good science, and there are numerous areas of controversy. This discussion focuses on the controversy over beta agonist treatment for acute asthma, the physiology of corticosteroids in asthma, and the emergency use of leukotriene-modifying agents.

Cutaneous manifestations of neurologic infections in children.

Neurologic infections in children are frequently accompanied by cutaneous findings that may direct the physician toward the correct diagnosis. In some instances, the appearance of an eruption (such as erythema chronicum migrans and Lyme disease) is specific or a rapid bedside diagnostic test (Tzanck preparation for herpes simplex) is extremely helpful in sorting out the differential diagnosis of a child's illness. In this article, cutaneous clues to some of the more important childhood infections will be reviewed.

Hemangiomas and vascular malformations.

Vascular lesions in the neonate and infant are categorized as hemangiomas or malformations. Although their appearances may be similar, the pathobiology, natural history, and prognosis of these lesions are different. Selected important syndromes that are characterized as hemangiomas and vascular malformations are discussed, and an update on what is new in treatment, including laser therapy, is presented.

Office-based treatment of pediatric skin disease.

This article is divided into three sections. The first is a selected review of important points that will enhance practitioners' treatment or approach to many of the disorders covered in depth elsewhere in this issue. It is hoped that this will reduce the reliance on specialists in the current managed care environment. The second section deals with "truisms for a happy practice." These should help practitioners of any specialty, field, or service industry who deal with parents and children. The final section is devoted to information management and what is available to practitioners to enhance their knowledge and the knowledge of their patients.

Steatocystoma multiplex treated with isotretinoin: a delayed response.

A patient with steatocystoma multiplex was treated with 0.75 mg per kg per day of oral isotretinoin. After one month of minimal improvement the patient discontinued therapy. Over the next two months he noted some shrinkage of his pre-existing lesions, which persisted for a follow-up period of six months. Isotretinoin may show a beneficial response in some cases of steatocystoma multiplex even after use of the drug is discontinued. Isotretinoin is known to have effects beyond its treatment period that are related to its long serum half-life. A small number of patients with steatocystoma multiplex have been treated with isotretinoin, with varied responses. This is the first case of a patient who discontinued therapy before a response occurred and then showed a response later.

Circadian variation in the frequency of myocardial infarction and death associated with acute pulmonary edema.

The records of 103 patients hospitalized for acute pulmonary edema were reviewed to determine the relationship between short-term outcome and time of presentation to the emergency department. Although only 17% of the patients arrived in the emergency department during the early afternoon hours, half of the deaths in the study occurred in this group. Patients presenting between noon and four PM had a significantly higher incidence of acute myocardial infarction (76% v. 28%, p = 0.03) and death (47% v. 9% p = 0.03) compared with patients presenting at other times. Differences in the pathophysiology of daytime versus nocturnal acute pulmonary edema may account for some of the variation in outcome.

Tetanus antibody protection among HIV-infected US-born patients and immigrants.

INTRODUCTION: Public health initiatives to immunize children and adults have effectively reduced the number of tetanus cases in the USA. However, in the Third National Health and Nutrition Examination Survey (NHANES III), immigrants from Mexico had a 67% nonprotective anti-tetanus antibody (ATA) level. Less work has been conducted among other vulnerable populations such as human immunodeficiency virus (HIV)-infected patients. The objective of this study was to measure ATA levels among the HIV immigrant population compared with US-born HIV-infected patients. METHODS: A convenience sample of 158 HIV-infected individuals was recruited to determine the levels of ATA. A nonprotective level of ATA was defined as below 0.15 IU/ml. RESULTS: Among the HIV-infected patients, 72% (114/158) were born in the USA. A total of 17% (27/158) lacked protective levels of ATA. A total of 6.1% (7/114) of those born in the USA lacked protection, compared to 45% (20/44) born outside the USA (p < 0.0001). CONCLUSION: The results illustrate that the country of birth is an important predictor of ATA protection, even among HIV-infected patients.

Twenty-nail dystrophy of childhood: a sign of localized lichen planus.

A 9 1/2-year-old girl was seen with 20-nail dystrophy. Lichen planus was suspected and further examination revealed other lesions localized to the oral mucosa. The diagnosis was confirmed as lichen planus by biopsy of tissue from the oral lesions. Careful examination of all mucocutaneous surfaces is recommended before accepting the diagnosis of so-called isolated 20-nail dystrophy of childhood.

Significant others and fear of crime among the elderly.

The authors examine demographic, environmental, behavioral, and social psychological factors that affect fear of crime among the elderly. Using a structural equation model, relevant variables are examined. Confirming earlier studies, elderly women are found to be more fearful than other groups. Further, social isolation, type of housing, length of residence, and area of the city are all related to fear of crime in a predicted direction. The fearful individual expressed low satisfaction with the job being done by the police in providing protection from crime. Social interaction with neighbors and friends reduces the fear of crime among the elderly. Surprisingly, the more they socialize with their relatives, the more fear they express.