A deep look into thin melanomas: What's new for the clinician and the impact on the patient.

Melanoma incidence and mortality are on the rise and although most new cases of melanoma are thin, a significant percentage of these patients still experience disease progression. The American Joint Committee on Cancer publishes staging criteria for melanoma, which were recently updated to the 8th edition. The most significant revision from the 7th edition affects the T1b classification, which now includes melanomas with a Breslow depth of 0.8 mm to 1.0 mm. The second major revision eliminates mitoses as a criterion to upstage a thin melanoma to T1b. Although mitotic figures have been established as an independent prognostic factor, they do not have a significant correlation with sentinel lymph node (SLN) biopsy positivity. SLN status remains the most important independent prognostic factor in thin melanomas. Nonetheless, the identification of patients who are at the highest risk for having a positive SLN test result remains difficult. Importantly, a positive SLN test result has high positive predictive value, but a negative one has very low negative predictive value. Since there is no proven survival benefit in performing an SLN biopsy in T1 disease, dermatologists need to have a personalized discussion with patients with thin melanomas to review expected risks and benefits before undertaking this procedure.

Warty (follicular) dyskeratoma on the mons pubis.

Warty (follicular) dyskeratoma (WD) is a discrete nodular lesion that demonstrates the characteristic histopathologic findings of acantholysis and dyskeratosis. WDs most commonly occur on the head and neck of adults. We present a case of WD that occurred on the mons pubis of a 53-year-old woman. Only a few other cases of WDs occurring on the vulva have been reported. WD most likely represents a tumor of the follicular infundibulum. Despite its name, there is no evidence that WD is caused by a human papillomavirus (HPV) infection. Although occurrences on the vulva are rare, they must be distinguished from HPV-induced squamous tumors when found in this area.

Social impact of atopic dermatitis.

AD most often arises in infants and children and can persist into adulthood. It is a common and important condition that can have a negative impact on quality of life by affecting psychosocial adjustment in children, creating embarrassment, disrupting sporting activities in older children, and by interfering with employment opportunities in adults. Substantial impact on family function can result from having a child with AD. Parents describe feelings of guilt, exhaustion, frustration and helplessness. AD disrupts sleep not only in patients but also in parents and family members. Parents can miss work or avoid outside work altogether due to a child with AD, and the caregiver's social functioning can be damaged. Spousal and other familial relationships can be affected along with parenting behavior. All of these challenges become even greater with low-income families, who often have minimal social support mechanisms. There is a profound need for enhanced and expanded efficacy and cost research regarding the treatment and control of AD. Informed and thoughtful changes of public policy could minimize its future socioeconomic toll on patients and their families.

From vitamin to Vesanoid: systemic retinoids for the new millennium.

Retinoids are a fascinating class of compounds that exert control over cellular function from the time of conception to death. They play a critical role in such vital processes as fetal morphogenesis, cellular differentiation and apoptosis. Over the years synthetic retinoids have provided dermatologists with a spectrum of medications that have profound therapeutic effects on a variety of recalcitrant skin disorders. Moreover, retinoids are an expanding component of the treatment arsenal against hematologic and solid malignancies. Retinoids are poised to offer exciting new therapeutic options in the field of endocrinology for the treatment of diabetes and lipid disorders. Researchers and clinicians are only beginning to unveil the therapeutic potential of this class of medications. The development of new retinoid compounds targeting specific receptors promises a wealth of new therapies for the new millennium.

Lymphokine-activated killer cell susceptibility and multidrug resistance in small cell lung carcinoma.

Intrinsic or acquired resistance to anticancer drugs necessitated the search for different treatment modalities. The sensitivity of tumor cells to lysis by natural killer (NK) and lymphokine-activated killer (LAK) cells was studied in multidrug resistant (MDR) small cell lung carcinoma (SCLC) by 51Chromium (51Cr) release and conjugate formation assays. The following observations were made: P-glycoprotein positive (P-gp+) MDR SCLC cell line variants were lysed by human LAK cells to a greater extent than were their drug sensitive counterparts. In contrast, P-gp, multidrug resistance protein positive (MRP+) variants of the same line did not exhibit an increased susceptibility to LAK cells. Differential LAK susceptibility is not due to a generalized increase in target fragility to cellular immunity, because NK sensitivity was not increased. Moreover, the P-gp+ MDR SCLC cells showed a higher frequency of binding to LAK cells than did the drug-sensitive parental line. These observations may lead to new insights on combining chemotherapy with immunotherapy.

Distribution of pontomesencephalic cholinergic neurons projecting to substantia nigra differs significantly from those projecting to ventral tegmental area.

Locations of pontomesencephalic cholinergic projection neurons from the laterodorsal tegmental (LDTg) and pedunculopontine tegmental (PPTg) nuclei to midbrain dopaminergic nuclei were mapped. Stereotaxic microinjections of Fluoro-Gold- or rhodamine-labeled microspheres were made either to substantia nigra (SN) or ventral tegmental area (VTA) in rat. Choline acetyltransferase was visualized immunohistochemically. Labeled cells were digitally mapped at multiple levels of the nuclei using an interactive computer/microscope system. SN-projecting neurons were distributed predominantly ipsilaterally in distinct regions of the PPTg: either at its rostral pole or caudally in an area ventromedial to the superior cerebellar peduncle. Few SN-projecting neurons were found in LDTg. VTA-projecting neurons were distributed bilaterally throughout the cholinergic group, primarily in the densest regions of the LDTg and caudal PPTg. Neurons were not strictly segregated into these patterns. Scattered cells belonging to either projection could be found throughout the cholinergic group on either side. Hierarchical log-linear analysis showed these differences in topographic distribution to be statistically significant. Subtraction of cell density images demonstrated well delineated regions of the cholinergic group where the projections were predominately either to SN or VTA. These data indicate a high degree of internal organization within the pontomesencephalic cholinergic group based on the location of efferent projections to SN or VTA. These findings support the concept that this cholinergic group is functionally organized in a manner which selectively innervates motor (SN) and limbic (VTA) dopaminergic nuclei.

Asthma management preceding an emergency department visit.

BACKGROUND: The burden of illness from asthma in North America has not decreased despite advancements in understanding disease pathogenesis and improved pharmacotherapeutics. This study examined the adequacy of preventive measures applied to asthma. METHODS: Using a standardized self-administered questionnaire, 111 consecutive patients presenting to the emergency department because of asthma were surveyed about their "usual" level of disability from asthma, usual medications, self-management plans to deal with an asthma attack, and environmental control measures. RESULTS: Twenty-five percent of subjects suffered sleep disturbance more than 15 days per month, had work/school attendance affected more than 14 days per year, and previously visited an emergency department twice in the past year. Thirty-seven percent had no effective plans to deal with an attack and another 32% had plans that were never discussed with a physician. Although 78% reported that cigarette smoke aggravated their asthma, one third of these were exposed at home. CONCLUSIONS: For a significant proportion of adults requiring emergency health services for asthma, preexisting management was poor by current standards. We recommend that patients be screened by emergency physicians and those with identifiable inadequacies in usual care be referred to physicians with expertise in asthma management.