Porcine reproductive and respiratory syndrome virus genetic variability a management and diagnostic dilemma.

As genetic analysis becomes less expensive, more comprehensive diagnostics such as whole genome sequencing (WGS) will become available to the veterinary practitioner. The WGS elucidates more about porcine reproductive and respiratory syndrome virus (PRRSV) beyond the traditional analysis of open reading frame (ORF) 5 Sanger sequencing. The veterinary practitioner will require a more complete understanding of the mechanics and consequences of PRRSV genetic variability to interpret the WGS results. More recently, PRRSV recombination events have been described in the literature. The objective of this review is to provide a comprehensive outlook for swine practitioners that PRRSV mutates and recombines naturally causing genetic variability, review the diagnostic cadence when suspecting recombination has occurred, and present theory on how, why, and where industry accepted management practices may influence recombination. As practitioners, it is imperative to remember that PRRS viral recombination is occurring continuously in swine populations. Finding a recombinant by diagnostic analysis does not ultimately declare its significance. The error prone replication, mutation, and recombination of PRRSV means exact clones may exist; but a quasispecies swarm of variable strains also exist adding to the genetic diversity. PRRSV nonstructural proteins (nsps) are translated from ORF1a and ORF1b. The arterivirus nsps modulate the hosts' immune response and are involved in viral pathogenesis. The strains that contribute the PRRSV replicase and transcription complex is driving replication and possibly recombination in the quasispecies swarm. Furthermore, mutations favoring the virus to evade the immune system may result in the emergence of a more fit virus. More fit viruses tend to become the dominant strains in the quasispecies swarm. In theory, the swine management practices that may exacerbate or mitigate recombination include immunization strategies, swine movements, regional swine density, and topography. Controlling PRRSV equates to managing the quasispecies swarm and its interaction with the host. Further research is warranted on the frequency of recombination and the genome characteristics impacting the recombination rate. With a well-defined understanding of these characteristics, the clinical implications from recombination can be detected and potentially reduced; thus, minimizing recombination and perhaps the emergence of epidemic strains.

Development and evaluation of the Adherence to Refills and Medications Scale (ARMS) among low-literacy patients with chronic disease.

OBJECTIVES: Patient literacy affects many aspects of medication use and may influence the measurement of adherence. The aim of the study is to design and evaluate a medication adherence scale suitable for use across levels of patient literacy. METHODS: The Adherence to Refills and Medications scale (ARMS) was developed, pilot tested, and administered to 435 patients with coronary heart disease in an inner-city primary care clinic. Psychometric evaluation performed overall and by literacy level, included an assessment of internal consistency, test-retest reliability, and factor analysis. Criterion-related validity was evaluated by comparing scores with Morisky's self-reported measure of adherence, medication refill adherence, and blood pressure measurements. Lexile analysis was performed to assess the reading difficulty of the instrument. RESULTS: The final 12-item scale had high internal consistency overall (Cronbach's alpha = 0.814) and among patients with inadequate (alpha = 0.792) or marginal/adequate literacy skills (alpha = 0.828). Factor analysis yielded two subscales, which pertained to taking medications as prescribed and refilling medications on schedule. The ARMS correlated significantly with the Morisky adherence scale (Spearman's rho = -0.651, P < 0.01), and it correlated more strongly with measures of refill adherence than did the Morisky scale. Patients with low ARMS scores (which indicated better adherence) were significantly more likely to have controlled diastolic blood pressure (P < 0.05), and tended to have better systolic blood pressure control. Lexile analysis demonstrated that the instrument had a favorable reading difficulty level below the eight grade. CONCLUSION: The ARMS is a valid and reliable medication adherence scale when used in a chronic disease population, with good performance characteristics even among low-literacy patients.

Mortality of bullous skin disorders from 1979 through 2002 in the United States.

OBJECTIVES: To identify and analyze trends in bullous disease mortality from 1979 through 2002 in the United States. DESIGN: Retrospective population-based analysis. SETTING: Mortality records from the Centers for Disease Control and Prevention mortality database. PARTICIPANTS: Mortality records from 1979 through 2002 for persons who died of bullous disease. MAIN OUTCOME MEASURES: Age-adjusted mortality rates and trends for 4 bullous disease subgroups: toxic epidermal necrolysis, pemphigoid, pemphigus, and epidermolysis bullosa. RESULTS: The overall age-adjusted (to the 2000 US standard population) annual mortality rate from bullous diseases of the skin was 0.103 death per 100 000. The average mortality from bullous disorders was 0.098 per 100 000 in 1979 through 1982 and remained stable at 0.099 per 100 000 during the final 4 years of the study, 1999 through 2002. Pemphigoid had a significant increase in mortality from 1979 through 2002, while pemphigus demonstrated a significant decrease in mortality. The mortality rate for toxic epidermal necrolysis was much higher among blacks (0.192 death per 100 000) than whites (0.025 per 100 000) (P < .001), with a mortality rate ratio of 7.57 (95% confidence interval, 6.97-8.21). CONCLUSIONS: Overall mortality from bullous diseases remained stable from 1979 through 2002, although an increasing mortality from pemphigoid and a decreasing mortality from pemphigus occurred during this period. A very large racial disparity in mortality from toxic epidermal necrolysis was observed.

Imipramine-induced hyperpigmentation: a case report and review of the literature.

Imipramine-induced hyperpigmentation is rare with only 13 cases reported in the literature to date. We report a 64-year-old female who presented with blue-gray discoloration on her face present for 4-5 years. The patient's medications included imipramine for depression for approximately 23 years. Physical examination revealed slate-gray hyperpigmented discrete and coalescing macules of the malar cheeks and the bilateral temples and periorbitally. She also had diffuse gray pigmentation of the bilateral dorsal hands. Histologic examination revealed an unremarkable epidermis with golden-brown round globules clustered in the superficial dermis, which stained strongly positive with a Fontana-Masson stain. Prussian blue stain for hemosiderin was negative. A diagnosis of imipramine-induced hyperpigmentation was made. Imipramine-induced hyperpigmentation as well as a detailed review of drug-induced hyperpigmentation is discussed.

The impact of total body photography on biopsy rate in patients from a pigmented lesion clinic.

BACKGROUND: Total body cutaneous photography is increasingly being used by dermatologists to monitor patients at risk for the development of melanoma, but limited evidence exists regarding the impact of such photography on melanoma and melanoma-related outcomes. OBJECTIVE: We sought to compare biopsy number in patients with multiple atypical nevi in their first year of care at our pigmented lesion clinic (PLC) between those who received total body skin examination alone and those who received total body skin examination and total body digital photography (TBDP). We sought to identify predictors of biopsy number and number of dysplastic nevi diagnosed in patients with multiple atypical nevi. METHODS: A chart review was performed of patients attending the PLC during the years 1998 to 2003 to identify the number of biopsies performed in the first year of care. Patient demographics, melanoma risk factors, and melanoma outcome events were also abstracted from the charts. RESULTS: The mean number of biopsies performed in patients in their first year of care at the PLC in those who did not receive TBDP was equal to the mean number of biopsies performed in patients who did receive TBDP (0.82 and 0.8, respectively). Linear regression analysis revealed that the interaction term between a lack of both personal history of melanoma and severe dysplastic nevi (-0.930, P = .005) has a significant protective effect on the number of biopsies. Similar regression analysis also showed that the interaction term between a lack of both personal history of melanoma and of severe dysplastic nevi (-1.209, P < .0001), increasing provider experience (-0.047, P = .029), and increased number of biopsies before the initial PLC (-0.028, P = .050) have a statistically significant protective effect on the number of dysplastic nevi diagnosed in the first year of PLC. TBDP did not have an effect on the number of biopsies or on the number of dysplastic nevi diagnosed in the first year of care at the PLC. LIMITATIONS: This study is limited by being retrospective in nature, having a small sample size, and having a short follow-up period. CONCLUSION: Overall, this small retrospective study does not provide evidence that would suggest that TBDP changes provider behavior in caring for patients at high risk for melanoma. Rather, our study supports the fact that a patient's positive history of melanoma and a history of severe dysplastic nevi have the most significant impact on provider biopsy behavior, resulting in a lower threshold to biopsy suggestive lesions.

Melanoma outcomes for Medicare patients: association of stage and survival with detection by a dermatologist vs a nondermatologist.

OBJECTIVE: To determine whether a difference in melanoma outcomes exists in the United States between tumors detected by dermatologists vs those detected by nondermatologists. DESIGN: Retrospective analysis of linked data from the Medicare enrollment and claims files from the Centers for Medicare and Medicaid Services and the National Cancer Institute's Surveillance, Epidemiology, and End Results program database from 1991 to 1996. The registries are from 12 US sites. PATIENTS: A study sample comprised of 2020 subjects. MAIN OUTCOME MEASURES: Tumor characteristics (Breslow thickness and histologic ulceration), stage at diagnosis, and survival and mortality rates. RESULTS: Tumor detection by a dermatologist vs nondermatologist was associated with an earlier stage melanoma (stage 0, stage I, and stage II vs stage III and stage IV; chi(2) test, P<.01) and a thinner tumor (Breslow thickness, 0.86 mm vs 1.00 mm; P<.05). At all time points (6 months, 2 years, and 5 years), patients whose melanoma was detected by dermatologists had better survival rates (98%, 87%, and 74%, respectively, for those whose melanoma was detected by dermatologists vs 95%, 79%, and 69%, respectively, for nondermatologists; P<.05). Non-cancer-related mortality was similar for the 2 groups, but the patients whose tumors were detected by dermatologists had lower cancer-related mortality (13% vs 21%; P<.01) and overall mortality (29% vs 37%; P<.01). Multivariate analysis showed that age, sex, stage at diagnosis, and melanoma detection by a dermatologist were all significantly predictive of survival. CONCLUSIONS: Earlier stage melanoma and improved survival are associated with detection by a dermatologist rather than by a nondermatologist. Increasing access to dermatologists, particularly for older patients, may represent one approach to improving melanoma-related health outcomes.

Development and psychometric evaluation of the Self-efficacy for Appropriate Medication Use Scale (SEAMS) in low-literacy patients with chronic disease.

Medication nonadherence remains a significant obstacle to achieving improved health outcomes in patients with chronic disease. Self-efficacy, the confidence in one's ability to perform a given task such as taking one's medications, is an important determinant of medication adherence, indicating the need for reliable and valid tools for measuring this construct. This study sought to develop a self-efficacy scale for medication adherence in chronic disease management that can be used in patients with a broad range of literacy skills. The Self-efficacy for Appropriate Medication Use (SEAMS) was developed by a multidisciplinary team with expertise in medication adherence and health literacy. Its psychometric properties were evaluated among 436 patients with coronary heart disease and other comorbid conditions. Reliability was evaluated by measuring internal consistency and test-retest reliability. Principal component factor analysis was performed to evaluate the validity of the SEAMS. Reliability and validity analyses were also performed separately among patients with low and higher literacy levels. The final 13-item scale had good internal consistency reliability (Cronbach's alpha = 0.89). A two-factor solution was found, explaining 52.3% of the scale's variance. The scale performed similarly across literacy levels. The SEAMS is a reliable and valid instrument that may provide a valuable assessment of medication self-efficacy in chronic disease management, and appears appropriate for use in patients with low literacy skills.