Clinical course outcomes for store and forward teledermatology versus conventional consultation: a randomized trial.

We assessed the clinical course of patients after store and forward teledermatology in comparison with conventional consultations. Patients being referred from primary care to dermatology clinics were randomly assigned to teledermatology or a conventional consultation. A total of 392 patients were randomized; 261 patients completed the study and were included in the analysis. Their clinical course was rated on a five-point scale by a panel of three dermatologists, blinded to study assignment, who reviewed serial digital image sets. The clinical course was assessed by comparing images sets between baseline and first clinic visit (if one occurred) and between baseline and nine months. There was no evidence to suggest a difference between the two groups in either clinical course between baseline and nine months post-referral (P = 0.88) or between baseline and the first dermatology clinic visit (P = 0.65). Among teledermatology referrals, subsequent presentation for an in-person dermatology clinic visit was significantly correlated with clinical course (P = 0.023). Store and forward teledermatology did not result in a significant difference in clinical course at either of two post-referral time periods.

Uveitis and desquamating rash of the palms and soles.

Syphilis, a sexually transmitted disease caused by the spirochete Treponema pallidum, can affect nearly every organ system in the body. In particular, skin manifestations of secondary syphilis are common but nonspecific and can be a true masquerader of other skin disorders. Concomitant infection with HIV has been increasing and may cause even more unusual skin presentations. We present a patient with the atypical combination of palmoplantar keratoderma and ocular symptoms that closely resembled reactive arthritis (or Reiter's syndrome). When evaluating patients with HIV infection, clinicians should maintain a high level of suspicion for syphilis to accurately diagnose and treat this curable but potentially fatal disease.

Dermatopathology workforce in the United States: a survey.

BACKGROUND: Although several studies have documented an undersupply of dermatologic services in the United States, little is known about the dermatopathology workforce. OBJECTIVE: Objectives included the following: (1) describe the dermatopathology workforce in the United States; (2) identify characteristics associated with academic dermatopathologists; and (3) explore issues surrounding dermatopathology training. METHODS: We conducted a cross-sectional survey of all Fellows of the American Society of Dermatopathology (ASDP) practicing in the United States and its territories. RESULTS: Of 913 ASDP Fellows, 437 (48%) returned a completed questionnaire. Most were male (72%), Caucasian (85%), and had graduated from US/Canadian medical schools (88%). Approximately half (49%) had completed a dermatology residency and a quarter (24%) were in academia. As compared with those in private practice, academic dermatopathologists were more likely to be female (P = .0028), have a medical degree only (P = .0197), and earn $300,000 or less annually (P < .0001). No associations were identified for practice type with either location of medical school (United States/Canada vs other) or year of fellowship graduation (≤1996 vs ≥1997). Although most respondents were satisfied overall with their training, the most common areas identified as inadequate included: coding/billing (47%), biostatistics (38%), pediatric clinical dermatology (27%), and electron microscopy (27%). LIMITATIONS: Moderate response rate and potential recall bias are limitations. CONCLUSIONS: This study of the US dermatopathology workforce provides benchmarks for future studies and strategies for workforce planning.

Chronic, recurrent neutrophilic dermatosis: a case report.

Sweet syndrome is a reactive neutrophilic dermatosis that develops in response to various systemic illnesses. The cutaneous manifestations include an acute eruption of painful, edematous papules, plaques, pustules, or vesicles associated with fever and other constitutional symptoms. Although the etiology cannot always be determined, Sweet syndrome most commonly arises in reaction to systemic illnesses, such as infections, inflammatory bowel disease, medications, and malignancies. We report a case of chronic, recurrent Sweet syndrome lasting over 15 years in a patient with no identifiable underlying illness.

Bilateral segmental leiomyomas: a case report and review of the literature.

Cutaneous leiomyomas are benign tumors of smooth muscles. We report a rare case of bilateral segmental leiomyomas in an 81-year-old man. We also provide a concise review of the literature on leiomyomas, their associations, and genetic defects of multiple cutaneous and uterine leiomyomatosis (MCUL) and hereditary leiomyomatosis and renal cell cancer (HLRCC) syndromes.

Naildex: pilot evaluation of an onychodystrophy severity instrument.

A valid and reliable measure that captures onychodystrophy disease severity is important for both clinical and research applications. Three hundred and twenty-two patients at two Veterans Affairs Medical Centers with clinical evidence of onychodystrophy suggesting onychomycosis (at least 25% in a distal subungual pattern) were examined using Naildex parameters. Naildex scores were calculated by a combination of: per cent of each nail infected, area of each nail and number of infected nails. Patients also completed a nail-specific quality of life questionnaire (NailQoL) and nail samples were collected and examined mycologically. Data was analysed for all enrolled patients (n = 322) and patients with mycologically-confirmed onychomycosis (n = 243). Inter-rater reliability was calculated from two examiners who each evaluated 17 patients with mycologically-confirmed onychomycosis. Significant correlations (P < 0.01) between Naildex and NailQoL as well as proxy measures (duration of infection) indicated construct validity of the instrument for all patients as well as mycologically-confirmed cases. Strong correlation (r = 0.754, P < 0.01, n = 17) indicated high inter-rate reliability. This pilot evaluation suggests that Naildex is a valid and reliable measure of onychomycosis severity.

Plaque-type syringoma: two cases misdiagnosed as microcystic adnexal carcinoma.

BACKGROUND: Plaque-type syringoma is a rare variant of syringoma. This benign neoplasm may be easily misdiagnosed as microcystic adnexal carcinoma (MAC), potentially resulting in unnecessary surgery with disfiguring consequences. METHODS: We report two cases of plaque-type syringoma that were initially diagnosed as MAC. Microscopically, these lesions were composed of nests of cuboidal cells arrayed within sclerotic collagen in the upper dermis. The deep reticular dermis was spared. No perineural involvement was observed. RESULTS AND CONCLUSIONS: Our cases are discussed in the context of histopathologic diagnosis. Detailed histopathologic findings of syringoma, as well as other considerations in the differential diagnosis, are reviewed. We also include a review of all cases of plaque-type syringoma published to date.

Pancreatic panniculitis in a 4-year-old child with nephrotic syndrome.

Pancreatic panniculitis is an uncommon disorder with a distinctive histopathology. We report the youngest patient with pancreatic panniculitis caused by hypertriglyceridemia in association with nephrotic syndrome.

Digital polarized light dermoscopy of clinically nonpigmented dermal nevi.

BACKGROUND: Hand-held dermoscopy improves the malignant/benign excision ratio for melanocytic lesions. Much has been described about its use in pigmented lesions; however, the use of dermoscopy in clinically nonpigmented lesions is less well studied. Existing studies have used a combination of traditional immersion dermoscopy and polarized light dermoscopy. This is the first study, to our knowledge, to strictly use digital polarized light dermoscopy for the evaluation of clinically nonpigmented, biopsy-proven dermal nevi. OBJECTIVE: The goal of this study was to describe the dermoscopic features of clinically nonpigmented, biopsy-proven dermal nevi using digital polarized light images. METHODS AND MATERIALS: The dermoscopic features of 32 histopathologically confirmed, clinically nonpigmented, dermal nevi were evaluated. Images were obtained with a digital camera equipped with an epiluminescence microscopy attachment (polarized light); no liquid interface was used. RESULTS The most frequent dermoscopic feature of 32 clinically nonpigmented, biopsy-proven dermal nevi was brown pigment (78%) followed by white areas (53%), comma-shaped vessels (50%), hair (47%), hairpin vessels (22%), comedolike openings (22%), and dotted vessels, respectively (19%). CONCLUSIONS: The most common dermoscopic features (using polarized light) of clinically nonpigmented, biopsy-proven dermal nevi are brown pigment, white areas, comma-shaped vessels, and hair.

Quality of care for diabetic patients in a large urban public hospital.

OBJECTIVE: We compared diabetes quality-of-care indicators for patients receiving medical treatment in three practice settings of the same hospital. RESEARCH DESIGN AND METHODS: A cross-sectional medical record review for patients receiving care between 1 July 2000 and 30 June 2001 was conducted. Records were abstracted from three practice settings: the Diabetes Clinic (DIABETES), a general medicine clinic staffed by internal medicine residents (RESIDENT), and a general medicine clinic whose providers were medical school faculty physicians (FACULTY). Record review (n = 791) yielded data on diabetes indicators that were derived primarily from the Diabetes Quality Improvement Project. RESULTS: There were significant differences between the DIABETES, RESIDENT, and FACULTY clinics for the percentages of patients with HbA(1c) testing (94 vs. 92 vs. 76%, P < 0.001), HbA(1c) >9.5% (31 vs. 36 vs. 43%, P < 0.05), nephropathy assessment (79 vs. 67 vs. 58%, P < 0.001), lipid assessment (86 vs. 79 vs. 76%, P < 0.050), LDL <130 mg/dl (54 vs. 44 vs. 43%, P < 0.05), blood pressure <140/90 mmHg (63 vs. 55 vs. 49%, P < 0.025), eye examinations (64 vs. 50 vs. 31%, P < 0.001), foot examinations (97 vs. 55 vs. 24%, P < 0.001), ACE inhibitor treatment (66 vs. 69 vs. 35%, P < 0.001), and aspirin treatment (71 vs. 59 vs. 15%, P < 0.001). CONCLUSIONS: There is considerable variation in diabetes management in different primary care settings of the same hospital. Although management in all settings was suboptimal, the results attained by the patients in the Diabetes Clinic represent minimal achievable goals for all diabetic patients in this hospital.

Effects of the thiazolidinediones on cardiovascular risk factors.

Rosiglitazone and pioglitazone are medications from the thiazolidinedione class of compounds currently available for the treatment of type 2 diabetes mellitus. Traditionally used to enhance insulin sensitivity and decrease plasma insulin levels, added applications have emerged beyond those involving glycemic control. Cardiovascular risk factors associated with insulin resistance such as elevated blood pressure, dyslipidemia, abnormal fibrinolysis, and endothelial and vascular dysfunction have been shown to improve after thiazolidinedione treatment. Therapy with rosiglitazone or pioglitazone has been found to modify vascular reactivity and other processes involved in atherosclerosis. There may be differences between the agents in their effects on plasma lipid characteristics and particle size. These agents serve as excellent adjuncts to oral and insulin therapy for patients with type 2 diabetes mellitus and hold promise for the prevention of cardiovascular disease associated with the insulin resistance syndrome. Clinical trials are in progress to determine whether such therapy will lead to a reduction in cardiovascular events.