Cutaneous insulin-derived amyloidosis presenting as hyperkeratotic nodules.

Amyloidosis consists of approximately 30 protein-folding disorders in which a specific soluble precursor protein aggregates to form the insoluble fibrils of amyloid. Insulin is the hypothesized precursor protein in localized cutaneous insulin-derived (AIns) amyloidosis. Amyloid deposition at insulin injection sites can interfere with absorption, leading to poor glucose control. Despite the increasing prevalence of diabetes mellitus and insulin use, there is a paucity of published cases of AIns amyloidosis and a lack of awareness of this condition among both dermatologists and general practitioners. We report 2 patients with insulin-dependent diabetes who developed hyperkeratotic nodules at insulin injection sites. Our cases complement the current data on iatrogenic amyloidosis and provide insight into this likely underreported phenomenon.

Treatment of multiple keratoacanthomas with erlotinib.

An 82-year-old male presented with numerous pruritic erythematous nodules over his trunk and extremities. Histopathology was consistent with keratoacanthomas. Given the extent of his disease, medical therapy was recommended. Based on phosphorylated epidermal growth factor receptor expression in lesional keratinocytes, treatment with erlotinib 150 mg daily was initiated, with rapid improvement in the number and appearance of nodules. Immunohistochemistry following treatment revealed a decrease in lesional pEGFR expression, consistent with inhibition of this receptor activation. This is the first report of multiple keratoacanthomas responding to therapy with an EGFR tyrosine kinase inhibitor, and it supports an emerging role for the use of EGFR inhibitors in the management of cutaneous malignancies.

Ataxia and paroxysmal dyskinesia in mice lacking axonally transported FGF14.

Fibroblast growth factor 14 (FGF14) belongs to a distinct subclass of FGFs that is expressed in the developing and adult CNS. We disrupted the Fgf14 gene and introduced an Fgf14(N-beta-Gal) allele that abolished Fgf14 expression and generated a fusion protein (FGF14N-beta-gal) containing the first exon of FGF14 and beta-galactosidase. Fgf14-deficient mice were viable, fertile, and anatomically normal, but developed ataxia and a paroxysmal hyperkinetic movement disorder. Neuropharmacological studies showed that Fgf14-deficient mice have reduced responses to dopamine agonists. The paroxysmal hyperkinetic movement disorder phenocopies a form of dystonia, a disease often associated with dysfunction of the putamen. Strikingly, the FGF14N-beta-gal chimeric protein was efficiently transported into neuronal processes in the basal ganglia and cerebellum. Together, these studies identify a novel function for FGF14 in neuronal signaling and implicate FGF14 in axonal trafficking and synaptosomal function.

Carcinoma en Cuirasse.

This case report describes hyperpigmented, indurated, and sclerotic plaques on the anterior trunk and upper abdomen with overlying scale that were studded with firm, erythematous papules.

Metronidazole in the treatment of rosacea: do formulation, dosing, and concentration matter?

BACKGROUND: Topical metronidazole is commonly used in the management of rosacea. No consensus on the optimal formulation, concentration, or dosing regimen exists. PURPOSE: To assess the relative efficacy of metronidazole cream, gel, and lotion at concentrations of 0.75% and 1%, in dosing regimens of once and twice daily. METHODS: A meta-analysis of published metronidazole efficacy rates was performed. RESULTS: In non-weighted analysis, the mean efficacy was 28.2% (95% confidence interval [CI], 22.0%-34.4%) for the cream, 38.4% (95% CI, 18.4%-58.4%) for the gel, and 35% for the lotion. Confidence intervals for QD versus BID dosing and 0.75% versus 1% concentrations also overlapped. In weighted analysis, the mean reduction was 31.3% for the cream, 22.1% for the gel, and 35% for the lotion. CONCLUSIONS: Metronidazole cream, gel, and lotion vehicles have similar efficacies. There were no substantial differences between concentrations of 0.75% and 1%, or between once daily and twice daily regimens.

Reliability of scapular positioning measurement procedure using the palpation meter (PALM).

BACKGROUND AND OBJECTIVES: Observation and measurement of the static position of the scapula is important for investigating both shoulder and neck pathology. Measurement of scapular position is complex and lacks a clinically useful instrument. The objective of this study was to investigate the reliability of the Palpation Meter (PALM) for measuring scapular position when the glenohumeral joint is held in various positions. METHODS: Thirty normal subjects were recruited for a test-retest reliability study. Three raters conducted measurements on two different occasions to estimate intra- and inter-rater reliability. The scapular positions evaluated in this study were: (1) the horizontal distance between the scapula and the spine in the scapular resting position and during elevation of the arm in the scapular plane; and (2) the vertical distance between C(7) and the acromion (C(7)-A). Intraclass correlation coefficient (ICC), standard error of measurement (SEM) and Bland and Altman limits of agreement were calculated. RESULTS: Reliability values for measurements of the horizontal distance between the scapula and the spine were generally good for both intra-rater (ICC 0.81 to 0.89; SEM 0.56 to 1.17cm) and inter-rater (ICC 0.67 to 0.89; SEM 0.59 to 0.98cm) evaluation. Reliability values of measurement of depression of the acromion were also good for both intra-rater (ICC 0.72 to 0.78; SEM 0.66 to 0.79) and inter-rater (ICC 0.76; SEM 0.64) evaluation. No systematic bias was observed with Bland and Altman analysis. CONCLUSIONS: The PALM is a reliable tool for the measurement of scapular positioning in a healthy sample. Future studies should be conducted to further investigate the clinometric properties of the PALM in patient populations before its clinical usefulness for measuring scapular position can be established.

Postoperative rehabilitation protocols for Achilles tendon ruptures: a meta-analysis.

UNLABELLED: The optimal postoperative rehabilitation protocol after surgical repair of an Achilles tendon rupture is unknown. Although a 6-week cast immobilization is common, many early functional rehabilitation protocols have been implemented. The purpose of this study was to conduct a meta-analysis to determine if an early functional protocol for surgical repair of an acute Achilles tendon rupture improves subjective patient satisfaction without an increase in rerupture rates. Secondary outcomes of interest from an early functional protocol include infections, range of motion, strength, and minor complications. An extensive literature search for randomized or quasirandomized studies identified six trials involving 315 patients. Early functional treatment protocols, when compared with postoperative immobilization, led to more excellent rated subjective responses and no difference in rerupture rate. Our conclusions are based on six trials with small sample sizes, and larger randomized trials are required to confirm these results. LEVEL OF EVIDENCE: Therapeutic Study, Level II (Systematic review of Level II studies or Level I studies with inconsistent results).

Clobetasol propionate foam in the treatment of psoriasis.

Psoriasis is a common, chronic, distressing skin disorder that frequently affects the scalp, skin, nails and joints. Despite treatment, many patients suffer from unremitting disease and decreased quality of life. Scalp-type psoriasis is particularly difficult to treat. Although topical corticosteroids are the mainstay of therapy for moderate-to-severe disease, patients frequently object to the messiness and unfavourable cosmetic appearance of topical treatments. In this context, foam vehicles, which have the advantage of minimal residue and increased ease of application, have emerged as novel alternatives to traditional creams, ointments and solutions. Clobetasol propionate foam 0.05% (OLUX, Connetics Corporation), a high potency topical steroid, has been shown to alleviate symptoms of several dermatological conditions, including scalp and body psoriasis, improve disease severity and increase quality of life. Dose should be limited to 50 g/week, given the risk of adrenal suppression. Because patient preference is an important determinant of medication efficacy in clinical practice, clobetasol foam is a useful new formulation in the treatment of psoriasis and other skin conditions.

Focusing the Diagnosis of Shoulder Pain.

In brief Whether shoulder pain stems from acute or overuse injury, a practical, methodical evaluation is essential for diagnosing the underlying cause and prescribing treatment. Systematic shoulder evaluation first addresses the broad categories of shoulder pain- impingement and instability- before focusing on more specific causes, such as nerve involvement. A detailed, refined assessment can help minimize reliance on radiologic tests.