Biomedical subjects
Publications and source records attributed to J L Shupack.
Low-dose oral methotrexate therapy was associated with the onset of anemia, leukopenia, and thrombocytopenia in two patients with psoriasis. Both patients survived, but required prolonged hospitalization. No precipitating factor other than methotrexate could be identified.
We have reviewed the issue of physician drug dispensing by focusing upon quality of care, economic considerations, drug availability, patient compliance, safety, and increased governmental regulation. From a quality of care perspective, the increased use of pharmacist assistants, the tendency toward generic and therapeutic drug substitution, and the less specialized clinical education of pharmacists all pose hazards rather than safety checks upon physician prescribing. There is no evidence that pharmacists charge less than physicians. If they did, there would be no need to protect their incomes legislatively by restricting physician dispensing. Economic motivation per se is less important to a physician than providing a true convenience for his patients and thus encouraging a closer doctor-patient relationship. Physician dispensing adds to the availability of medication and may minimize the number of patients shuttling between pharmacies to obtain complex multi-ingredient preparations. Compliance is enhanced as availability increases. Prepackaged pharmaceuticals prepared under the auspices of pharmacists and dispensed by physicians are at least as safe as those prepared by the ungloved hands of a pharmacist hidden behind store counters. Thus, restricting the physician's right to dispense can negatively affect the quality of medical care, the cost of medications, safety, the availability of pharmaceuticals, and patient compliance. Such limitation is certainly not in the best interest of our patients.
In a retrospective study of 533 patients with psoriasis treated with etretinate in several centers in the United States, 22 adverse drug reactions related to hepatic dysfunction were reported. On analysis, 6 of these adverse hepatic reactions were probably drug related, 7 possibly related, 6 unlikely to be related and in 3 there was insufficient evidence to implicate or associate the reported event as a hepatic adverse reaction. Most of the adverse drug reactions were asymptomatic changes in liver function test (LFT). No death occurred which could be attributed to adverse hepatic reaction from etretinate.
Fifty-eight men with Hamilton scale type III vertex or type IV male pattern baldness were studied to determine the dose-response activity of low concentrations of topical minoxidil in promoting hair growth. The patients were treated with topical minoxidil at doses of 0.01%, 0.1%, 1%, or 2% or placebo in a randomized double-blind design for 6 months. At the end of 6 months, patients using 0.1%, 1%, and 2% topical minoxidil solutions showed a significantly greater difference in the mean increase of nonvellus hair growth in comparison with those using 0.01% minoxidil or placebo. There was a clear dose-response correlation for the increase of nonvellus hairs in the 0.1%, 1%, and 2% minoxidil treatment groups. There was a statistically significant difference in patient's self-evaluation of overall hair growth and degree of decreased hair shedding in the 1% and 2% minoxidil groups when compared with the other study groups. From this study we conclude that significant increases in nonvellus hair counts occur with 0.1% and greater doses of minoxidil. However, only in patients treated with the 1% and 2% solutions of minoxidil was there clinically perceptible hair growth.
Cutaneous hyperpigmentation resembling acanthosis nigricans developed in two patients with malignant brain tumors following chemotherapy with triazinate (Baker's Antifol), a folic acid antagonist. In both cases, the eruption resolved after the cessation of drug administration and reappeared after the reinstitution of triazinate therapy. A skin biopsy specimen from one patient showed microscopic changes consistent with those found in acanthosis nigricans. The other patient had a decreased serum folate level that returned to normal as the hyperpigmentation resolved. Folate may have a role in triazinate-induced acanthosislike hyperpigmentation.
Scolecobasidium humicola, a soil fungus and etiologic agent of phaeohyphomycosis in fish, is herein reported to cause cutaneous lesions in a tortoise, Terrapine carolina var. carolina. S. humicola was isolated from lesions on the foot and dematiaceous hyphae were observed in KOH preparations of the biopsy and in stained preparations. This isolate and others were compared morphologically and physiologically with isolates of Dactylaria gallopava which it resembles. As a result of this investigation, we concluded that D. gallopava may be differentiated from S. humicola macroscopically, by the production in D. gallopava of an extensive diffusible purplish-red to reddish-brown pigment when cultured on Sabouraud dextrose agar; microscopically, by the presence and usually predominance of conidia, whose apical cell is markedly wider than the basal cell, and usually constricted at the septum; and physiologically, by the ability to grow on media containing cycloheximide and by the ability to grow well at 36-45 degrees C. In contrast, S. humicola does not usually produce a diffusible pigment on Sabouraud's dextrose agar or if present, is not extensive; it lacks the wider upper cell; is less constricted or non-constricted at the central septum; grows on media containing cycloheximide, although some inhibition may occur and lastly, does not grow at 36 degrees C or higher. Both species were urease positive, hydrolysed tyrosine but not casein, xanthine, or gelatin.
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Eleven institutions participated in an eight-week controlled clinical study to evaluate treatment of acne vulgaris with topical clindamycin hydrochloride and clindamycin phosphate. Three hundred fifty-eight patients with comparable baseline pustule, papule, and nodule counts applied 1%, clindamycin hydrochloride, 1% clindamycin phosphate, or a hydroalcoholic vehicle twice daily. Every two weeks, lesions were counted, and patients' evaluations of their acne conditions were scored. By week 8, pustule and papule counts in the groups who were receiving clindamycin were significantly lower than those in the group receiving placebo. Also, more patients who were receiving clindamycin thought their acne improved by week 8 (with significantly higher change-in-acne scores) than did the patients receiving placebo. Patients receiving clindamycin reported 12 episodes of diarrhea; only one episode was considered to be treatment related. These results substantiate the clinical impression that topical clindamycin is effective treatment for acne.
Many materials now used in hospitals are sterilized with EO. EO gas retained in porous materials, which have not been properly aired, can produce skin irritation. The experiments reported here were designed to determine the level of EO and duration of skin contact required to produce adverse effects. The role of EO by-products in such reactions was also investigated. To obtain this information, patches retaining EO or its by-products, EC and EG, were applied to the backs of human volunteers. The patches were removed at intervals between 1 and 8 hr and the reactions were observed. The resulting skin reactions directly related to the total dose of EO received. Patch materials that rapidly lose EO, such as fabric or rubber, produced few reactions, even at EO levels as high as 5000 ppm. A patch material that loses EO more slowly, PVC film, produced reactions at EO levels above 1700 ppm. The patch materials that retained EO the longest, thick PVC blocks and petrolatum applied to Webril pads, produced the most reactions. When the EO level in those materials approximated 1000 ppm or higher, skin reactions usually appeared after 4 to 8 hr contact. The level of reactivity among the volunteers was quite consistent. One subject, however, who developed sensitivity to EO, showed a mild delayed reaction to approximately 100 ppm of EO in PVC. The characteristics of that sensitivity are discussed. Since little or no reactions developed to the patches containing EO by-products, EO itself can be assumed to be the toxic agent. The experiments support the conclusion that the lowest level of EO which produces skin irritation in nonsensitized subjects approximates 1000 ppm, when retained in slow-airing material against the skin for 4 hr or more.
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The case histories of two elderly patients with cutaneous histiocytosis X treated topically with nitrogen mustard are presented. The cutaneous lesions cleared within 2 to 3 weeks, and remission was maintained with daily topical administration of nitrogen mustard. The clinical impression of improvement was substantiated by light and electron microscopic studies prior to and after therapy.
Identical twins with mal de Meleda, a rare genodermatosis, displayed the characteristic "glove and sock" hyperkeratosis, hyperhidrosis, and malodor. Their parents, who are first cousins, are unaffected and originated from Calabria, Italy, which is not far from Meleda (Mljet). The disorder is probably transmitted as an autosomal recessive trait. Previous therapy with grenz rays, topical preparations of adrenocorticosteroids, lactic acid, retinoic acid, and bland emollients had been unsuccessful. One of the twins was treated with 13-cis retinoic acid taken by mouth for 16 weeks with dramatic improvement. The major adverse effect was cheilitis, which did not force discontinuation of the treatment.
The glucagonoma syndrome is characterized by necrolytic migratory erythema, glossitis, ungual dystrophy, diabetes mellitus, anemia, weight loss, elevated plasma glucagon levels and an alpha-cell glucagon-secreting neoplasm of the pancreas. We are reporting a case of this syndrome in a middle-aged woman, in whom the first complaints and signs were cutaneous. The recognition of the distinctive skin manifestations of the syndrome led to early diagnosis and treatment of the underlying malignant pancreatic tumor.
Three cases of allergic contact dermatitis due to N,N-dimethyl-para-phenylenediamine in a bacteriology laboratory are presented. This chemical, a dye closely related to the common contact allergen para-phenylenediamine, is used in laboratories to screen bacterial culture plates for Neisseria gonorrhoeae. The three patients had strongly positive patch test reactions to N,N-dimethyl-para-phenylenediamine, but had negative reactions to para-phenylenediamine. A brief discussion of allergic contact cross-sensitization among compounds with the para-aminophenyl grouping is presented.
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Four patients had thalassemia and leg ulcers. In three patients the hematologic diagnosis of thalassemia had not been previously made; the presenting symptom was the leg ulcer. The diagnosis of thalassemia should be considered in patients who have unexplained chronic leg ulcers; the incidence of this complication of thalassemia may be higher than previously reported.