Prevalence of dermatologic diseases among patients with selective immunoglobulin A deficiency

BACKGROUND

There are no published large-scale epidemiologic studies regarding the prevalence of skin diseases in patients with selective immunoglobulin A (IgA) deficiency (sIgAD). The purpose of this study was to investigate the prevalence of dermatological diseases in patients with sIgAD.

METHODS

This retrospective matched case-control study was based on data from the Leumit Healthcare Services data base (approximately 725,000 residents of Israel), which was searched for all subjects aged ≥12 years who had undergone serum total IgA measurements during 2004-14 for any reason. The case group included subjects with sIgAD. The control A group was randomly sampled from those subjects in whom an IgA was drawn (n ≈ 725,000), with a ratio of 10 controls for every case (1:10). The control A group was randomly sampled from those subjects in whom an IgA was drawn (n = 104,729) and the control B group was randomly sampled from the full study population (n ≈ 725,000), with a ratio of 10 controls for every case (1:10). Comorbidity was compared between the study groups.

RESULTS

The sIgAD group was characterized: 1) By a higher prevalence of atopic dermatitis (AD) (16 [4.6 %]) than the control A group (76 [2.1 %]; p = 0.004 and the control B group (64 [1.9 %]; p = 0.002). 2) By higher prevalence of acne (69 [19.9 %]) than the control A group (516 [13.8 %]; p = 0.013) and control B group (494 [14.2 %]; p < 0.001). 3) By higher rate of chronic spontaneous urticaria (CSU) (17 [4.9 %)] than in the control A group (31 [0.9 %], with odds ratio 5.54 [3.04-10.13]; p < 0.001) and the control B group (28 [0.8 %]; p < 0.001).

CONCLUSIONS

sIgAD is characterized by a higher prevalence of AD, CSU and acne.

[TEN YEARS OF OPIOID CONSUMPTION BY CHILDREN (2001-2010)]

BACKGROUND

Opioids are considered a cornerstone in the treatment of pain. They are rarely used in almost half of the countries of the world, especially in children.

OBJECTIVE

The aim of this study was to assess opioid use over a ten-year study period from 2001-2010, among children 0-18 years old who are members of Clalit Health Services (CHS), the largest HMO in Israel

METHODS

Data on the purchase of opioids, authorized for use in Israel, was obtained from the computerized databases of CHS. In addition, the patient's demographic details and cancer morbidity were also extracted. The data was analyzed after all the doses of all opioids consumed (fentanyl patch, oxycodone, methadone, hydromorphone, oral transmucosal fentanyl) were converted into oral morphine equivalents (OME).

RESULTS

In all, 1,098 children purchased at least one opioid prescription during the study period. Of them, 27.3% had a diagnosis of cancer and 55.5% were female. A 42% decrease in total annual OME (mg) purchased, from 209,443 mg to 122,048 mg, was observed from 2001 to 2010. There was no specific pattern or trend in the annual number of pediatric and adolescent patients who purchased at least one opioid drug during the study period. In 86.5% of the cases, children with a non-cancer cause of pain purchased opioids for only one month.

CONCLUSIONS

There is a low and inconsistent rate of opioid consumption among pediatric and adolescent members of the CHS. Further study is needed to explore the reasons for this low opioid consumption rate in this population group.

Selective IgE deficiency and cardiovascular diseases

Selective immunoglobulin E (IgE) deficiency (IgED) is defined as serum levels of IgE more than or equal to 2 kIU/L and is associated with immune dysregulation and autoimmunity. This study aimed to investigate a prevalence of atherosclerotic cardiovascular disease (ASCVD) in population with IgED. Within the electronic patient record (EPR) database of Leumit Health Care Services (LHS) in Israel, data capture was performed using IBM Cognos 10.1.1 BI Report Studio software. The case samples were drawn from the full study population (n = 18,487), having any allergy-related symptoms and/or those requesting antiallergy medications and performed serum total IgE measurement during 2012 at LHS. All subjects aged more than or equal to 40 years old, with serum total IgE less than 2 kIU/L were included in case group. Control group was randomly sampled from the remained subjects, with a case-control ratio of 10 controls for each case (1:10). The comorbid cardiovascular diseases during less than or equal to 10 years before serum total IgE testing were identified and retrieved using specific International Classification of Diseases, 9th Revision, Clinical Modification diagnostic codes. There were 103 in case and 1030 subjects in control group. Compared with control group patients, the case group had significantly more arterial hypertension [34 (37.7%) versus 187 (18.2%), p < 0.001], ischemic heart disease (IHD) [26 (25.2%) versus 87 (8.4%), p < 0.001], carotid stenosis [5 (4.9%) versus 7 (0.7%), p = 0.003], cerebrovascular disease (CVD) [3 (2.9%) versus 5 (0.5%), p = 0.029], and peripheral vascular disease (PVD) [4 (3.9%) versus 9 (0.9%), p = 0.024]. IgED is associated with higher prevalence of arterial hypertension and ASCVD.

Helicobacter pylori infection in patients with selective immunoglobulin E deficiency

AIM: To investigate the prevalence and clinical characteristics of Helicobacter pylori (H. pylori)-infected dyspeptic patients with selective immunoglobulin E deficiency (IgEd).

METHODS: All individuals who underwent serum total immunoglobulin E (IgE) measurement at the Leumit Healthcare Services (Israel) in 2012 were identified in an electronic database search (n = 18487). From these, selected case group subjects were ≥ 12 years of age and had serum total IgE < 2 kIU/L (n = 158). The control group was selected from a random sampling of the remaining subjects ≥ 12 years of age to obtain a case-control ratio of 1:20 (n = 3160). Dyspeptic diseases, diagnosed no more than 5 years before serum total IgE testing, were identified and retrieved from the electronic database using specific International Classification of Diseases diagnostic codes. Results of C¹³-urea breath tests were used to identify subjects infected with H. pylori. Categorical variables between case and control subjects were analyzed using Fisher’s exact tests, whereas continuous variables were analyzed using χ² tests.

RESULTS: Dyspepsia was present in 27.2% (43/158) of case subjects and 22.7% (718/3160) of controls. Of these, significantly more case subjects (32/43, 74.4%) than controls (223/718, 31.1%) were positive for H. pylori (P < 0.01). Esophagogastroduodenoscopy was performed in 19 case and 94 control subjects, revealing that gastritis was more prevalent in IgEd case subjects than in controls (57.9% vs 29.8%, P < 0.05). Furthermore, a significantly greater proportion of case subjects presented with peptic duodenal ulcers (63.2% vs 15.9%, P < 0.01). Histopathologic examination showed marked chronic inflammation, lymphoid follicle formation and prominent germinal centers, with polymorphonuclear cell infiltration of gastric glands, that was similar in case and control biopsy tissues. Finally, IgEd case subjects that underwent esophagogastroduodenoscopy were more likely to exhibit treatment-refractory H. pylori infections that require second-line triple antibiotic therapy (47.4% vs 11.7%, P < 0.01).

CONCLUSION: IgEd is associated with higher rates of H. pylori-associated gastritis and peptic duodenal ulcers.

Selective IgE deficiency, immune dysregulation, and autoimmunity

Selective IgE deficiency (IgED) is currently defined as a significant decrease in serum levels of IgE (<2 kIU/L) in a patient whose other immunoglobulin levels are normal. There are no published large-scale epidemiological studies regarding the prevalence of and clinical features of IgED. In the population-based case-control study, we investigated clinical and laboratory characteristics of patients with IgED. Case samples were drawn from all subjects (n = 18487), with serum total IgE measurement during 2012 at Leumit Health Care Services (Israel) and had serum total IgE of <2 kIU/L. The control group was randomly sampled from the remaining 18,261 subjects with a case-control ratio of four controls for each case (1:4). Comorbid diseases were identified by specific International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes given by the corresponding board-certificated physicians. Two hundred twenty-six subjects showed serum total IgE levels of <2 kIU/L; 68 (30.9%) were between the ages of 4 and 12 years (children) and 250 (69.1%) were ≥12 years old (adults). Matched control groups were selected for each age group. The children group was characterized by higher prevalence of asthma and hyperreactive airways disease; and both children and adult groups had significantly higher prevalence of chronic sinusitis, otitis media, autoimmune, and oncological diseases than their respective controls. Undetectable serum total IgE may serve as a marker of immune dysregulation and autoimmunity.

Patterns of opioid consumption in cancer patients

BACKGROUND

Opioids are considered a cornerstone in the treatment of cancer pain.

OBJECTIVES

To assess opioid use during a 6 year period (2001-2006) among cancer patients served by Clalit Health Services, the largest health management organization in Israel.

METHODS

Purchasing data of opioids authorized for use in Israel were obtained from the computerized databases of Clalit for the period 2001-2006. Patients' demographic and cancer morbidity data were extracted. The data were analyzed by translating the purchased opioids (fentanyl patch, oxycodone, buprenorphine, methadone, hydromorphone) to oral morphine equivalents (OME).

RESULTS

During the study period 182,066 Clalit members were diagnosed with cancer; 58,443 (32.1%) of them died and 31,628 (17.3%) purchased opioids at least once. In 2001, 7.5% of Clalit cancer patients purchased opioids at least once within 5 years of the initial diagnosis. Between 2002 and 2006 this percentage increased consistently, reaching 9.9% in 2006. The average daily dose of opioids increased from 104.1 mg OME in the year 2001 to 115.2 mg OME in 2006 (11% increase). The average duration of opioid purchasing was 5.0 +/- 8.3 months (range 1-84 months, median 2). During the study period 19,426 cancer patients who purchased opioids at least once died; only 14.3% (3274) were still alive 2 years after their first opioid prescription.

CONCLUSIONS

Opioid purchasing increased during the study period, especially during the final months of life. Children (0-18 years old) and elderly male patients (> or = 65 years) began opioid treatment later compared to other age groups. Only a few patients had an opioid early enough to relieve their pain.

Behind the scenes of adherence in a minority population

BACKGROUND

The rate of adherence to treatment for diabetes mellitus (DM), hypertension (HTN) and lipid metabolic disorder (LMD) is significantly lower in the Bedouin population compared with the lewish population in southern Israel.

OBJECTIVES

To investigate the reasons for non-adherence associated with cardiovascular risk factors among Bedouins.

METHODS

We identified Bedouin patients with HTN, DM or LMD from medical records and randomly selected 443 high adherent and 403 low adherent patients. Using trained interviewers we conducted in-depth structured interviews regarding knowledge and attitudes to chronic illness and its treatment, health services evaluation, and socio-demographic factors.

RESULTS

The study population included 99 high and 101 low adherent patients. More low adherent patients agreed that traditional therapy can replace prescribed medications for DM, HTN or LMD (47% vs. 26%, P< 0.01), and 10% used only traditional medications. Also, more low adherent patients believed that the side effects of prescribed drugs are actually worse than the disease itself (65% vs. 47%, P 0.05), and 47% cited this as a reason for discontinuing drug treatment (47% vs. 31%, P < 0.05).

CONCLUSIONS

Our findings suggest that in this minority population the basis for non-adherence derives directly from patients' perceptions of chronic disease and drug treatment. A focused intervention should emphasize the importance of early evidence-based drug therapy with open patient-physician dialogue on the meaning of chronic disease and the side effects of prescribed drugs.

Opioid use in an Israeli health maintenance organization: 2000-2006

OBJECTIVE

The objective of this study was to assess opioid use during 7 years (2000-2006) among Clalit Health Services (CHS) members.

DESIGN

Purchasing data of opioids authorized for use in Israel were obtained from the computerized databases of CHS. Patient demographics and cancer morbidity were also extracted. The data were analyzed by converting the purchased opioids to oral morphine equivalents (OMEs).

SETTING

CHS is the largest health maintenance organization in Israel (3,774,600) and insures almost 54% of the Israeli population.

PATIENTS

All CHS members who purchased an opioid at least once during the 7-year study period (2000-2006).

INTERVENTION

There were no interventions in this study.

OUTCOME MEASURES

The outcome measures of this study were total OME purchased per year, OME (mg) per capita/per year, and OME (mg) daily dose.

RESULTS

There were 119,562 patients who purchased an opioid at least once (3.2% of CHS population). Of them, 57.4% were women, 69.0% aged 65 years and above (average age 56.05 years +/- 26.7), 7.7% purchased opioids for more than 12 months, and 81.3% purchased opioids for only 1-4 months. A 96% increase in total OME purchased was found between 2000 and 2006 (from 56.4 kg to 110.6 kg). The annual OME purchased per capita increased from 15.7 mg in the year 2000 to 29.3 mg in 2006. The total number of patients who received at least one opioid prescription increased by 60%, while the growth in total number of CHS members was smaller (4.8%).

CONCLUSIONS

There is a growing use of opioids at CHS during the 7-year period, a potential indicator of the progress made in improving accessibility and availability of opioids in our health care organization in Israel.

Computerized community cholesterol control (4C): meeting the challenge of secondary prevention

BACKGROUND

Dyslipidemia remains underdiagnosed and undertreated in patients with coronary artery disease. The Computer-based Clinical Decision Support System provides an opportunity t close these gaps.

OBJECTIVES

To study the impact of computerized intervention on secondary prevention of CAD.

METHODS

The CDSS was programmed to automatically detect patients with CAD and to evaluate the availability of an updated lipoprotein profile and treatment with lipid-lowering drugs. The program produced automatic computer-generated monitoring and treatment recommendations. Adjusted primary clinics were randomly assigned to intervention (n=56) or standard care arms (n=56). Reminders were mailed to the primary medical teams in the intervention arm every 4 months updating them with current lipid levels and recommendations for further treatment. Compliance and lipid levels were monitored. The study group comprised all patients with CAD who were alive at least 3 months after hospitalization.

RESULTS

Follow-up was available for 7448 patients (median 19.8 months, range 6-36 months). Overall, 51.7% of patients were adequately screened, and 55.7% of patients were compliant with treatment to lower lipid level. In patients with initial low density lipoprotein >120 mg/dl, a significant decrease in LDL levels was observed in both arms, but was more pronounced in the intervention arm: 121.9 +/- 34.2 vs. 124.3 +/- 34.6 mg/dl (P < 0.02). A significantly lower rate of cardiac rehospitalizations was documented in patients who were adequately treated with lipid-lowering drugs, 37% vs. 40.9% (P < 0.001).

CONCLUSIONS

This initial assessment of our data represent a real-world snapshot where physicians and CAD patients often do not adhere to clinical guidelines, presenting a major obstacle to implementing effective secondary prevention. Our automatic computerized reminders system substantially facilitates adherence to guidelines and supports wide-range implementation.

Seasonality of antibiotic-resistant streptococcus pneumoniae that causes acute otitis media: a clue for an antibiotic-restriction policy?

BACKGROUND

It is unclear whether reducing antibiotic prescriptions can reduce rates of resistance once resistance becomes prevalent. We attempted to determine whether reduced antibiotic consumption, which is observed yearly in children during the warm season, is associated with a reduction in antibiotic resistance in pneumococcal acute otitis media (AOM).

METHODS

Antibiotic prescriptions and resistance were measured prospectively during 1999-2003 in 2 demographically distinct populations: Jewish and Bedouin children (aged <5 years) in southern Israel. Associations were assessed using seasonally clustered logistic regression models.

RESULTS

The study included 236,466 prescriptions and 3609 pneumococcal isolates. Prescription rates decreased during the warm months by 36% and 15% in Jewish and Bedouin children, respectively (P < .001 for the season). Among Jewish children, higher resistance rates were observed during the cold than the warm months (P < .001 for each antibiotic). This difference remained significant after adjustment for age, ethnic group, study year, history of antibiotic use, and serotype. The difference was not observed in Bedouin children.

CONCLUSIONS

Rapid seasonal decline in resistant AOM-causing pneumococci occurred only in Jewish children, among whom a marked prescribing seasonality was noted, and not in Bedouin children, among whom prescription was less seasonal. The rapid seasonal decrease in resistance associated with markedly reduced antibiotic use suggests that drug-resistant pneumococci may pay a fitness cost.

[Trend in opioids use for chronic pain treatment at Clalit Health Services (2000-2004)]

BACKGROUND

Opioids are considered a cornerstone in the treatment of cancer and non-cancer pain. The World Health Organization considers a country's morphine consumption to be an important indicator of the quality of pain control. There is little or no use of opioids in nearly half of the countries in the world.

OBJECTIVE

To assess the change in trends of opioids use for chronic pain treatment over a period of five years (2000-2004) among members of Clalit Health Services (CHS) in Israel.

METHOD

Data on the consumption of opioid analgesic drugs that were authorized for use in Israel during the years 2000-2004 were obtained from the computerized data bases of CHS. In addition, patient's demographic details and cancer morbidity were also extracted. To make the patient's use of opioids comparable, we analyzed the data by translating all opioids consumption (fentanyl patch, oxycodone, methadone, hydromorphone) to oral morphine equivalents.

RESULTS

An increase of 68% in total morphine consumption was found between the years 2000 and 2004 (from 56.4 Kg to 94.9 Kg) and in mg morphine per prescription from 15.7 to 25.3 mg. The total amount of morphine per prescription increased from 834.2 mg to 892.9 mg. The total number of patients who received an opioid prescription multiplied by 1.47 (from 18,551 to 27,302) while the growth in total number of CHS members was significantly smaller. No significant differences were found during the years in the characteristics of patients who received opioids; regarding gender (58% were woman) and age (about 80% were 65 years old and above). During the year 2004, a preliminary examination of opioids consumption, comparing cancer and non-cancer pain patients, showed that cancer pain patients used 2.74 times higher dosage than non-cancer pain patients (6110.8 vs. 2225.6 mg/patients/year).

CONCLUSIONS

During the 5 year period evaluated, there is a growing trend in use of opioids at CHS in Israel. This trend may be an indication of the improvement in treatment of chronic pain.

Cardiovascular risk factors in the Bedouin population: management and compliance

BACKGROUND

Until three decades ago coronary heart disease and stroke were considered rare in the Israeli Bedouin population. Today, this population shows increasing high prevalence compared to the Jewish population.

OBJECTIVES

To evaluate the prevalence of diagnosed cardiovascular risk factors among Bedouins (hypertension, diabetes mellitus, dyslipidemia), and to assess compliance with follow-up tests and drug treatment.

METHODS

The study included all listed patients aged 20 years and older in eight clinics in major Bedouin towns, and in two large teaching clinics in Beer Sheva (Jewish population). Risk factor data were extracted from the clinics' computerized databases. For those diagnosed with hypertension, diabetes or dyslipidemia, drug purchasing data were collected from the pharmacy database to determine compliance with treatment, and from the central laboratory mainframe (HbAlc and low density lipoprotein-cholesterol) to evaluate follow-up and control.

RESULTS

A significantly higher prevalence of diabetes in all age groups was found in the Bedouin population compared to the Jewish population; age-adjusted results show a prevalence of 12% vs. 8% respectively (P < 0.001). The prevalence of dyslipidemia and age-adjusted hypertension was lower among Bedouins (5.8% vs. 18.2%, P < 0.01 and 17% vs. 21%, P < 0.001 respectively). Two-thirds of hypertensive Bedouin patients and 72.9% of diabetic Bedouin patients were not compliant with treatment. For dyslipidemia only 10.4% of the Bedouins were compliant compared with 28.2% in the Jewish population (P < 0.001).

CONCLUSIONS

Compliance with drug therapy and follow-up tests was found to be a major problem in the Bedouin population.

Community prescribing and resistant Streptococcus pneumoniae

We investigated the association between prescribing antimicrobial agents and antimicrobial resistance of Streptococcus pneumoniae among children with acute otitis media in southern Israel. During a 6-year period, all prescriptions of a sample of ≈20% of Jewish and Bedouin children <5 years of age were recorded and all pneumococcal isolates from middle ear fluid were collected. Although antimicrobial drug use was significantly higher in Bedouin children, the proportion of S. pneumoniae isolates with penicillin MIC ≥1.0 μg/mL was significantly higher in Jewish children. In both populations, antimicrobial prescriptions were markedly reduced over time, especially for penicillins and erythromycin. In contrast, azithromycin prescriptions increased from 1998 to 2001 with a parallel increase in macrolide and multidrug resistance. Penicillin resistance was associated with macrolide resistance. These findings strongly suggest that azithromycin affects increased antimicrobial resistance, including multidrug resistance, in S. pneumoniae.

Health services utilization by depressive patients identified by the MINI questionnaire in a primary care setting

OBJECTIVES

To identify patients with depression, in primary care clinics in Israel, using the MINI (Mini-International Neuropsychiatric Interview) as a screening tool and to evaluate the health services utilization and costs of the patients identified.

DESIGN

Phone interviews (between 1997 and 2000) and health services utilization data extracted from computerized databases.

SETTING

Three primary care clinics belonging to Clalit Health Services (HMO).

PARTICIPANTS

A random sample of 2755 patients, aged 21-65.

MAIN OUTCOME MEASURES

MINI score results, utilization data.

RESULTS

The study included interviews with 2507 patients. The screening questionnaire identified 5.9% with major depression, 1.6% with minor depression and 14.3% with depressive symptoms. Higher rates of depression were found among women, immigrants, secular or traditional religious Jews, and the unemployed. Those identified with major depression had higher health services utilization and costs. Logistic regression analysis showed that depression was related to older age, female gender, fewer years of education and among seculars. Depressed patients had significantly more somatic comorbidity.

CONCLUSIONS

Health services utilization and costs of people identified as depressed by the screening tool were higher. Depressive patients had higher comorbidity, which might be partially responsible for the higher cost.

Screening South Indian medicinal plants for antifungal activity against cutaneous pathogens

In this study, twenty-eight South Indian medicinal plants were screened for their anti-fungal activity against six species of fungi (Trichophyton mentagrophytes, T. rubrum, T. soudanense, Candida albicans, Torulopsis glabrata, and C. krusei). Three plant species extracts, Celastrus paniculatus, Eriodendron anfractuosum and Ficus glomerata showed inhibitory activity. An aqueous extract of galls of Terminalia chebula showed inhibitory effects on three dermatophytes (Trichophyton spp.) and three yeasts (Candida spp.). Seeds extract of T. chebula inhibited only the growth of T. glabrata. An aqueous extract of T. chebula showed inhibitory effects higher than those measured in ethanol extracts. It is therefore suggested that tannins are plausible candidates for the anti-dermatophytic effects of T. chebula. Chebulinic acid, a known tannin of T. chebula was tested and found not inhibitory, thus a search for the active compound is needed.

Office treatment of congenital ankyloglossia

BACKGROUND

Congenital oral adhesions may pose both aesthetic and functional disturbing ailments to wary parents. Most of these as we have experienced, are benign, easily cured and may be treated as soon as possible in the office. A local survey elucidated that these youngsters are usually advised to wait until one year of age and then taken into the operating room and incision of the adhesion is performed under general anesthesia. We assessed the benign nature of this ailment and relative avascularity of the tissue involved and concluded that with minimal risk an office procedure under local anesthesia can replace current practice. We also found that most referrals with this condition present with the lowest grade of severity of ankyloglossia, amenable to a very brief intervention.

MATERIAL/METHODS

During the period 1998-2002 we diagnosed nineteen congenital lesions in thirteen patients. All children were treated in a community clinic setting using electrocautery under local anesthesia. Surgical success was defined as significant improvement in the ability to protrude the tongue outwards beyond the gums and teeth. Gingival adhesions were judged by release of soft tissue adhesions.

RESULTS

Tongue Surgical success was accomplished in all cases with minimal discomfort and without complications. In one single case the previous functional limitation was not relieved.

CONCLUSIONS

Our experience indicates that office-based electrocautery dissection is an efficacious economical and safe treatment of mild congenital oral adhesions. We recommend this method as therapy of choice for such lesions.

Topical treatment of persistent cutaneous leishmaniasis with ethanolic lipid amphotericin B

A 1.5-year-old infant was referred because of spreading skin lesions diagnosed earlier as cutaneous leishmaniasis that did not respond to repeated courses with paromomycin-containing ointment. After consideration of the alternative therapeutic options, the infant was treated with a topical colloidal solution of amphotericin B for 3 weeks, This mode of therapy resulted in resolution of the skin lesions. No local or systemic side effects were observed. There were no signs of recurrence 3 months after cessation of the treatment.

Office management of penile skin bridges with electrocautery

BACKGROUND

Penile skin bridges are an uncommon complication of circumcision that are often found in general practice. This condition can be treated successfully in the office, avoiding referral for a surgical procedure.

METHODS

Four case reports of the technique of treating penile skin bridges are described, and the literature on the cause and treatment of skin bridges is reviewed.

RESULTS AND CONCLUSIONS

Using local anesthesia and bipolar diathermy, penile skin bridges were successfully treated in the office on 4 patients of different ages. There was no bleeding and the wounds healed without complication. This brief and simple technique, described in detail, is appropriate for an office procedure in family practice.

Experiences of stigmatization play a role in mediating the impact of disease severity on quality of life in psoriasis patients

BACKGROUND

Psoriasis may have a severe impact on patients' quality of life (QOL) in several ways, an impact mediated by the mental or physical difficulties they have to deal with during the course of the disease and the various treatment regimens. In addition, psoriatic patients often suffer from experiences of stigmatization (EOS) related to the disease.

OBJECTIVES

This study was designed to test the hypotheses that psoriasis patients report higher levels of stigmatization than a comparison group, and that their EOS play a role in mediating the impact of the severity of psoriasis on their QOL.

METHODS

One hundred patients with psoriasis (study group) and 100 patients with mixed skin problems (comparison group) were matched according to age, sex and education. All subjects answered questionnaires on EOS and QOL. A dermatologist diagnosed the diseases and measured severity scores. The Psoriasis Area and Severity Index score was used for psoriasis and a linear severity score for the comparison patients. The mediating effect of EOS was analysed using structural equation modelling (SEM). SEM is a multivariate statistical method used to examine the consistency of a theory relating one group of variables (termed a 'latent construct') to another: in the present study, the relationship between EOS and QOL.

RESULTS

Psoriatic patients were found to report significantly higher levels of EOS related to the disease, compared with the comparison group. No significant differences were found regarding QOL or severity of disease. Clinical severity of psoriasis was found to correlate negatively with QOL in psoriasis patients. EOS were found to have a complete mediating effect for the severity of disease on the QOL in patients with psoriasis. This result was not found among the comparison group patients.

CONCLUSIONS

The results of this study indicate that psoriasis patients experience higher levels of stigmatization than do other dermatological patients, and that these EOS mediate the association between disease severity and patients' reported low levels of QOL. Treatment of psoriatic patients should consider these results and should include tools for psychosocial intervention.

[Psoriasis, biblical afflictions and patients' dignity]

The currently accepted Hebrew word for psoriasis is 'sapachat'. The word 'sapachat' is biblical and its original meaning is unknown. Similar uncertainty applies also to the biblical word 'tzaraat', the currently accepted Hebrew term for leprosy. This article discusses possible explanations of the biblical terms 'sapachat' and 'tzaraat'. The link between 'sapachat' and psoriasis was made only several decades ago. The word 'sapachat' conveys a definite negative connotation, and imposes an emotional burden on psoriatic patients. We therefore recommend preferable use of the word 'psoriasis' and avoid using the offending term 'sapachat'.

Pyogenic granuloma of the penile shaft following circumcision

Pyogenic granuloma is a benign vascular, inflammatory proliferation that appears following minor trauma in children. The exact pathogenesis of pyogenic granuloma is unknown, but its formation is closely related to minor trauma, chronic irritation, and hormonal influences. We present a unique case of a pyogenic granuloma that appeared in an infant following circumcision.

Monilethrix: mutational hotspot in the helix termination motif of the human hair basic keratin 6

Monilethrix is a rare autosomal dominant disease characterized by hair fragility and follicular hyperkeratosis. Mutations in the human basic hair keratins hHb1 and hHb6 have recently been reported in this disease. Twelve families and sporadic cases were clinically diagnosed with monilethrix and were available for the study. The gene segment encoding the helix termination motif region of keratin hHb6 was PCR amplified and sequenced. Mutations were recognized in 6 families. Four families had the previously described mutations, Glu413Lys and Glu413Asp. In 2 unrelated families, a novel mutation, Glu402Lys, was identified. No clear association was found between the severity of the phenotype and the mutation carried. Furthermore, heterozygous members of the same family had variable degrees of hair and skin involvement. Homozygous patients identified in one large consanguineous family were more severely affected. Other genetic or environmental factors may also play a role in monilethrix.

Association of Ureaplasma urealyticum colonization in male urethra and Condyloma acuminatum

BACKGROUND

The frequent coexistence of two or more sexually transmitted diseases in one patient has been reported in non-dermatological literature, mostly in languages other than English. Identification of Ureaplasma urealyticum, Chlamydia trachomatis and Mycoplasma hominis in men with other STDs is important, since these bacteria have been implicated in a variety of diseases such as non-gonococcal urethritis, premature rupture of fetal membranes, and infertility in female sexual partners of these patients.

OBJECTIVE

To assess the frequency of concomitant STD, particularly urethral colonization of U. urealyticum, C. trachomatis and M. hominis, in men consulting for suspected STD-related symptoms.

METHODS

All patients attending our dermatology clinic for STD-related symptoms during a 12 month period in 1996-97 underwent systematic clinical and laboratory screening for syphilis, gonorrhea, NGU, prostatitis, genital herpes simplex infection, Condyloma acuminatum, urethral carriage of U. urealyticum, C. trachomatis and M. hominis, as well as serological screening for HIV, and hepatitis B and C infections.

RESULTS

A total of 169 men with STD-related symptoms were enrolled in the study. The following clinical diagnoses were established: NGU in 109 men, C. acuminatum in 40, genital herpes simplex in 10, prostatitis in 7, latent syphilis in 6, primary syphilis in 1, and Behcet's disease in 1. No clinical evidence of STD was found in 13 patients. Of the 169 patients, 39 (23%) had two or more concomitant STDs, of whom 27 (69%) had C. acuminatum associated with one or more of the urethral pathogens. A positive U. urealyticum culture was found in 67.5% (27/40) of the men with C. acuminatum as compared to 42% (40/96) among the patients with NGU who did not have C. acuminatum (P = 0.004, chi 2 test). Conversely, the prevalence of C. acuminatum among patients positive for U. urealyticum was significantly higher than the prevalence among those who were negative--27/75 (36%) vs. 13/94 (14%), P < 0.0009, chi 2 test. About half of the U. urealyticum-positive patients with C. acuminatum had no clinical signs or symptoms of urethritis.

CONCLUSION

Our findings suggest that patients with C. acuminatum should be assessed for U. urealyticum carriage and, when identified, their sexual contacts should be actively sought and treated.

Davener's dermatosis: a variant of friction hypermelanosis

BACKGROUND

As part of our clinical experience we encountered a group of patients from a specific population with a similar peculiar pigmentation over the lower dorsal spine.

OBJECTIVE

We investigated these patients to see whether we could determine a common origin.

METHODS

Patients meeting the inclusion criteria underwent detailed history and complete physical examination; biopsy specimens from 3 patients were studied.

RESULTS

All 13 patients were full-time male students at Orthodox Jewish Talmudic seminaries (Yeshivas). The lesion consisted of an elongated, vertical, midline, hyperpigmented patch with indistinct borders, which was distributed along the skin overlying the bony protuberances of the inferior thoracic and lumbar vertebrae. It was often unrecognized by the patients. Mean body mass index was lower than that for the general population. Histologic study showed a marked diffuse hyperkeratosis and hyperplastic epidermis with diffuse hyperpigmentation. We attributed the phenomenon to friction from the rigid backrests against the cutaneous surface of the lower back generated by the characteristic swaying activity that traditionally accompanies Torah study or "davening" (praying) and termed it Davener's dermatosis.

CONCLUSION

We believe this phenomenon represents a new form of benign friction hypermelanosis. This report highlights the importance of a thorough history in patients presenting with pigmented lesions.

[Primary dermatology--who is the gate keeper?]

For several years health funds in Israel have allowed patients to see dermatologists, gynecologists, orthopedic surgeons and ENT specialists without being referred by their primary care physician. There is heated debate about whether this practice is justified and if it is cost effective. Is it better medicine for the patient? What are the roles of the primary care physician and of the primary dermatologist in the care of skin diseases? What do patients want? We examined the practices of 4 dermatology clinics and discuss the issues involved.

Extramammary Paget's disease recurring on the skin of the lower abdomen and entire right leg two and half years after simple vulvectomy for minimally invasive Paget's disease of the vulva

We encountered an unusual case of extramammary Paget's disease (EMPD) recurring on the skin of the lower abdomen and entire right leg two and a half years after simple vulvectomy for minimally invasive Paget's disease of the vulva. Histologic examination of the skin metastases demonstrated that the proliferation of Paget cells was confined to the dermis, most of them were located in lymphatic vascular spaces. This case confirms that minimally invasive Paget's disease of the vulva may sometimes be an aggressive disease. We consider that lymphatic metastases already existed in this patient at the time of initial surgery; thus, the recurrence of EMPD on extragenital skin sites may have been prevented if initial treatment would have included radical vulvectomy and bilateral groin lymph node dissection instead of simple vulvectomy without groin lymph node dissection.

Eosinophilic pustular folliculitis (Ofuji disease) in a child

Eosinophilic pustular folliculitis (EPF) has been described mostly in adults from Japan. From the few reports of children with EPF it is clear that the disease displays the characteristic features, with some clinical differences compared to EPF in adults. We describe the case of an 8-year-old boy with multiple vesicles, pustules, and erythema multiforme-like lesions on the trunk and lower extremities. Results of histopathologic examination revealed subcorneal and intraepidermal pustules, and an inflammatory infiltrate consisting of lymphocytes and eosinophils mainly with a perifollicular distribution. The patient also had impaired chemotaxis, IgG3 subclass deficiency, and elevated IgE levels.

Antiproliferative effects of tyrosine kinase inhibitors (tyrphostins) on human bladder and renal carcinoma cells

Growth factor receptors with tyrosine kinase activity mediate paracrine and autocrine growth regulation of normal and malignant cells. The epidermal growth factor receptor (EGF-R) is a tyrosine kinase transmembrane protein that is overexpressed by many epithelial malignancies, including transitional cell and renal cell carcinoma. Ligand-induced stimulation of cell growth depends on activation of the tyrosine kinase activity of the EGF-R. Tyrphostins are small molecular weight compounds that have been shown to preferentially inhibit the EGF-R tyrosine kinase and thus may inhibit EGF-R-dependent cell growth. We examined the effect of two tyrphostins, RG14620 and AG555, on the proliferation of three transitional cell carcinoma lines (RT4, J82, and T24) and three renal cell carcinoma lines (A-198, Caki-1, and Caki-2). Both tyrphostins inhibited proliferation of all six cell lines in a dose-dependent fashion. They were equally effective with IC50s ranging between 3 and 16 microM. Complete inhibition of growth was achieved at tyrphostin concentrations between 10 and 30 microM. Although both tyrphostins inhibited proliferation of T24 transitional carcinoma cells in growth assays, only RG14620 but not AG555 was found to specifically inhibit EGF-R autophosphorylation in this cell line. These results suggest that other intracellular targets in addition to the EGF-R are affected by these agents. In summary, tyrphostins are potent growth inhibitors for urological malignancies.

Serial study of the immune response of an individual with exacerbated simple cutaneous leishmaniasis

The immunological responses of a patient with exacerbated cutaneous leishmaniasis, measured during the course of the disease, are described. Except for skin lesions the patient was healthy and showed no signs of immunosuppression. Three immunological parameters were measured: specific lymphocyte proliferation (LPA), monocyte effector activity (MEA), and antibody levels. LPA was positive early in the course of the disease, became negative as the lesions enlarged, and was positive again as the lesions healed 28 weeks after initiation of the study. In the MEA test, in which the mononuclear cells of the patient were incubated in the presence of Leishmania major promastigotes in a 3-day assay, the number of amastigotes per 100 monocytes remained constant until week 28 and then decreased significantly. Antibody levels remained elevated until week 28 and then decreased to background levels. The results indicate that the cell-mediated immune response parallels the course of the disease while circulating antibodies show an inverse relationship.

Case study: full thickness chemical burn of the abdomen and chest

An 81 year old patient, suffering from Alzheimer's disease sustained a full thickness HCI Acid burn of her abdomen and chest wall due to leakage of gastric content from her gastrostomy feeding tube. The controversial management of such a patient is discussed and early surgical treatment is recommended.

Local cutaneous reaction induced by subcutaneous interleukin-2 and interferon alpha-2a immunotherapy following ABMT

Immunotherapy using subcutaneous injections of recombinant interleukin-2 (IL-2) and recombinant interferon alpha-2a (IFN-alpha) for advanced hematologic and solid tumors is rapidly developing. We report five patients with Hodgkin's and non-Hodgkin's lymphoma who developed a local cutaneous reaction consisting of inflammatory painful nodules with a central multiloculated vesicle at the site of sc injections of IL-2 and IFN-alpha immunotherapy following ABMT. This is the first report of a local cutaneous adverse reaction induced by IL-2 and IFN-alpha immunotherapy following ABMT.

An analysis of mortality in patients with burns covering 40 per cent BSA or more: a retrospective review covering 24 years (1964-88)

The charts of patients with burns covering more than 40 per cent of the body surface area (BSA) who were admitted to the Burn Unit of the Soroka Medical Center, Beersheva, Israel, between the years 1964 and 1988 were reviewed for mortality rate and causes of deaths. The factors affecting survival are reviewed and analysed.

The failure of traditionally used desert plants to act against cutaneous leishmaniasis in experimental animals

Several desert plants that are traditionally used by the Bedouin community as folkloristic treatment for skin diseases were examined for their efficacy against cutaneous leishmaniasis (CL) in BALB/c mice. Water and chloroform extracts made from these plants were incorporated into cetomacrogol and soft white paraffin respectively and some were supplemented with DMSO. These preparations were applied twice daily for up to 30 days to CL lesions caused by Leishmania major. None of the extracts tested showed any leishmanicidal effect.

Erythema multiforme minor associated with Mycoplasma pneumoniae infection

A young Bedouin woman with serologically proven Mycoplasma pneumoniae infection is presented. Along with pulmonary involvement, fever and bullous myringitis, she presented with erythema multiforme minor, a rare complication of mycoplasma infection of which many physicians may not be aware. The skin participation in mycoplasma infections is discussed. Mycoplasma infection should be considered in the differential diagnosis of erythema multiforme.