Primary cutaneous amyloidosis of the external ear: a clinicopathological and immunohistochemical study of 17 cases

Primary cutaneous amyloidosis includes several forms of localized amyloidosis characterized by superficial amyloid deposits occurring at or near the dermal-epidermal junction in the absence of systemic involvement. Primary cutaneous amyloidosis of the auricular concha and external ear represents a rarely described variant. There have been 27 cases reported in the English language literature, and herein we report 17 additional cases. This article demonstrates that the amyloid observed in this context is generally positive for Congo red, crystal violet and thioflavin T. It also expresses cytokeratin 34ßE12 via immunohistochemistry. Our immunohistochemical results and review of the literature suggest that the amyloid in amyloidosis of the external ear is the result of basal keratinocyte degeneration and does not signify deposition from a systemic or generalized process.

Incontinentia pigmenti: treatment of IP with topical tacrolimus

Incontinentia pigmenti (IP), or Bloch-Sulzberger syndrome, is a rare X-linked dominant genodermatosis primarily affecting females. Although IP affects many organ systems, the hallmark feature of this disease is its characteristic cutaneous eruption along the lines of Blaschko that evolves through four distinct stages: inflammatory/vesiculobullous, verrucous, hyperpigmented and hypopigmented/ atrophic. We describe a case of IP in its vesicular stage that completely resolved with topical Protopic (tacrolimus) 0.1% ointment. The treatment successfully halted the progression of disease through its subsequent disfiguring stages.

Withdrawal from dialysis: a palliative care perspective

A retrospective chart review was conducted in this pilot study of 35 patients who withdrew from dialysis and were followed by a palliative care team. Data included etiology of end-stage renal disease, comorbid illnesses, mode of dialysis and duration, survival time after withdrawal, reason for withdrawal, mental competency, symptom management, and the nature of death. Mean survival time was 10 days. The most frequent symptoms following withdrawal were confusion, agitation, pain and dyspnea. 1/3 of the sample were cognitively impaired at the time of the withdrawal decision. 17% experienced suffering during the withdrawal period, 24% had unrelieved symptoms, 19% psychological distress, while just over 1/3 of patients died alone. With the provision of palliative care, symptom prevalence in the last 24 hours dropped from 53 to 20% for pain, 68 to 33% for agitation and 46 to 26% for dyspnea. Opioids and benzodiazepines were used in the treatment of over 90% of patients. Palliative medicine has the potential to improve the care of patients who discontinue dialysis.

Clear cell fibrous papule with NKI/C3 expression: clinical and histologic features in six cases

Fibrous papule of the nose is a common benign lesion of dermal fibroblast lineage. Two unusual variants have been described, namely, fibrous papule with granular cells and fibrous papule with clear fibrocytes. We report a second case series (six cases) of clear cell fibrous papule to add to the first series of 9 cases. Clinical and histologic features in our cases are similar to those in the first series. All of our specimens were dome-shaped, 2- to 5-mm skin-colored to slightly erythematous papules on the faces of three male and three female adults ranging from 18 to 48 years of age. All but one lesion were on the nose. Clinical differential diagnoses included fibrous papule, verruca, basal cell carcinoma, and a variety of other neoplasms. Histologically, dermal aggregates of clear cells with finely granular to vacuolated cytoplasm, and centrally located nuclei, were found. Most specimens also contained ectatic capillaries, and all showed evidence of irritation or trauma. Periodic acid-Schiff stain was negative in all specimens to which it was applied (5/6). Neural, melanocytic, and epithelial origins were eliminated by negative staining with S-100, Mart-1, cytokeratins, epithelial membrane antigen, and carcinoembryonic antigen, performed on some of the specimens. A mesenchymal nature was confirmed in one specimen staining strongly positive for vimentin. Five of six cases stained positively for CD68, and all five cases studied were strongly and diffusely positive for NKI/C3. Factor XIIIa stain highlighted scattered dendritic cells within the lesion but was otherwise negative in all six cases studied. Recognition of this variant of fibrous papule is important to distinguish this benign lesion from other clear cell neoplasms.

Local melanoma recurrence: a clarification of terminology

BACKGROUND

The current medical literature contains multiple different meanings for the term "local melanoma recurrence." Confusion regarding locally persistent and locally metastatic disease makes interpretation and analysis of previously published reports difficult if not impossible.

OBJECTIVE

The objective was to present a more precise definition of local melanoma recurrence.

METHODS

A case is reported and the literature is reviewed.

CONCLUSION

Owing to the myriad of different definitions that exist in the medical literature, the term "local melanoma recurrence" is ambiguous and at times misleading. Melanoma that recurs locally from persistence of tumor at the resection margins has a vastly different prognosis than recurrence developing from local (satellite) metastases adjacent to the surgical resection site. We propose the use of the terms "persistent melanoma" and "local metastasis" as more precise and predictive of a patient's prognosis.

Specific dermatoses of pregnancy: an evidence-based systematic review

OBJECTIVE

We conducted an evidence-based systematic analysis of the literature on specific dermatoses of pregnancy.

STUDY DESIGN

The bibliographic databases MEDLINE and EMBASE were screened for studies and reports in all languages about herpes gestationis, pruritic urticarial papules and plaques of pregnancy, pruritic folliculitis of pregnancy, and prurigo of pregnancy from January 1962 to January 2002. As main index terms, including analogs and derivatives, we used the names of specific dermatoses of pregnancy. Intrahepatic cholestasis of pregnancy, not a primary dermatosis, was included herein because this disorder is associated with pregnancy and its secondary skin manifestations must be differentiated from specific dermatoses of pregnancy. Other sources were abstract books of symposia and congresses, theses, textbooks, monographs, reviews, editorials, letters to the editor, free or rapid communications, and the reference lists from all the articles that were retrieved. All articles selected for inclusion in this review were evaluated critically with regard to their impact factor and evidence-based contribution to this field, as measured by their citation index and impact factor of the journal in which they were published. Approximately 39% of articles met the selection criteria.

RESULTS

The clinical features and prognosis of the specific dermatoses of pregnancy have been delineated through a number of retrospective and cohort studies. The molecular biologic and immunogenetic properties of herpes gestationis, pruritic urticarial papules and plaques of pregnancy, and intrahepatic cholestasis of pregnancy have been further clarified. A meta-analysis in this review reveals a higher prevalence of multiple gestation pregnancy (11.7%) among patients with pruritic urticarial papules and plaques of pregnancy. Several investigations have unraveled the fetal complications in intrahepatic cholestasis of pregnancy and herpes gestationis. New treatment modalities in intrahepatic cholestasis of pregnancy (cholestyramine, ursodeoxycholic acid) and herpes gestationis (cyclosporin, intravenous immunoglobulin, and tetracyclines postpartum) have shown promise and warrant further evaluation.

CONCLUSION

During the past few decades, a significant amount of new data has provided new insights into the classification, pathogenesis, treatment, prognosis, and fetal risks that are associated with the specific dermatoses of pregnancy.

Lentigo maligna with spread onto oral mucosa

BACKGROUND

Lentigo maligna (LM) is a form of melanoma in situ most often seen in white patients on sun-exposed areas, primarily the head and neck. Spread of LM onto the conjunctiva has been reported. There have been no reports of LM extending onto oral mucosa.

OBSERVATIONS

We report 4 cases of LM in white women with contiguous spread from perioral areas to oral mucosa. The locations of the primary lesions were the vermilion of the lip, vermilion and perioral skin, cheek, and cutaneous aspect of the lip. Three cases showed focal histopathologic evidence of invasion during the course of the disease. The lesions ran a prolonged course characterized by repeated recurrences after surgery. Three of the cases required a complicated reconstruction after surgical excision. Mohs surgery with rush permanent (paraffin-embedded) sections resulted in a long remission in 2 cases, while in 1 patient, treatment with carbon dioxide laser was unsuccessful.

CONCLUSIONS

In a perioral distribution, LM can spread onto oral mucosa. This clinical presentation may cause significant long-term morbidity, as indicated by a high recurrence rate and/or progression to invasive melanoma. The oral mucosa should be examined in patients with atypical pigmented perioral lesions.

Cigarette smoking and chewing gum: response to a laboratory-induced stressor

The current study examined the anxiolytic effects of cigarette smoking and chewing gum on urge to smoke, withdrawal, and anxiety in response to a public speaking task in 45 undergraduate smokers. Participants were asked to smoke, chew gum, or do nothing in response to the stressor. Participants completed measures of anxiety, withdrawal symptoms, and urge to smoke pre- and poststressor. The smoke group reported fewer urges to smoke pre- and poststressor than the other groups. The smoke and gum groups reported fewer withdrawal symptoms than did the control group poststressor. Chewing gum was helpful in managing levels of withdrawal symptoms compared with the control group. Groups did not differ on measures of anxiety. Results suggest that smoking in response to a stressor may not reduce levels of affective stress. Furthermore, chewing gum may be helpful in managing withdrawal symptoms in response to a stressor.

Intradermal melanocytic nevus with prominent schwannian differentiation

Features of peripheral nerve sheath differentiation such as neuroid cords, nerve corpuscles, fascicle-like structures, and, exceptionally, palisading have been reported in melanocytic nevi. We report an intradermal melanocytic nevus with prominent Verocay-like bodies. The upper portion of the neoplasm was composed of typical round intradermal nevus cells, many of which were pigmented. Within the deeper portion, there was a nonpigmented spindle cell proliferation with prominent Verocay bodies, simulating a neurilemmoma. Typical nevus nests merged with neurilemmoma-like areas. The entire lesion stained positively for S-100 and Mart-1 proteins and negatively for HMB-45 stain. Diffuse Mart-1 positivity excluded a collision of a melanocytic lesion with a neurilemmoma. The histopathologic features of this nevus further support a close relation between nevus cells and Schwann cells.

Linear IgA bullous dermatosis occurring after carbamazepine

Linear IgA bullous dermatosis (LABD) is an immunobullous disorder in which IgA antibodies are deposited within the basement membrane zone. The cause is unknown, but the eruption may occur in association with certain medications. We report a patient who experienced LABD shortly after starting carbamazepine therapy.

A very good death: measuring quality of dying in end-stage renal disease

A case is presented of an exceptionally good death after discontinuation of dialysis, and the authors trace the evolution of their attempts at measuring quality of dying in patients with end-stage renal disease. The Dialysis Quality of Dying Apgar is based on the pediatric tool for measuring the condition of newborn babies. Previous research with termination of dialysis has revealed that staff, patients, and families characterize a good death as being pain-free, peaceful, and brief. The quality of dying tool has corresponding domains to which it adds advance care planning and non-pain symptoms. Quantification of patient deaths combined with descriptive narratives can be used to establish benchmarks for the provision of terminal care. Very good deaths need to be recognized and valued as goals for palliative medicine.

Cigarette smoking and chewing gum: response to a laboratory-induced stressor

The current study examined the anxiolytic effects of cigarette smoking and chewing gum on urge to smoke, withdrawal, and anxiety in response to a public speaking task in 45 undergraduate smokers. Participants were asked to smoke, chew gum, or do nothing in response to the stressor. Participants completed measures of anxiety, withdrawal symptoms, and urge to smoke pre- and poststressor. The smoke group reported fewer urges to smoke pre- and poststressor than the other groups. The smoke and gum groups reported fewer withdrawal symptoms than did the control group poststressor. Chewing gum was helpful in managing levels of withdrawal symptoms compared with the control group. Groups did not differ on measures of anxiety. Results suggest that smoking in response to a stressor may not reduce levels of affective stress. Furthermore, chewing gum may be helpful in managing withdrawal symptoms in response to a stressor.

Dermatoses of pregnancy

The dermatoses of pregnancy can be classified into the following 3 groups: physiologic skin changes in pregnancy, dermatoses and cutaneous tumors affected by pregnancy, and specific dermatoses of pregnancy. Correct diagnosis and classification are essential for the treatment of these disorders, when necessary. Laboratory investigations are required when the diagnosis remains in question despite a careful history and thorough physical examination. A discussion with the pregnant woman about the nature of her skin condition, and the possible fetal risks associated with it, is imperative.

Multimodal assessment of the effect of chewing gum on nicotine withdrawal

The present study was designed to evaluate the usefulness of chewing gum to reduce nicotine withdrawal, craving, and salivary cortisol concentrations during temporary nicotine deprivation. A total of 20 male smokers were studied under conditions when gum was and was not accessible during a 4-hour deprivation period. All subjects smoked an initial cigarette shortly after arrival for the two experimental sessions and were informed that they would be unable to smoke for the remainder of each session. The sessions consisted of each subject watching a movie, then waiting in the lab for two consecutive 30-min intervals. Self-reported nicotine withdrawal and craving were assessed four times and salivary cortisol five times during each experimental session. Results from this study indicate that chewing gum helps with self-reported withdrawal but not craving when a smoker is prevented from smoking. This study also provides preliminary data on the use of salivary cortisol as a physiological marker that may map these self-reports of nicotine withdrawal and craving.

Dying well after discontinuing the life-support treatment of dialysis

BACKGROUND

Cessation of life-prolonging treatments precedes death in an increasing number of cases, but little attention has been accorded to the quality of dying.

OBJECTIVE

To examine the quality of dying following dialysis termination.

PATIENTS AND METHODS

A prospective cohort, observational study involved 6 dialysis clinics in the United States and 2 clinics in Canada, and 131 adult patients receiving maintenance dialysis who died after treatment cessation. Sixty percent (n = 79) underwent patient (n = 23) and/or family (n = 76) interviews and follow-up with caretakers. A quality of dying tool quantified duration, pain and suffering, and psychosocial factors.

RESULTS

The sample was 59% female, the age was 70.0+/-1.2 years old, the duration of dialysis was 34.0+/-2.8 months, and death occurred 8.2+/-0.7 days after the last dialysis treatment. (Data are given as mean +/- SE.) Thirty-eight percent of the subjects who completed the protocol were judged to have had very good deaths, 47% had good deaths, and 15% had bad deaths. During the last day of life, 81% of the sample did not suffer, although 42% had some pain and an additional 5% had severe pain. According to the psychosocial domain of the quality of dying measure, patients who died at home or with hospice care had better deaths than those who died in a hospital or nursing home.

CONCLUSIONS

Most deaths following withdrawal of dialysis were good or very good. The influence of site of death and physician attitudes about decisions to stop life support deserves more research attention. Quality of dying tools can be used to establish benchmarks for the provision of terminal care.

Pruritic folliculitis of pregnancy

Pruritic folliculitis of pregnancy is a rare pregnancy dermatosis that clears spontaneously in the postpartum period. We describe a patient with characteristic clinical and histopathologic features of this dermatosis.

Dialysis discontinuation and palliative care

Little attention has been accorded to the terminal course and end-of-life care of patients after dialysis discontinuation. This prospective cohort observational study involves six dialysis clinics in the United States and two clinics in Canada. Data were collected on 131 patients who were undergoing maintenance dialysis and died after treatment discontinuation. Seventy-nine of the patients (60%) were prospectively studied until their deaths. Caregivers and families provided information about the symptoms and treatment provided in the final 24 hours of life, and structured interviews were conducted at the time of stopping dialysis with patients and families. The patient population was primarily white (73%), elderly (70 +/- 1.2 years), and diabetic (46%). Three quarters of the subjects had between three and seven comorbid conditions. Pain and agitation were the most common symptoms during the last day of life. Terminal treatment was generally considered to be satisfactory, and most people had good deaths. Although dialysis prolongs life, the integration of palliative medicine into dialysis programs offers opportunities to improve the quality of end-of-life care, especially for those patients who elect to stop treatment. Recommendations include making advance care planning an expectation at all clinics and using quality-of-dying measures to establish benchmarks for the provision of terminal care.

Psychiatric evaluation of death-hastening requests. Lessons from dialysis discontinuation

The authors aim to facilitate the psychiatric evaluation of death-hastening decisions, such as cessation of life-support treatment or physician-assisted suicide, by deriving principles for evaluating patients from a literature review and a recently completed prospective study on dialysis discontinuation conducted by consultation psychiatrists. Factors are delineated and suggestions are provided for the evaluation of requests to accelerate dying. Included are the authors' method for determining major depression in the context of terminal illness and their "vector analysis" in assessing patient requests to stop dialysis. As our society heatedly examines the care provided to the terminally ill, psychiatry also needs to reconsider whether actions that foreshorten life can be normative and permissible. Familiarity with competency, psychiatric diagnosis, and ease in communication and negotiation between patient, family, and staff are resources that psychiatrists can bring to these complicated assessments. Challenging areas include diagnosing depression, establishing the adequacy of palliative care, and appreciating issues related to personality features, family dynamics, and ethnic differences.

Ethical issues in aging and renal disease

The incidence of elderly patients reaching end-stage renal disease (ESRD) and requiring renal replacement is increasing. Better medical care is helping patients live longer but, at the same time, is raising ethical questions. Treatment decisions for ESRD patients present a forum for the consideration of ethical questions surrounding the issues of scarce health care resource allocation and the withholding or withdrawal of life-sustaining treatment. As background for the consideration of ethical issues in ESRD patients, the quality of life they experience and what they may expect as death approaches also are discussed.

Chewing gum affects smoking topography

In a previous study, Wrigley's chewing gum was shown to reduce cravings to smoke and nicotine withdrawal when smokers were not allowed access to cigarettes. The present study expanded these findings by examining smoking behavior of 20 dependent cigarette smokers who were allowed free access to cigarettes throughout the study session but were encouraged and rewarded not to smoke. Each experimental session consisted of the participant watching a movie, then waiting an additional 30 min. Half of the participants were assigned to a gum condition in which they were asked to chew at least one piece of gum and had free access to chewing gum throughout the experimental session; half were assigned to a no-gum control. Results from this study indicate that when gum was present, participants took significantly fewer puffs and abstained for a longer period of time until their first cigarette. These results suggest that chewing gum may facilitate quit attempts.

Maturation of the hepatitis A virus capsid protein VP1 is not dependent on processing by the 3Cpro proteinase

Most details of the processing of the hepatitis A virus (HAV) polyprotein are known. Unique among members of the family Picornaviridae, the primary cleavage of the HAV polyprotein is mediated by 3Cpro, the only proteinase known to be encoded by the virus, at the 2A/2B junction. All other cleavages of the polyprotein have been considered to be due to 3Cpro, although the precise location and mechanism responsible for the VP1/2A cleavage have been controversial. Here we present data that argue strongly against the involvement of the HAV 3Cpro proteinase in the maturation of VP1 from its VP1-2A precursor. Using a heterologous expression system based on recombinant vaccinia viruses directing the expression of full-length or truncated capsid protein precursors, we show that the C terminus of the mature VP1 capsid protein is located near residue 764 of the polyprotein. However, a proteolytically active HAV 3Cpro that was capable of directing both VP0/VP3 and VP3/VP1 cleavages in vaccinia virus-infected cells failed to process the VP1-2A precursor. Using site-directed mutagenesis of an infectious molecular clone of HAV, we modified potential VP1/2A cleavage sites that fit known 3Cpro recognition criteria and found that a substitution that ablates the presumed 3Cpro dipeptide recognition sequence at Glu764-Ser765 abolished neither infectivity nor normal VP1 maturation. Altered electrophoretic mobility of VP1 from a viable mutant virus with an Arg764 substitution indicated that this residue is present in VP1 and that the VP1/2A cleavage occurs downstream of this residue. These data indicate that maturation of the HAV VP1 capsid protein is not dependent on 3Cpro processing and may thus be uniquely dependent on a cellular proteinase.

Imipramine-induced hyperpigmentation: four cases and a review of the literature

BACKGROUND

Hyperpigmentation is a side effect of several medications, including amiodarone, bleomycin, chlorpromazine, and minocycline.

OBJECTIVE

The purpose of this study is to describe the clinical and light microscopic findings in 4 patients with imipramine-induced hyperpigmentation and to better understand its origin.

METHODS

All 4 patients underwent a skin biopsy for light microscopy. In 1 patient, a biopsy specimen was obtained for electron microscopy. Tissue from patient 1 was analyzed with a mass spectrophotometer, and energy-dispersive x-ray analysis was performed on tissue from patients 1 and 2.

RESULTS

All 4 women had been taking imipramine for at least 2 years. Hyperpigmentation occurred in a photodistribution on the face, arms, and backs of the hands. Light microscopy in all cases demonstrated golden-brown granules in the superficial dermis, which were strongly positive for Fontana-Masson stain. Electron microscopy demonstrated areas of electron-dense inclusion bodies within macrophages, which were distinct from melanosomes. Mass spectrophotometric and energy-dispersive x-ray analysis of the electron-dense bodies showed the presence of sulfur atoms, and no peak corresponding to that expected for imipramine was found. A peak closely corresponding to phaeomelanin, a sulfur-containing compound, was found.

CONCLUSION

Hyperpigmentation is a side effect of long-term imipramine use. It may result from the deposition of melanin in an unusual form. The melanin pigment is possibly complexed with a metabolite of imipramine, and does not represent the deposition of imipramine in its native form.

Erythema multiforme associated with contact dermatitis to poison ivy: three cases and a review of the literature

Erythema multiforme (EM) is a hypersensitivity reaction that occurs mainly after exposure to certain medications or in the setting of infection, most commonly that due to herpes simplex virus. Rare cases of EM have been reported after allergic contact dermatitis due to various substances. There has been one case in the literature of EM following Rhus contact dermatitis. We report three patients who developed EM after allergic contact dermatitis due to poison ivy. In all three patients, targetoid lesions developed primarily on the palms and soles, either after a brief course of prednisone or during its taper. Two of the patients have had more than one episode of EM after poison ivy dermatitis. Although EM has been described after allergic contact dermatitis due to a variety of antigens (nickel being the most common), there is only one report in the literature of EM following Rhus contact dermatitis. Given the prevalence of allergic contact dermatitis due to poison ivy, this may be an under-reported complication.

Mohs micrographic surgery for lentigo maligna and lentigo maligna melanoma. A follow-up study

BACKGROUND

We previously reported our experience using Mohs micrographic surgery (MMS) for 45 patients with lentigo maligna (LM) and lentigo maligna melanoma (LMM). The patients were treated between 1985 and 1992. In our initial publication, all of the patients were free of local disease and evidence of metastases at an average of 29.2 months after therapy.

OBJECTIVE

The purpose of this study was to report long-term follow-up of our previously published data.

METHODS

MMS was performed in 26 patients with LM and 19 patients with LMM using frozen sections followed by rush permanent sections. Follow-up was obtained by contacting the referring physician, examination by one of our two Mohs surgeons, or by contacting the patient or his or her family.

RESULTS

After a median follow-up of 58.0 months (214.3 patient-years), there was one recurrence. This patient was a 56-year-old woman with five prior recurrences before MMS. Six patients were decreased of other causes during the study.

CONCLUSIONS

MMS using frozen and rush permanent sections resulted in a 97% cure rate for LM and LMM. Because MMS minimizes the removal of normal tissue, and the cure rate exceeds that of conventional therapies, the authors recommend this technique for the treatment of LM and LMM.

The effect of chewing gum on tobacco withdrawal

When smokers are in situations where smoking is prohibited, chewing gum is believed to reduce cravings to smoke. However, there is little scientific evidence to support this widely held assumption. The present study assessed craving for a cigarette and nicotine withdrawal in 20 dependent cigarette smokers under one of two conditions. All subjects smoked an initial cigarette upon arrival to the experimental session and were informed that they would not be allowed to smoke for the remainder of the session. The session consisted of each subject watching a movie, then waiting an additional 30 minutes. Half of the subjects were assigned to a Gum Condition where they were given free access to chewing gum throughout the experimental session; half were assigned to a No-Gum Control. Nicotine withdrawal was assessed immediately following the movie (Time 1) and again 30 minutes later (Time 2). Results from this study indicate that chewing gum reduces craving and helps with withdrawal when a nicotine-dependent person cannot smoke.

Hypermelanotic nevus: clinical, histopathologic, and ultrastructural features in 316 cases

We report on a series of benign melanocytic nevi that have unique clinical, histopathologic, and ultrastructural features. Between March 1993 and February 1994, 316 examples of hypermelanotic nevi were received by the dermatopathology laboratory at Denver General Hospital. Our study identified the clinical characteristics, histopathologic criteria, and ultrastructure of this lesion. Clinically, the lesions were dark brown to black macules or papules. The most common location was the back. There was a slight female predominance, and the mean age of our patients was 40 years. Histopathologically, the nevus showed the following characteristics: (a) melanin within a compact stratum corneum, (b) small nests of nevus cells at the dermal-epidermal junction and (in 52% of the cases), nests within the papillary dermis, (c) heavy melanin within keratinocytes in the lower epidermis, (d) a sparse to moderate lymphocytic infiltrate and melanophages in the superficial dermis, and (e) an absence of cytologic atypia. Electron microscopy revealed that abundant melanin was packaged in melanosome complexes within keratinocytes. Less pigmented melanocytes and nevus cells contained well-developed dendritic processes and golgi, indicative of efficient melanin transfer. According to our retrospective case control analysis, patients with hypermelanotic nevi were older and more likely to be male than those with ordinary nevi. Hypermelanotic nevi were more likely than controls to be junctional nevi; they were smaller, dark brown or black in color, and clinically suspicious for melanoma. We propose the name "hypermelanotic nevus" to describe this benign lesion, which is often biopsied to exclude melanoma.

Denying the dying. Advance directives and dialysis discontinuation

A structured interview was administered to a sample of patients on maintenance dialysis and their attending physicians to obtain information on the documentation of their end-of-life treatment preferences. The majority of the patients reported never having considered stopping dialysis, or having discussed with their nephrologist or family the circumstances in which treatment should be discontinued. Only 7 patients (6%) had completed an advance directive; these patients were all men (P = 0.01) and tended to be better educated (P = 0.02). Only one of the nine physicians had completed an advance directive. In most cases, the dialysis patients and their treatment team staff were preoccupied with the struggles of daily life and had avoided or denied considerations of terminal illness and death. The literature on denial, medical illness, and dying is also reviewed as it relates to dialysis patients, end-of-life treatment, and terminal care.

Multiple retiform hemangioendotheliomas. A low-grade angiosarcoma

We present the case of a 30-year-old woman who over a 10-year period has developed multiple well-differentiated angiosarcomas involving the trunk and extremities. The clinical and histologic features are characteristic of retiform hemangioendothelioma (RH), a distinctive form of low-grade angiosarcoma. This case is unique in that multiple lesions developed in different anatomic sites. We discuss the clinical and histologic characteristics, diagnosis, and prognosis of RH.

The starburst giant cell is useful for distinguishing lentigo maligna from photodamaged skin

BACKGROUND

Because lentigo maligna (LM) occurs in areas of the body that are subjected to long-term UV radiation (UVR), it may be difficult to distinguish atypical melanocytes in LM from the pleomorphic, atypical melanocytes in actinically damaged skin.

OBJECTIVE

The purpose of this study was to determine whether the presence of multinucleated melanocytes would help to make this distinction.

METHODS

A total of 89 cases of LM were reviewed for the presence or absence of multinucleated melanocytes and, if present, the maximum number of nuclei was recorded. As controls, 107 elliptical excisions of basal cell carcinoma or squamous cell carcinoma were randomly selected. The tips of the ellipses were reviewed for the presence or absence of multinucleated melanocytes.

RESULTS

Multinucleated melanocytes with a "starburst" appearance, because of their prominent dendritic processes, were present in 85% of LM cases but in only 21% of sun-damaged control specimens (p < 0.00001; odds ratio [OR] = 22.6; 95% confidence interval [CI] = 10.6-47.9). The sensitivity and specificity of starburst giant cells (SGCs) in the diagnosis of LM was 85% and 78%, respectively. The maximum number of nuclei per SGC ranged from 2 to 30 in the LM cases (mean, 6.8 +/- 6.1) and from 2 to 6 in the controls (mean, 2.7 +/- 1.1) (p < 0.001). If only those SGCs with more than two nuclei are considered, 76% of cases but only 8% of controls contained SGCs (p < 0.00001; OR = 35.3; CI = 15.2-81.7). Similarly, 64% of cases and 3% of controls had SGCs with more than three nuclei (p < 0.00001; OR = 61.8; CI = 18.1-210.6).

CONCLUSION

The SGC is a useful indicator for the diagnosis of LM. The diagnosis of LM is also more likely as the number of nuclei in SGC increases.

Panniculitis: diagnosis and management

Panniculitis, or inflammation of the subcutaneous fat, may present in a variety of ways. It is generally divided into septal and lobular types based on the histopathologic features. The different types of panniculitis are associated with a wide range of etiologies and systemic manifestations. Although some forms of panniculitis are self-limited, treatment depends upon eliminating the underlying cause in addition to using anti-inflammatory and immunosuppressive agents.

Ambivalence and dialysis discontinuation

Although dialysis discontinuation is the second leading "cause" of death among individuals who are maintained with chronic dialysis, little attention is accorded in the literature to patient ambivalence with this crucial decision. Three cases are presented of clinical situations involving termination of dialysis and ambivalence. The ambivalence of the patients is mirrored by the literature's vacillation between viewing cessation of life-support as pathological, and perceiving it as rational. There is considerable variability in the presentation of these cases, and they require exquisite sensitivity and flexibility on the part of medical personnel. As patient-physician communication is encouraged, and staff attempt to honor requests for initiation and/or discontinuation of treatment, we will see increasing numbers of ambivalent patients.