Development of a Web-Based Registry to Support Diabetes Care in Free Medical Clinics

The United States has more than 1,000 free medical clinics. Because these clinics do not bill Medicare or Medicaid, they are not eligible for federal reimbursement for electronic health record (EHR) adoption. As a result, most do not have EHRs or electronic disease registries. A web-based diabetes registry was created with all open-source components for use in an urban free clinic to manage patients with type 2 diabetes and comorbidities. The registry was modeled after the Chronic Disease Electronic Management System and recommendations of the American Diabetes Association. The software was enhanced to include multiple other features, such as progress notes, so that it can function as a simple EHR. The configuration permits other free clinics to join securely, and the software can be shared.

Oncologic results following abdominoperineal resection for adenocarcinoma of the low rectum

PURPOSE

The role of abdominoperineal resection for rectal cancer has changed because of advances in sphincter-preserving surgery. Our aim was to evaluate the results of this operation in the five-year period following introduction of the concept of total mesorectal excision

METHODS

Data on all patients undergoing abdominoperineal resection for very low rectal cancer between 1992 and 1997 were collected prospectively. All patients had had total mesorectal excision. Curative resection was defined as absence of macroscopic disease after resection and local recurrence as any infiltration or tumor identified in the pelvis, alone or combined with distant disease. Survival and local recurrence rates were calculated using the Kaplan-Meier method and log-rank analysis.

RESULTS

Of 165 abdominoperineal resections performed, 106 were for primary adenocarcinoma of the rectum. The male:female ratio was 50:56, with a median age of 65 (range, 33-85) years. There was one postoperative death. Twenty-seven patients received short-course preoperative radiotherapy (25 Gy over 1 week), whereas 22 had a longer course, with concomitant chemotherapy in 2. Postoperative chemotherapy was administered in 29, postoperative radiotherapy in 4, and combined therapy in 8. After curative resection (n = 91), survival at five years was 76 percent and differed significantly by stage. Recurrence at any site was 7 percent (3/34) for Stage I, 27 percent (6/26) for Stage II, and 53 percent (16/31) for Stage III. Nine patients presented with local recurrence, with an overall rate at five years of 10 percent. Isolated locale recurrence was observed in only 5 percent of patients

CONCLUSIONS

After abdominoperineal resection and total mesorectal excision, good rates of local control may be achieved provided surgical technique is meticulous.

Successful case of extracorporeal life support in a patient with postcardiotomy cardiogenic shock

Over the past five years, the use of extracorporeal life support in the adult population has gained acceptance. Indications have ranged from respiratory failure secondary to trauma, and adult respiratory distress syndrome, to cardiac failure secondary to a number of causes. The results of extracorporeal life support, when applied to postcardiotomy patients, have been variable. In this article, we present the successful utilization of extracorporeal life support for 28 hours in a patient with postcardiotomy cardiogenic shock following mitral valve replacement.

Instability of lymphocyte chromosomes in a girl with Rothmund-Thomson syndrome

Rothmund-Thomson syndrome is a rare autosomal recessive syndrome characterised by poikiloderma of the face and extremities, alopecia, short stature, and skeletal defects. We report a patient with the characteristic features of Rothmund-Thomson syndrome who also had lymphocyte chromosome abnormalities. She has a small flat face with short palpebral fissures and micrognathia together with severe skeletal abnormalities of the upper extremities with absence of both radii, short dysmorphic ulnae, a rudimentary right thumb, and aplasia of the left thumb. She also has anal atresia with a rectovaginal fistula. From the age of 3 months she developed poikiloderma skin changes on the face and extensor surfaces of the extremities. Mental development seems to be normal. Lymphocyte chromosomes in the neonatal period showed an unidentified marker chromosome in eight of a total of 32 cells. A repeat analysis at the age of 10 months showed three abnormal cells out of 100 analysed: 47,XX,-7,+i(7q),+7p, 46,XX,t(3;18)(p14.2;q22), and 49,XX,+del(3)(p11.2),+mar,+mar. A skin biopsy from an affected area showed poor growth and five of 48 cells analysed had structural abnormalities. The father had one of 48 cells with an additional marker chromosome and two cells with different 7;14 translocations. The abnormal chromosome complements in lymphocytes indicate that there may be in vivo chromosome instability in Rothmund-Thomson syndrome.

Aluminum-induced granulomas in a tattoo

A patient who developed localized, granulomatous reactions in a tattoo is described. With the use of scanning electron microscopy and energy dispersive x-ray microanalysis, both aluminum and titanium particles were found in the involved skin sections. Intradermal provocation testing with separate suspensions of aluminum and titanium induced a positive response only in the case of aluminum. Examination by scanning electron microscopy and energy dispersive x-ray microanalysis of the provoked response established aluminum as the only nonorganic element present in the test site tissue. This is the first report of confirmed aluminum-induced, delayed-hypersensitivity granulomas in a tattoo.

[A study of new patients at a dermatologic outpatient clinic]

Data on all new dermatology outpatients seen during the period 1 January to 30 June 1987 were analyzed in order to obtain information on the types of patients attending the clinic and on the skin diseases presented. We also recorded the source of referral, the frequency of the need for surgery, and patient compliance. There was a general predominance of female patients (60%), particularly in the 21-30 years age group. The leading diagnoses were atopic dermatitis (18%) and psoriasis (11%), and 2/3 of the atopic dermatitis patients were female. A skin biopsy was performed in 12% of the new patients and the clinical pre-biopsy diagnosis was correct in 72% of the cases. Surgery was necessary in 16% of all new patients. 54% of the patients required a follow-up appointment. 11% of these (108 patients) failed to appear. Patients with atopic dermatitis were the chief offenders in this latter group. The results of the study suggest that out-patient costs and waiting lists could be reduced by revising the indications for biopsy and follow-up appointments.

The Scandinavian multicenter photopatch study 1980-1985: final report

At 16 different dermatology clinics in Scandinavia from 1980-1985, photopatch testing was performed on 1993 patients with suspected photodermatosis. The collective results are presented in this article. The most common cause of sun-related dermatosis was polymorphic light eruption (PLE) (38%), while secondary aggravation of pre-existing skin diseases was established in 16% of the patient group. Photocontact dermatitis (11%) and contact dermatitis (10%) were responsible for 274 and 369 positive test reactions (respectively) on photopatch testing using the SPDRG standard series. Musk ambrette and para-aminobenzoic acid were the leading photosensitizers, while perfume mixture, balsam of Peru and lichen mixture were the most frequent causes of contact sensitivity. The principal photoallergens and contact allergens in the PLE, persistent light reaction and actinic reticuloid groups are discussed, together with the problems, risks and possible mechanisms of induction of photosensitization in these patients. The incidence, causes and diagnostic and therapeutic implications of secondary sunscreen sensitivity in these groups are also addressed.

Scleredema adultorum associated with a monoclonal gammopathy and generalized hyperpigmentation

Scleredema associated with a monoclonal gammopathy and generalized skin pigmentation is described in a 56-year-old man with hyperlipoproteinemia and cardiovascular disease. The patient had IgG-lambda paraproteinemia, without any evidence of multiple myeloma or immunoglobulin deposition in affected skin. Ultrastructural studies of pigmented lesional skin showed increased transfer of melanosomes to basal keratinocytes and dermal melanophages containing complex melanosomes. In addition, cytoplasmic, electron-opaque lipid droplets were seen in approximately every third keratinocyte or melanocyte, while only an occasional dermal cell contained lipid droplets. The hyperpigmentation appeared to be directly related to the scleredema, while the lipid deposition in skin was a likely consequence of the hyperlipoproteinemia. The findings further support the contention that paraproteinemia and hyperpigmentation may, in some patients, be associated features of scleredema adultorum.

Polymorphous light eruption: the properties of a UVA-induced PLME patient group

Experimental induction of PLME lesions in 22 patients, using a pure, high-intensity UVA light source is reported. Fourteen patients had a reduced MED value for either UVB (11 patients) and/or UVA (7 patients). The UVA-SUN 2000 dose required to provoke a positive PLME reaction varied from 26 to 104 J/cm2. The small papular PMLE-type patients were shown to be more photosensitive and the UVA provocation doses required exceeded 50 J/cm2 in 20/22 patients. Lesional immunoglobulin deposition along the BMZ was seen in 3 patients while lesional BMZ complement deposits occurred in 9/15 patients, 2 of whom had similar findings in the dermal capillaries. Complement deposition occurred in non-irradiated control sites in 4 patients. The immunohistologic findings, for reasons given, fail to support the hypothesis of an immune cell-mediated response as the primary event in the pathogenesis of PMLE.

Infantile acropustulosis

We report two patients with infantile acropustulosis; one patient with a history of atopic dermatitis and the second with an abnormally high IgE serum value. Atopy has not been reported previously in patients with infantile acropustulosis. Immunofluorescent studies of involved skin gave negative results.

UVA sensitivity and topical photoprotection in polymorphous light eruption

The efficacy of a non-PABA, non-benzophenone broad-spectrum sunscreen was investigated experimentally in 8 patients with polymorphous light eruption (PMLE). A UVA-SUN 2000 lamp, emitting high intensity UVA radiation was used to irradiate unprotected and sunscreen protected skin sites of the upper back of each patient. Morphological and histological skin changes were noted in non-protected test-sites, while no clinical or microscopic changes were observed in the sunscreen-treated test-sites. Low minimal erythema dose (MED) values for both UVA and UVB light were noted in several PMLE patients.

Perfume allergy due to oak moss and other lichens

During a period of 2 1/2 years, 7 of 2000 patients routinely tested at our laboratory revealed contact allergy to oak moss in perfumes. All reacted to a mixture of different lichens and to some specific lichen compounds. The sensitivity was probably induced by cosmetics containing lichen substances. The following 3 compounds caused reactions in all patients tested: atranorin, evernic and usnic acids. 3 patients were photosensitive, but stronger reactions were elicited by prolonged contact during occlusion of the patches and complete protection against light, rather than by irradiation alone. The data suggest that the sensitizing capacity of the lichen compounds is primarily of a contact rather than of a photocontact nature.