The Treatment of Eruptive Syringomas in an African American Patient with a Combination of Trichloroacetic Acid and CO2 Laser Destruction

BACKGROUND: Eruptive syringomas are uncommon benign adnexal neoplasms. They are numerous and disseminated and often have a predilection for the neck, face, chest, and axillary fossae. Because they are persistent, usually numerous, and often on exposed sites, the lesions may be disfiguring and often pose significant cosmetic concerns for patients. Many treatment modalities such as dermabrasion, electrodesiccation with curettage, and scissors excision have been tried with some success, but more recently lasers have provided good to excellent results. OBJECTIVE: To describe an approach to the treatment of eruptive syringomas in an African American patient with a combination of trichloroacetic acid (TCA) and CO2 laser resurfacing, providing acceptable cosmetic results without significant side effects. METHODS: We describe an African American patient with eruptive syringomas of the face treated with a combination of TCA and CO2 laser resurfacing with good results. RESULTS: While the syringomas were not completely ablated, the combination of TCA and CO2 laser resurfacing provided acceptable cosmetic results without significant side effects. CONCLUSION: The TCA pretreatment probably removed some of the bulk of the surface of the lesions, thereby reducing the number of laser passes required to flatten the remainder of the lesions and thus lessening the potential for thermal damage at the treated sites and of surrounding normal skin.     

Contact dermatitis from a presumed allergy to paraphenylenediamine

Paraphenylenediamine (PPD) is a potent skin allergen found in permanent hair dye and temporary henna tattoo ink. Several cases of adverse skin reactions to PPD have been reported in the literature. Here we present a case involving a patient who acquired a temporary tattoo while vacationing in Mexico and subsequently developed contact dermatitis at the tattoo site. He provided a history of permanent hair dye use in the past with associated cutaneous reaction. Temporary tattoos have become increasingly popular with travelers and as a result so have reports of associated allergic contact dermatitis. Of concern is cross‐reaction of PPD to related compounds, severe reactions in younger populations and sequelae including increased sensitization, permanent scarring, and persistent postinflammatory hyperpigmentation.     

The nuclear factor-kappaB pathway controls the progression of prostate cancer to androgen-independent growth

Typically, the initial response of a prostate cancer patient to androgen ablation therapy is regression of the disease. However, the tumor will progress to an "androgen-independent" stage that results in renewed growth and spread of the cancer. Both nuclear factor-kappaB (NF-kappaB) expression and neuroendocrine differentiation predict poor prognosis, but their precise contribution to prostate cancer progression is unknown. This report shows that secretory proteins from neuroendocrine cells will activate the NF-kappaB pathway in LNCaP cells, resulting in increased levels of active androgen receptor (AR). By blocking NF-kappaB signaling in vitro, AR activation is inhibited. In addition, the continuous activation of NF-kappaB signaling in vivo by the absence of the IkappaBalpha inhibitor prevents regression of the prostate after castration by sustaining high levels of nuclear AR and maintaining differentiated function and continued proliferation of the epithelium. Furthermore, the NF-kappaB pathway was activated in the ARR(2)PB-myc-PAI (Hi-myc) mouse prostate by cross-breeding into a IkappaBalpha(+/-) haploid insufficient line. After castration, the mouse prostate cancer continued to proliferate. These results indicate that activation of NF-kappaB is sufficient to maintain androgen-independent growth of prostate and prostate cancer by regulating AR action. Thus, the NF-kappaB pathway may be a potential target for therapy against androgen-independent prostate cancer.     

A Review of the Federal Guidelines That Inform and Influence Relationships Between Physicians and Industry

The effective delivery and continued advancement of health care is critically dependent on the relationship between physicians and industry. The private sector accounts for 60% of the funding for clinical research and more than 50% of the funding sources for physician education. The nature of the physician–industry relationship and the role of the physician as a gatekeeper for health care make this association vulnerable to abuse if certain safeguards are not observed. This article will review the current federal guidelines that affect the physician–industry relationship and highlight several illustrative cases to show how the potential for abuse can subvert this relationship. The recommendations and "safe harbors" that have been designed to guide business relationships in health care are discussed.     

Serious Bacterial Infections in Febrile Infants in the Post–Pneumococcal Conjugate Vaccine Era

Objectives: The objective was to identify the epidemiology of serious bacterial infections (SBI) and the current utility of obtaining routine complete blood counts (CBC) and blood cultures to stratify infants at risk of SBI, in the study population of febrile infants in the post–heptavalent pneumococcal conjugate vaccine (PCV7) era. Methods: A cohort study with nested case-controls was undertaken at a tertiary care military hospital emergency department (ED) from December 2002 through December 2003. Irrespective of clinical findings at the initial encounter, patients were included if they were under 3 months of age and had a home or ED temperature of ≥100.4°F or if they were between 3 and 24 months of age with a temperature of ≥102.3°F. Data abstracted included age, temperature, peripheral white blood cell (WBC) count, and discharge diagnosis. Culture (blood, urine, and cerebrospinal fluid [CSF]) and chest radiograph (CXR) results were obtained through review of the electronic hospital archives. SBI was defined as pneumonia, urinary tract infection (UTI), meningitis, or bacteremia. Results: A total of 985 children aged 0 to 24 months were enrolled. Fifty-five percent were male, the median age was 12 months (interquartile range = 8–17 months), and 79% had received at least one PCV7. A total of 132 cases of SBI were identified in 129 infants (13.1%): 82 pneumonias, 45 UTI, five bacteremias, and no cases of bacterial meningitis. The frequency of bacteremia was 0.7%. No statistical difference was detected in the WBC count between the SBI and non-SBI groups (13.8 ± 5.8 and 11.7 ± 5.6, respectively; p = 0.055). No readily available WBC cutoff on the receiver operating characteristic (ROC) curve proved to be an accurate predictor of SBI. No statistical difference was detected in mean temperature between the SBI and non-SBI groups (103.3 ± 1.2 and 103.2 ± 1.2°F, respectively; p = 0.26), nor was there a difference noted when groups were broken down by age or height of fever. Conclusions: The WBC count and height of fever were not found to be accurate predictors of SBI in infants age 3 to 24 months. UTI and pneumonias made up the vast majority of SBI in this population of infants. The overall bacteremia frequency was well below 1%. This calls into question the continued utility of obtaining routine complete cell counts and blood cultures in the febrile infant in the post-PCV7 era.     

Virtue in Emergency Medicine

At a time in which the integrity of the medical profession is perceptibly challenged, emergency physicians (EPs) have an opportunity to reaffirm their commitment to both their patients and their practice through acceptance of a virtue-based ethic. The virtue-based ethic transcends legalistic rule following and the blind application of principles. Instead, virtue honors the humanity of patients and the high standards of the profession. Recognizing historical roots that are relevant to the modern context, this article describes 10 core virtues important for EPs. In addition to the long-recognized virtues of prudence, courage, temperance, and justice, 6 additional virtues are offered unconditional positive regard, charity, compassion, trustworthiness, vigilance, and agility. These virtues might serve as ideals to which all EPs can strive. Through these, the honor of the profession will be maintained, the trust of patients will be preserved, and the integrity of the specialty will be promoted.     

Quality Indicators for Geriatric Emergency Care

Objectives:  Emergency departments (EDs), similar to other health care environments, are concerned with improving the quality of patient care. Older patients comprise a large, growing, and particularly vulnerable subset of ED users. The project objective was to develop ED-specific quality indicators for older patients to help practitioners identify quality gaps and focus quality improvement efforts.
Methods:  The Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, including members representing the American College of Emergency Physicians (ACEP), selected three conditions where there are quality gaps in the care of older patients: cognitive assessment, pain management, and transitional care in both directions between nursing homes and EDs. For each condition, a content expert created potential quality indicators based on a systematic review of the literature, supplemented with expert opinion when necessary. The original candidate quality indicators were modified in response to evaluation by four groups: the Task Force, the SAEM Geriatric Interest Group, and audiences at the 2007 SAEM Annual Meeting and the 2008 American Geriatrics Society Annual Meeting.
Results:  The authors offer 6 quality indicators for cognitive assessment, 6 for pain management, and 11 for transitions between nursing homes and EDs.
Conclusions:  These quality indicators will help researchers and clinicians target quality improvement efforts. The next steps will be to test the feasibility of capturing the quality indicators in existing medical records and to measure the extent to which each quality indicator is successfully met in current emergency practice.     

Hybrid Simulation Combining a High Fidelity Scenario with a Pelvic Ultrasound Task Trainer Enhances the Training and Evaluation of Endovaginal Ultrasound Skills

Objectives: In this study, an endovaginal ultrasound (US) task trainer was combined with a high‐fidelity US mannequin to create a hybrid simulation model. In a scenario depicting a patient with ectopic pregnancy and hemorrhagic shock, this model was compared with a standard high‐fidelity simulation during training sessions with emergency medicine (EM) residents. The authors hypothesized that use of the hybrid model would increase both the residents’ self‐reported educational experience and the faculty’s self‐reported ability to evaluate the residents’ skills. Methods: A total of 45 EM residents at two institutions were randomized into two groups. Each group was assigned to one of two formats involving an ectopic pregnancy scenario. One format incorporated the new hybrid model, in which residents had to manipulate an endovaginal US probe in a task trainer; the other used the standard high‐fidelity simulation mannequin together with static photo images. After finishing the scenario, residents self‐rated their overall learning experience and how well the scenario evaluated their ability to interpret endovaginal US images. Faculty members reviewed video recordings of the other institution’s residents and rated their own ability to evaluate residents’ skills in interpreting endovaginal US images and diagnosing and managing the case scenario. Visual analog scales (VAS) were used for the self‐ratings. Results: Compared to the residents assigned to the standard simulation scenario, residents assigned to the hybrid model reported an increase in their overall educational experience (Δ VAS = 10, 95% confidence interval [CI] = 4 to 18) and felt the hybrid model was a better measure of their ability to interpret endovaginal US images (Δ VAS = 17, 95% CI = 7 to 28). Faculty members found the hybrid model to be better than the standard simulation for evaluating residents’ skills in interpreting endovaginal US images (Δ VAS = 13, 95% CI = 6 to 20) and diagnosing and managing the case (Δ VAS = 10, 95% CI = 2 to 18). Time to reach a diagnosis was similar in both groups (p = 0.053). Conclusions: Use of a hybrid simulation model combining a high‐fidelity simulation with an endovaginal US task trainer improved residents’ educational experience and improved faculty’s ability to evaluate residents’ endovaginal US and clinical skills. This novel hybrid tool should be considered for future education and evaluation of EM residents.