Therapy of nail mycoses

Onchomycosis is the most common nail disease, accounting for approximately 30% of all cutaneous fungal infections. The treatment approach needs to take into account the location and extent of onychomycosis, sensitivity of drug to fungal organism, adverse-effects profile, dosage schedule, duration of therapy, concomitant medical conditions, and concurrent medications. To confirm the diagnosis, it is important to correctly select the appropriate site for specimen collection used for both direct microscopy and fungal culture. Topical antifungal agents may be considered for the treatment of early onychomycosis, in the absence of nail matrix involvement. The newer generation of oral antifungal agents for the treatment of onychomycosis are terbinafine, itraconazole and fluconazole. These drugs used alone, or in combination with topical antifungals, are providing the basis for effective treatment of onychomycosis in a large proportion of patients.     

Surgical treatment of mycotic toenails

The authors present several options for the surgical treatment of painful and dystrophic mycotic toenails. The procedures include total and partial nail avulsion as well as chemical and excisional matrixectomies, both partial and total. Adjunctive treatment with topical and oral antifungal agents is also discussed.     

Oral treatment options for onychomycosis

The author discusses the new oral antifungal agents for the treatment of onychomycosis. The history, mechanisms of action, efficacies, dosing, safety profiles, and costs of itraconazole, terbinafine, and fluconazole are reviewed. The author emphasizes that use of these effective antifungals represents an important paradigm shift for podiatric physicians away from the palliative therapy of nail debridement to a potentially curative treatment.     

Superficial tinea infections

Dermatophytes commonly cause superficial dermatoses, especially in children, but these infections are frequently misdiagnosed as nonfungal disease. Superficial tinea infections can vary widely in appearance, ranging from a single, small, circular lesion with mild erythema and a scaling active border to multiple large areas of marked inflammation with vesicle formation. Therefore, laboratory tests, particularly the potassium hydroxide slide preparation, are often necessary to establish the diagnosis. The culture becomes particularly important if the smear is negative but a superficial dermatosis is strongly suspected. Tinea capitis is frequently diagnosed only by culture. Since many agents are available to treat superficial dermatoses, cost should be an important consideration in the selection of a topical antifungal agent. Oral agents are recommended for scalp and nail infections, as well as extensive body infections. Griseofulvin is the oral agent of choice because of its efficacy and low toxicity.     

Nail disorders. Diagnosis and treatment of infectious, inflammatory, and neoplastic nail conditions

Nail disorders are very common, and about 50% of all nail conditions are of fungal etiology. A proper diagnosis is essential because many nail conditions look alike. Diagnosis and treatment of other nail disorders, such as psoriasis, lichen planus, and neoplasms, are discussed.     

Locoregional anesthesia for injuries of the lower limbs

OBJECTIVE: To determine whether quantification of specific antifungal antibody responses in serum can provide supplemental information for the diagnosis of Aspergillus fumigatus infections and the monitoring of antifungal treatment in patients after lung transplantation. DESIGN: Retrospective study. SETTING: Center for lung transplantation, University Hospital Groningen, the Netherlands. PATIENTS: 4 patients with proven A. fumigatus infections after lung transplantation and fatal outcome. MEASUREMENTS: The IgG antibody response specific for A. fumigatus antigens was measured by enzyme-linked immunosorbent assay and was compared with radiographic features, cytologic findings, microbiological cultures, and clinical diagnosis. RESULTS: Increasing IgG antibody responses specific for A. fumigatus antigens closely paralleled cytologic or microbiological identification of A. fumigatus from bronchoalveolar lavage fluid and decrease of lung function. Increasing specific IgG antibody responses were found to precede radiographic identification of lung cavitation by 1 to 2 weeks, precede the diagnosis of aspergillosis by 2 to 20 weeks, and detect fungal reinfection. In most cases, successful antifungal treatment decreased specific IgG antibody response. A decrease in specific IgG antibody response correlated with the inability to culture or identify A. fumigatus in bronchoalveolar lavage fluid and with radiographic and clinical improvement. CONCLUSIONS: Specific IgG antibody responses in serum correlate with radiographic, cytologic, and microbiological findings and with the clinical diagnosis of A. fumigatus infections in patients who have had lung transplantation. Increased IgG antibody responses in serum may provide important information that is helpful in the diagnosis and early treatment of pulmonary fungal infections and in monitoring antifungal treatment.     

Endogenous fungal endophthalmitis

Endogenous fungal endophthalmitis has increased in the past half-century because of the advent of antibiotics and indwelling catheters. The disease process can produce highly suggestive, though nonpathognomonic, ocular signs that assist the clinician in reaching a diagnosis. Intraocular inflammation, especially if it is granulomatous in nature in a patient with one or more of the risk factors already discussed, should raise the suspicion of fungal endophthalmitis. If a diagnosis remains elusive, vitreous biopsy is indicated for proper identification of a fungal organism. Although a particular therapeutic regimen has not yet been prospectively established, compelling arguments can be made to treat nearly all patients with endogenous fungal endophthalmitis with a systemic antifungal such as amphotericin B or fluconazole. A possible exception includes an IVDA-related endophthalmitis in a patient with negative blood cultures and without other evidence of fungemia. Vitrectomy and intravitreal amphotericin B (with or without intravitreal corticosteroid) should be considered in cases of endogenous fungal endophthalmitis in which there is substantial vitreous involvement, and also in cases in which there is clear progression of disease despite initial therapy with an appropriate systemic antifungal agent. Prompt therapy following early diagnosis will help reduce significant visual loss in all forms of fungal endophthalmitis.     

Hyperthermic treatment of canine tibia through RF inductive heating of an intramedullary nail: a new experimental approach to hyperthermia for metastatic bone tumours

Although the incidence of metastatic bone tumours is recently increasing, the local control rate of conventional treatment modalities is not satisfactory. If an intramedullary nail for the fixation of a weakened bone with metastatic lesions can be used as a heat-generating material for hyperthermia, the treatment result is expected to improve. This new approach to hyperthermic treatment of bone tumours has been investigated in a canine tibia. An intramedullary nail made of stainless steel was put into a medullary canal of a canine tibia. The leg was exposed to an alternating magnetic field of 100 kHz in the frequency and 100 Oe in the maximum intensity. The nail was inductively heated for 60 min. The temperature of the nail > 50 degrees C and the cancellous bone 5 mm from the nail was heated to a therapeutic temperature, 42.5 degrees C. After a bone labelling with tetracycline and calcein, the dogs were killed 2, 4 and 12 weeks after the heating. The area of osteonecrosis was evaluated by fluorescence microscopy analysis. The heated cancellous bone around the nail showed osteonecrosis in 2 weeks after the treatment, but it recovered completely in 12 weeks. This experiment has demonstrated the heating capability of the new hyperthermic technique and minimal toxicity to the bone, and suggests the clinical application to metastatic bone tumours.     

Various possibilities for managing subtrochanteric fractures

Subtrochanteric fractures are highly unstable. For treatment, open reduction and internal fixation are the method of choice. The 95 degrees condylar plate is widely used for stabilization of these fractures. Alternative devices are the gamma nail and the recently developed intramedullar nail with a twisted plate which allows immediate postoperative weight bearing. The reported complications of the gamma nail restrict its general application, whereas preliminary reports of the intramedullar nail with the twisted plate are encouraging. Further clinical data are necessary before its general application can be recommended.     

Treatment of invasive aspergillosis: relation of early diagnosis and treatment to response

Aspergillus infections in patients with cancer are difficult to diagnose, and such diagnoses are frequently made at necropsy. Earlier therapy has been proposed to provide better response. We reviewed 17 consecutive patients with documented aspergillosis to determine the impact of earlier diagnosis and prompt treatment with amphotericin B. Sixteen had hematologic malignancies, and all had marked granulocytopenia. Six were diagnosed and treated within 96 h of the appearance of infiltrates. Three of these six had complete resolution of all signs and symptoms of aspergillus infection. The other three had a partial response to therapy despite continued granulocytopenia. All 11 patients in whom antifungal therapy was either delayed (six) or not given (five) for at least 2 weeks after the infiltrate was present diet with progressive aspergillosis aggressive diagnostic methods to establish the diagnosis of aspergillosis are warranted so that antifungal therapy can be started early, which may then be successful in resolving these potentially fatal infections.     

Response of segmental vitiligo to 0.05% clobetasol propionate cream

New antifungals for oral therapy have improved the chances of healing onychomycoses. Nevertheless, in daily practice the failure rate is 20-30% both with itraconazole and terbinafine. In our investigations for the fungicidal effects of terbinafine, we could show that the same strain of Trichophyton rubrum or T. mentagrophytes in the rest period needs 1000 times higher concentration of terbinafine (2.0 to 0.002 microgram/ml) for complete fungal killing as in the growth phase. Thus resting fungi in the nail are not harmed, and if the concentration of terbinafine is lower than the MIC for the fungi, they can cause a relapse. Itraconazole is a fungistatic agent. Its concentration in the nail plate must be higher than the MIC for the causative fungi for a long time-10 to 12 months. The usual short-term treatment of onychomycosis over 3 months can be insufficient in individual cases such as patients with disorders, e.g. circulatory disorders or slowed nail growth.     

Control of nuclear transcription of vitamin D-dependent genes by vitamin D

Contrary to the case with bacterial infections, progress in the diagnosis and treatment of invasive mycoses in cancer patients has been unsatisfactory. Amphotericin B deoxycholate has remained the drug of choice for severe invasive fungal infections for nearly 40 years. However, its infusion-related side effects, as well as its toxicity, may at times lead to dose reduction or early discontinuation of the treatment. The introduction of the new triazoles, fluconazole and itraconazole, has improved the therapeutic chances against several fungal infections; however, the need for a broad-spectrum drug in empiric antifungal therapy, the emergence of fluconazole-resistant Candida species, and the limitations of itraconazole in terms of speed action and erratic oral absorption represent important limitations. Recently, laboratory and clinical research has been directed at the development of new formulations of older classes of antifungals, the introduction of new classes of antifungals, and the use of immunomodulation associated with antifungal therapy. This paper reviews the more recent advances in the treatment of fungal infections in cancer patients.     

Analgesic effect of bupivacaine on extraperitoneal laparoscopic hernia repair

BACKGROUND: Occurrence of cryptococcal endophthalmitis is rare and commonly is associated with widespread disseminated diseases. The authors report here a well-documented case of endogenous cryptococcal endophthalmitis without the preceding meningeal infection. METHODS: A 45-year-old female with a history of long-term use of systemic corticosteroid and cytotoxic drugs for systemic lupus erythematosus suffered from progressive visual loss in her left eye over 1 month. Large exudative retinal detachment and severe vitreous infiltration were observed. RESULTS: Histopathologic study of the retinal biopsy specimen established the diagnosis of cryptococcal endophthalmitis. Subsequent positive histopathologic study of the aspiration vitreous smear and epiretinal membrane confirmed the recurrence and persistence of the disease over 4 months after the initial presentation. Systemic amphotericin B-fluconazole and two doses of intravitreous amphotericin B injection eliminated the infection successfully. CONCLUSION: The authors report here a well-documented case of cryptococcal endophthalmitis and present the serial clinical and histopathologic pictures. The importance of retinal biopsy in diagnosis and the combined form of antifungal treatment also are shown.     

Hearing loss. The physician's responsibility

Hearing loss is a very important and common problem in the United States, affecting 13 to 14 million people. It is primarily a medical problem, requiring diagnosis and, when indicated, treatment by a physician, preferably in collaboration with an audiologist. History taking is the most important part of the diagnostic process, followed by a physical examination with special attention to the head, neck, and ears. The primary object of the workup is to exclude all possible extrinsic causes of hearing loss. Intrinsic or genetic deafness is a diagnosis of exclusion. After the hearing loss has been classified as congenital or delayed and as genetic or nongenetic, a differential or working diagnosis can be made in all cases and a specific diagnosis in most cases. The hearing loss must then be identified as stable, progressive, or fluctuant over time. Follow-up at least every two years is important to check for possible changes in status.     

Behavior of Calculated Nail Head Strength in Soil-Nailed Structures

Nail head strength is one of the parameters used in design of soil-nailed structures. It determines the stability of the nailed structure against failure involving the facing element. The nail head strength is a function of a number of factors, primarily the material strengths, vertical and horizontal nail spacing, and the nail head connection details. The variations in nail head strength as a result of changes in the vertical and horizontal soil-nail spacing and material strength properties are examined in this paper. Both temporary and permanent facing design is considered. For equal vertical to horizontal spacing, the nominal nail head strength for a temporary facing decreases continuously as the spacing is increased. The nominal nail head strength for permanent facing decreases initially and then remains nearly constant. For a fixed vertical spacing (Sv) the nail head strength for temporary facing decreases linearly as the horizontal spacing (Sh) increases. For permanent facing the nail head strength decreases very slowly for vertical to horizontal nail spacing ratio between 0.8 and 1.0 and then declines rapidly. The nail head strength increases most rapidly with increase in facing thickness. Higher strength reinforcement and concrete have a relatively smaller influence in raising the nail head strength. Charts are presented that can help in optimizing the design of soil-nailed structures.     

Osteoporosis: pathogenesis, diagnosis, and treatment in older adults

Prevention of osteoporosis is a major health concern. Bone loss occurs throughout life in both women and men due to calcium deficiency, hormonal deficiency, and changes in bone formation. The diagnosis of osteoporosis can now be made prior to fragility fracture, allowing for prevention as well as treatment. Criteria for diagnosis of osteoporosis are reviewed, and a plan for the evaluation of secondary causes of osteoporosis is discussed. Also reviewed are prevention and treatment options such as exercise, calcium supplementation, hormone replacement, and new and investigational drugs.     

Diabetic foot ulcers: prevention, diagnosis and classification

Diabetic ulcers are the most common foot injuries leading to lower extremity amputation. Family physicians have a pivotal role in the prevention or early diagnosis of diabetic foot complications. Management of the diabetic foot requires a thorough knowledge of the major risk factors for amputation, frequent routine evaluation and meticulous preventive maintenance. The most common risk factors for ulcer formation include diabetic neuropathy, structural foot deformity and peripheral arterial occlusive disease. A careful physical examination, buttressed by monofilament testing for neuropathy and noninvasive testing for arterial insufficiency, can identify patients at risk for foot ulcers and appropriately classify patients who already have ulcers or other diabetic foot complications. Patient education regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation. Adherence to a systematic regimen of diagnosis and classification can improve communication between family physicians and diabetes subspecialists and facilitate appropriate treatment of complications. This team approach may ultimately lead to a reduction in lower extremity amputations related to diabetes.     

Use of an electric ear syringe in the emergency department

Verrucous carcinoma is a rare, highly keratinizing variant of squamous cell carcinoma of the skin or mucosae characterized by a local aggressiveness but a low potential for metastasis. The plantar form is also known as epithelioma cuniculatum. Fingers and toes are rarely affected, and tumors of the nail bed are exceptional. Clinically, the lesion presents like a wart and is then often misdiagnosed. Treatment of choice is wide surgical excision. A case of verrucous carcinoma of the nail apparatus is presented, and diagnosis is discussed.     

Managing patients with vulvovaginal candidiasis

Epidemiologic studies have demonstrated a continuing increase in the prevalence of vulvovaginal candidiasis. Although in the past most of these infections were caused by Candida albicans, an increasing percentage are caused by non-albicans Candida species that are less sensitive to the most frequently used antifungal agents. An accurate diagnosis of these infections and the subsequent choice of the most appropriate therapy can only be made after a thorough evaluation of the patient. Successful treatment of vulvovaginal candidiasis is dependent on compliance with therapy; thus, the treatment regimen chosen should fit the patient's daily lifestyle. Newer single-dose regimens offer the option of completing therapy with a single treatment for most patients with uncomplicated vaginal candidiasis. Use of topical agents avoids the potential systemic adverse effects and drug interactions that have been noted with oral antifungals. Patient education and support can also enhance satisfaction with the treatment plan and promote compliance.     

Candida albicans endophthalmitis in brown heroin addicts: response to early vitrectomy preceded and followed by antifungal therapy

The management of Candida albicans endophthalmitis in intravenous drug abusers (IVDAs) has yet to be established. Early vitrectomy was previously reported as a promising treatment for C. albicans endophthalmitis. In our series, C. albicans endophthalmitis was diagnosed for 15 IVDAs. Funduscopic examinations confirmed severe vitritis in 12 patients and chorioretinitis in three. Blood and vitreal cultures were positive for C. albicans for seven and eight patients, respectively. Patients with vitritis received antifungal therapy before and after vitrectomy. Amphotericin B or fluconazole therapy was given according to the physician's preference. Vitrectomy was defined as early if it was performed within 1 week after the diagnosis of vitritis. All seven patients who underwent early vitrectomy had a favorable response without complications. Two of three patients who underwent late vitrectomy developed blindness or scotoma. Blindness was also described in two patients with vitritis who did not undergo vitrectomy. Early vitrectomy preceded and followed by antifungal therapy seems to be appropriate management of vitritis in IVDAs.