Correspondence.

(Letters to the Editor are welcomed. They may report new clinical or laboratory observations and new developments in medical care or may contain comments on recent contents of the Journal. They will be published, if found suitable, as space permits. Like other material submitted for publication, letters must be typewritten, double-spaced, and submitted in duplicate. They must not exceed two typewritten pages in length. No more than five references and one figure or table may be used. See "Information for Authors" for format of references, tables, and figures. Editing, possible abridgment, and acceptance remain the prerogative of the Editors.)

Behcet's Syndrome Coexisting With Clinically Occult Ankylosing Spondylitis

To the Edit or: Whether Behcet's syndrome (BS) is part of the seronegative spondyloarthropathy complex is a debated point; especially controversial is whether or not sacroiliitis and ankylosing spondylitis (AS) are more common in patients with BS. Some investigators have reported an increased prevalence of AS in patients with BS, but others have found a prevalence no different from that of the general population. We present a case with clinical manifestations of AS 16 years after the diagnosis of BS.

A 36-year-old man presented to our unit with an 18-month history of neck pain, low back pain, and decreasing range of motion of the spine. The pain and stiffness were more prominent in the early morning and were relieved by exercise. His medical history included BS, diagnosed 16 years previously at another facility. Subsequently, he had been treated with non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and cyclophosphamide. During the previous 16 years, he had episodes of disseminated oral ulceration, disseminated papulopustular skin lesions, genital ulceration, and uveitis. He had an episode of arthritis in his knee 6 years previously, which improved after systemic corticosteroid therapy. His family history was negative for seronegative arthritis, BS, or idiopathic recurrent aphthous stomatitis, but did reveal that he had a son with arthritis who bad tested positive for HLA-B27 antigen.

Physical examination showed severe restriction of movement in all directions of the cervical and lumbar spine. Modified Schober's test showed a distance of 1.5 cm, and the distance between the fingers and floor was 47 cm. Chest expansion was 2 cm. Results of complete blood count and routine biochemical evaluations were normal. Erythrocyte sedimentation rate was 64 mm/h (Westergren method) and C-reactive protein level was 21.3 mg/L. HLA typing revealed HLA-B5 and HLA-B27 antigens.

Cervical spine x-ray showed anterior syndesmophytic bridging in the lower cervical vertebrae and posterior ligamentous calcifications. Lower thoracic and lumbar spine assessment revealed syndesmophytes and bamboo spine. Periarticular sclerosis without narrowing of the sacroiliac joints was noted (Fig. 1). Computed tomography of the sacroiliac joints showed bilateral grade 3 sacroiliitis (Fig. 2).

Our patient met the diagnostic criteria for BS suggested by International Study Group for Behcet's Disease (1) and the New York criteria for AS. (2) He was positive for HLA-B5 antigen, which has been found to be associated with BS in Japanese, Turkish, and other Middle Eastern and Mediterranean populations.

The inclusion of BS among the seronegative spondyloarthropathies has long been debated. Dilsen et a1 (3) reported that, in their study of 331 Turkish patients with BS, 10% of patients had AS and 34% had sacroiliitis. Both HLA-B5 and HLA-B27 antigens were more frequent in patients with coexisting BS and AS. On the other hand, some investigators reported no association between BS and AS. Yazici et al (4) did not find an increased frequency of sacroiliitis among BS patients, and stated that reports of sacroiliitis in BS might reflect a chance association. Olivieri et al (5) suggested that the variation in the frequency of sacroiliitis reported in BS was a result of variations in criteria used for diagnosing BS before the development of International Study Group criteria and differences in the patient populations of the studies. They concluded that BS cannot be considered a spondyloarthropathy.

Our patient received follow-up for BS for years; he had an episode of arthritis, but did not show symptoms of AS until 15 years after the diagnosis of BS. His disease progressed functionally and radiographically, but only after he had been asymptomatic for many years. The AS may have remained asymptomatic because the NSAIDs, corticosteroids, and cytotoxic drugs which the patient had been receiving for BS masked the clinical features of spondyloarthropathy. This case may also be an example of the limited value of medical therapy in arresting the disease progression of AS.

Ozlem Bolgen Cimen, MD

Gunsah Sahin, MD

Ali Bicer, MD

Canan Erdogan, MD

Department of Physical Medicine and Rehabilitation 

University of Mersin

FTR Anabilim Dali

33070 Mersin, Turkey

References

(1.) International Study Group for Behcet's Disease: Criteria for diagnosis of Behcet's disease. Lancet 1990; 335:1078-1080

(2.) Russell AS: Ankylosing spondylitis: history. Rheumatology: Klippel JH, Dieppe PA (eds). London, Mosby, 1998, Vol 6, pp 14.1-15.6

(3.) Dilsen N, Konice M, Aral O: Why Behcet's disease should be accepted as a seronegative arthritis. Recent Advances in Behcet's Disease. Lehner T, Barnes CG (eds). London, Royal Society of Medicine Services, 1986, pp 281-284

(4.) Yazici H, Tuzlaci M, Yurdakul S: A controlled survey of sacroiliitis in Behcet's disease. Ann Rheum Dis 1981; 40:558-559

(5.) Olivieri I, Salvarani C, Cantini F: Is Behcet's disease part of spondyloarthritis complex? J Rheumalol 1997; 24:1870-1871

Rhabdomyolysis of Infectious and Noninfectious Causes

To the Editor: We read with interest the report of the study performed by Blanco et al. (1) The authors concluded that the most common cause of rhabdomyolysis in their population of hospitalized patients, after excluding patients with myocardial infarctions, cerebrovascular accidents, and recent history of trauma, surgery, immobilization, or intramuscular injections, was infection. Respiratory tract infections accounted for the majority of the cases of contagion-related rhabdomyolysis. The authors also reported the microorganisms that were identified; however, the infectious agents responsible for the patients' illnesses were identified in only 50% of their patients. In addition, the correlations between the site of infection and the microbacteria identified were not given. It was also not stated whether special studies were obtained in an attempt to identify the etiologic agents in their patients.

Bacterial and viral infections typically account for only 5% of rhabdomyolysis cases. (2) The high rate of infection-related rhabdomyolysis in the study by Blanco and colleagues may be due to a selection bias based upon their exclusion criteria and/or the influence of the demographic characteristics of their hospitalized patient population. Interestingly, there was a male predominance in their patients with infection-associated rhabdomyolysis. The average age of their patients with infection and rhabdomyolysis was 70.81 years. Renal failure necessitating dialysis occurred in 12.5% of this subset of patient, and the mortality rate was 37.5%.

In the United States, approximately 1 million cases of community-acquired pneumonia occur annually and account for 2.6% of hospital admissions. Rhabdomyolysis, however, is rarely identified with pneumonia. (3) When rhabdomyolysis does occur in association with pneumonia, the leading microbacterial causes are Legionella pneumophila and Streptococcus pneumonie. (4) An elevated serum creatinine kinase level in the setting of L pneumophila and pneumococcal pneumonia may serve as an early clinical marker for increased risk of morbidity and mortality in these patients. (4,5)

L pneumophila typically infects elderly patients with underlying pulmonary disease, and the mortality rate from progressive respiratory failure is 15%. Patients with this infection and rhabdomyolysis, however, are relatively young (49.3 years of age). Men account for 93% of the reported cases of rhabdomyolysis associated with L pneumophila pneumonia. Renal dysfunction occurs in 80% of these patients. The triad of L pneumophila pneumonia, rhabdomyolysis, and renal failure increases the mortality rate from this infection to 40%. (4)

Pneumoccocal pneumonia is also a disease of the older population. When rhabdomyolysis occurs with this pulmonary infection, however, the typical patient is a relatively young male (average age, 55.6 years). Renal dysfunction and bacteremia have been documented in 75% of patients who have rhabdomyolysis associated with pneumoccocal pneumonia. Thus, an elevated serum creatinine kinase level in the setting of S pneumoniae pneumonia may serve as an early indicator for bacteremia and impending renal failure. (5)

The lack of an identifiable cause of pneumonia in a number of the patients in the study by Blanco and colleagues suggests that viral agents may have been responsible for some of the lower respiratory infections in their study group. While a number of viruses are capable of causing rhabdomyolysis in humans, the significance of myofibril damage associated with viral infections of the lung has not been well described. For example, influenza A is a common infection afflicting numerous humans each year; however, there are few well-documented cases of rhabdomyolysis associated with influenza A pneumonia detailed in the literature. When these studies are pooled, the average age of the patients is 43.3 years, and a male predominance again is evident. (6) While the small number of patients with this combination of influenza A infectious complications makes firm conclusions difficult, the mortality rate does not appear to be increased.

Blanco et al confirm the observation that males are at greater risk of infection-related rhabdomyolysis than females. Whether this is due to the greater muscular mass of men compared with women or some other factor is not known. A close review of the literature concerning pneumonia-associated rhabdomyolysis, however, reveals that it is younger patients who are at greatest risk for infection-related myofibril injury. The conclusion by Blanco and colleagues that elderly patients are at greater risk may be due to the demographics of their hospitalized patients rather than an actual increased risk of rhabdomyolysis. We agree with the authors that early recognition and aggressive treatment with fluids and electrolytes may improve outcomes in patients with infection-related rhabdomyolysis. Further study is necessary to better define the incidence, pathogenesis, and prognostic connotations of infection-related rhabdomyolysis.

Ryland P. Byrd, Jr., MD Thomas M. Roy, MD

Division of Pulmonary Medicine and Critical Care

J.H. Quillen College of Medicine

East Tennessee State University 

Johnson City, TN 37614

References

(1.) Blanco JR, Zabalza M, Salcedo J, et al: Rhabdomyolysis of infectious and noninfectious causes. South Med J 2002; 95:542-544

(2.) Gabow PA, Kaehny WD, Kellcher SP: The spectrum of rhabdomyolysis. Medicine 1982; 61:141-152

(3.) National Center for Health Statistics: National Hospital Discharge Survey: Annual Summary, 1987. Hyattsville, Md, US Department of Health and Human Services, 1989. Vital and Health Statistics Publication, Series 13, No. 99

(4.) Byrd RP Jr, Roy TM: Rhabdomyolysis and bacterial pneumonia. Respir Med 1998; 92:358-364

(5.) Garcia MCC, Ebeo CT, Byrd RP Jr, et al: Rhabdomyolysis associated with pneumococcal pneumonia: an early clinical indicator of increased morbidity? Tenn Med 2002; 95:67-69

(6.) Morton SE, Mathai M, Byrd RP Jr, et al: Influenza A pneumonia with rhabdomyolysis. South Med J 2001; 94:67-69

Into the Future: Genetic Testing for Type 2 Diabetes Mellitus 

To the Editor: A little over a decade ago, an undertaking which will cause a shift in the paradigms of medicine began: the Human Genome Project, the work of an international consortium committed to sequencing the human genome. When completed, this information will have implications in all aspects of medicine, but especially in genetic testing and preventive medicine. People who could potentially be susceptible to diabetes mellitus seem to be excellent candidates for genetic testing, since diabetes affects a large number of people and because there is new evidence that the onset of type 2 diabetes can be delayed or even prevented by lifestyle modifications.

In the Finnish Diabetes Prevention Study, the incidence of type 2 diabetes in people with impaired glucose tolerance (IGT) was reduced by lifestyle changes, such as weight reduction, reduction of dietary fat and saturated fat intake, increase in dietary fiber intake, and daily exercise. (1) In a similar study, reduction in consumption of dietary fat reduced body weight and improved glucose tolerance. (2) Another possible method for preventing type 2 diabetes is through prophylactic treatment with medication. The Diabetes Prevention Program was designed to evaluate the effectiveness of metformin (an oral hypoglycemic agent) therapy versus lifestyle modification in reducing the incidence of type 2 diabetes in people with IGT. (3) This large trial, which included 3,234 participants, ended a year early, after showing that both metformin therapy and lifestyle modification can reduce the incidence of type 2 diabetes in people with IGT. (3)

Since the Human Genome Project is almost complete and there is evidence that type 2 diabetes can be prevented, let us assume that a genetic test will be developed that will predict with 95% probability if a person will develop type 2 diabetes in the absence of medical intervention (lifestyle modification or pharmacologic prevention). Is it in the best interest of the patient to be tested? At first thought, the answer would seem to be yes, since the disease can be prevented. But there are many possible consequences of genetic testing that need to be examined, particularly insurance/employment discrimination issues and possible psychologic harm.

Many people fear genetic discrimination, and this may influence their decisions regarding genetic testing. (4) In response to this fear, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 was passed by the federal government. (4) Under HIPAA, insurers are prevented from classifying people in group plans who have presymptomatic genetic diagnoses as having pre-existing conditions; however, HIPAA does not prevent the insurer from requiring mandatory testing, disclosing genetic information to third parties, raising premiums, or setting caps, as long as everyone in the plan is treated equally. (4) In addition, employees are now protected from genetic discrimination under the Americans With Disabilities Act. (4) Although exceptions may occur, most patients should be able to avoid insurance or employment discrimination based upon genetic information, and thus should not necessarily let fear of discrimination be a deterrent in making decisions regarding genetic testing for type 2 diabetes predis position.

Another factor that should be considered is the psychologic implications of genetic testing. The psychologic detriments of genetic testing include anxiety, depression, or anger about the results, and fear of discrimination, despite legal safeguards. (4) It has been shown that results of genetic tests can cause people to develop fatalistic outlooks, which can result in their decreased motivation to change behavior and avoid risks. (5)

Completion of the Human Genome Project will add valuable tools for public health and preventive medicine practitioners, including a genetic test for type 2 diabetes mellitus predisposition. Because it will be in the best interest of patients at risk to be tested, physicians should act as both advocates and educators. It will be important for physicians to discuss with patients the clinical benefits of knowing, based upon current evidence, that type 2 diabetes can be prevented with lifestyle modification and, possibly, medication. Physicians should educate patients and their families about ways to prevent type 2 diabetes, in order to decrease the risk that patients will have fatalistic outlooks if genetic test results are positive. It will also be important to let patients know that, despite public fears of genetic discrimination, there are federal laws to protect their privacy. It may be necessary for physicians to act on patients' behalf by expressing to state and federal lawmakers that better regulations a re needed in order to guarantee the total confidentiality of genetic information so that patients feel reassured that their genetic information is private, allowing them to benefit from new technology without worry.

Matthew B. Totten, BS

Debra L. Simmons, MD

University of Arkansas for Medical Sciences 

4300 W Seventh St, 111J-LR, Little Rock, AR 72205

References

(1.) Tataranni PA: Changing habits to delay diabetes. N Engl J Med 2001; 344:1390-1392

(2.) Mayer-Davis EJ: Low-fat diets for diabetes prevention. Diabetes Care 2001; 24:613-614

(3.) Diabetes Prevention Program Research Group: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346:393-403

(4.) White MT, Callif-Delay F, Donnelly J: Genetic testing for disease susceptibility: social, ethical, and legal issues for family physicians. Am Fam Physician 1999; 60:748, 750, 755, 757, 758

(5.) Senior V, Marteau TM, Peters TJ: Will genetic testing for predisposition for disease result in fatalism? a qualitative study of parents' responses to neonatal screening for familial hypercholesterolaemia. Soc Sci Med 1999; 48:1857-1860

An Unusual Progression of Untreated Osteosarcoma 

To the Editor: Osteosarcoma classically presents in early adolescence, with the highest incidence being in people between the ages of 10 and 30 years. (1) The tumor is most often located at the metaphyseal area of a long bone. Patients usually present with moderate pain and a hard, fixed, gradually enlarging mass, followed within 12 to 18 months by pulmonary metastases. Death from progressive, disseminated disease usually ensues within 18 to 24 months after the onset of symptoms. (2) The overlying skin is stretched and shiny, edematous, or may show erythema and dilated vessels. We describe an unusual case of osteosarcoma presenting with an ulceroproliferative lesion at the biopsy site and pulmonary metastases. The case is being reported due to its unusually advanced presentation in the era of chemotherapy and limb conservation.

A 17-year-old adolescent presented with a 9-month history of gradually progressive swelling in the right leg, with pain and difficulty walking for 2 months. Examination revealed a bony, hard swelling measuring 8 x 6 cm, just below the right knee. There was no sensory or motor weakness. Anteroposterior and lateral radiographs of the right leg showed irregular destruction of the tibia involving the cortex, with sunray spicules and periosteal elevation suggestive of osteosarcoma. The patient underwent an open bone biopsy, and the histopathologic examination showed osteogenic sarcoma. The biopsy wound healed well. Initiation of chemotherapy was planned, to be followed by limb-conservation surgery. After receiving the first cycle of ifosfamide, adriamycin, and cisplatinum (IAP) chemotherapy, however, the patient absconded.

Four months later, the patient presented with an ulceroproliferative growth over the biopsy site, measuring 18 x 15 cm, which had grown rapidly over the preceding 15 days. The swelling bled on touch, and there was a foul odor and necrotic debris due to secondary infection. Multiple large inguinal lymph nodes were palpable. Anteroposterior and lateral radiographs of the right leg were repeated and showed a large soft tissue mass extending above the knee joint and filling the popliteal region and calf. The swelling extended anteriorly, and another nodular mass was seen to be superimposed upon it. The underlying upper half of the tibia (the diaphysis, metaphysis, and epiphysis) showed irregular destruction involving the medullary region as well as the cortex. Sunray spicules, soft tissue opacification, and both continued and interrupted periosteal reaction (Codman's triangle) were present. Chest radiography showed volume loss in the right hemithorax, with multiple opacities and pleural effusion. The patient was in severe agony. Intercostal drainage of the pleural effusion was carried out, followed by a mid-thigh amputation with inguinal node dissection, with third generation cephalosporin antiobiotic coverage. The postoperative period was uneventful; the patient was mobilized on crutches on the tenth postoperative day and chemotherapy was restarted. Follow-up 8 months later found the patient alive with stable metastatic disease.

The natural history of osteosarcoma is very aggressive, with rapid hematogenous metastatic spread and death within 18 to 24 months in untreated patients. (2) Cutaneous metastases, although rare, have been described in osteogenic sarcoma. (3-5) To our knowledge, fungation of the primary tumor through overlying skin has not been described previously. Since the majority of these patients present with painful swelling, they get early medical care, whereby the tumor is diagnosed and treated, arresting or modifying the natural course of the disease. Our patient absconded because he could not afford the cost of chemotherapy and subsequent limb-conservation surgery, only to return 4 months later with a huge, ulcerated lesion, inguinal lymphadenopathy, and pulmonary metastases.

Manoj Pandey, MS

Paul Sebastian, MS

M. Iqbal Ahamed, MS

Department of Surgical Oncology

Anitha Francis, MD

Elizabeth K. Abraham, MD

Department of Pathology

K. Ramachandran, MD

Department of Radiodiagnosis

Krishnan M. Nair, FRCR 

Department of Radiotherapy

Regional Cancer Centre 

Medical College PO

Thiruvananthapuram

Kerala 695 011, India

References

(1.) Campanacci M: Bone and Soft Tissue Tumors. New York, Springer-Verlag, 1990, pp 455-505

(2.) Enneking WF (ed): Musculoskeletal Tumours. Vol 2. Edinburgh, Churchill Livingstone, 1983, pp 1021-1123

(3.) Setoyama M, Kanda A, Kanazaki T: Cutaneous metastasis of an osteosarcoma: a case report. Am J Dermatol 1996; 18:629632

(4.) Finnerud CW: Ossifying sarcomas of the skin metastatic from ossifying sarcoma of the humerus. Arch Dermatol 1924; 10:56-62

(5.) Myhand RC, Hugh PH, Coldwell JB, et al: Osteogenic sarcoma with skin metastasis. J Am Acad Dermatol 1995; 32:803-805

Symptom Improvement in Patients With Onychomycosis Receiving Oral Antifungal Therapy *

To the Editor: Onychomycosis is a common infection of the nail, and the effect of the condition on quality of life often drives patients to seek treatment.

Approximately 40% to 50% of patients with onychomycosis have pain. (1,2) Many have other symptoms, such as discomfort; ingrown nails; nail thickening, splitting, roughening, or discoloration; or secondary bacterial infections. According to physician reports in an observational study, 54% of patients seeking medical attention for onychomycosis have toenail pressure or discomfort, and more than one third experience painful ambulation. (3) Other reasons for seeking treatment include embarrassment over nail appearance, limitation of ability to wear shoes comfortably, reduced work-related performance, and limitation of physical activities.

Patients also report a connection between symptoms and the seeking of medical treatment. Among patients seeking treatment, 85% reported symptoms of nail dystrophy, including thickening, deformity, or disfigurement of their toenails. (4) In this study, 62% of patients receiving oral therapy had pain or soreness under or around the toenails at baseline. Other common complaints included nail thickening (82%), toenail splitting (68%), and toenail deformity (80%).

Despite obvious symptoms, possible complications, and psychosocial impact, onychomycosis is frequently regarded by some clinicians as a cosmetic problem not requiring medical attention. The purpose of this observational study was to evaluate the patients' perceptions of the symptoms associated with onychomycosis, and the change in these symptoms in response to alternative therapeutic approaches. Patient assessment data are presented on the frequency and bothersomeness of onychomycosis symptoms and the degree of symptom improvement that occurred with an oral versus nonoral therapeutic approach.

Details of the methods used in this multisite, longitudinal study have been reported previously. (3) Patients received either oral therapy (defined as any regimen that included an oral anitfungal agent) or nonoral therapy (defined as treatment with topical medication and/or debridement, not supplemented by an oral antifungal agent). Patients received standard nail care with the treatment chosen by the attending physician. Patients were surveyed at enrollment (baseline) and 4 and 9 months later, and asked to assess the frequency and annoyance of onychomycosis symptoms. The specific symptoms assessed were toe/toenail pain and soreness, and aspects of nail appearance, including thickening, splitting, discoloration, and deformity. Patient data at 9 months were compared with the baseline data using the McNemar test. Statistical comparisons between oral and nonoral treatment groups were made using the Student l test.

Ninety-three patients completed and returned the questionnaires. The mean age of the patients was 60 years (range, 19 to 88 years). All patients had a clinical diagnosis of onychomycosis requiring initiation of treatment at the baseline visit. Figure 1 illustrates the percentage of patients reporting toenail symptoms for both oral and nonoral therapy, at baseline and at 9 months. At baseline, both groups showed a high frequency of symptoms. Over the 9-month period, however, the oral-therapy group showed a significant improvement in all symptoms. In contrast, the group receiving nonoral therapy did not show a significant improvement in any of the symptoms from baseline to 9 months. In fact, 2 of the symptoms--pain and soreness--actually worsened over this time period in the group receiving nonoral therapy.

Figures 2 and 3 present the average change in patients' perceptions of the frequency and bother of nail symptoms at 9 months after initiation of treatment. At 9 months, patients from both groups reported some improvement for most categories of symptom frequency and annoyance, including all symptoms related to nail appearance. Patients treated with oral antifungal agents reported improvement in all symptom categories at 9 months, with the greatest effects seen for symptoms related to nail appearance. In contrast, patients treated with nonoral therapies reported no change in the frequency of soreness and a worsening of their pain condition at 9 months. Comparing the extent of change reported in the 2 groups for each symptom, the oral-therapy group almost always had significantly greater improvement than the group receiving nonoral therapy. For symptom categories related to nail appearance, patients receiving oral therapy reported 2.5 to 11.2 times greater improvement. The only exception was frequency of nail s plitting, in which the difference between treatment groups was not significant.

The majority (73%) of patients receiving oral agents were given terbinafine; others received itraconazole or fluconazole. Podiatrists were much more likely to use non-oral treatments, especially debridement, than dermatologists, who strongly favored oral antifungal drugs. (3) Patients reported greater satisfaction with overall toenail appearance after oral therapy.

These results suggest that onychomycosis is much more than a cosmetic issue; it can have substantial physical and psychosocial effects on a person's health and quality of life. Toenail pain and deformity can affect the ability to function on one's feet, whether at work or play. In this study, improvement at 9 months was significantly greater for most symptoms in patients treated with oral antifungal therapy than in those treated with nonoral therapy. Thus, effective treatment of onychomycosis with oral antifungal agents can produce greater symptom improvement and patient satisfaction over time.

Jeffrey Galitz, MD, DPM Podicare Management Services Doctors' Hospital Medical Center 210 S Federal Highway, No. 401 Hollywood, FL 33020

Jeffrey R. Schein, DrPH, MPH JosephJ. Doyle, RPh, MBA 

Novartis Pharmaceuticals Corp One Health Plaza East Hanover, NJ 07936

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

FIGURE 1

Percent of patients receiving oral therapy (A) and nonoral therapy (B)
reporting toenail symptoms at baseline and at 9-month follow-up.

                        Baseline   9 Months

Oral Therapy (N=34)

Pain                       62 *       38
Soreness                   62 **      32
Thickening                 82 ***     47
Splitting                  65 *       38
Discoloration              94 ***     62
Deformity                  82 ***     50

Nonoral Therapy (N=59)

Pain                       53         60
Soreness                   56         58
Thickening                 75         70
Splitting                  60         49
Discoloration              85         80
Deformity                  76         68

P value between vs 9-month follow-up calculated using McNemar test.

* P<.05

* P<.05

* P<.05

Note: Table made from bar graph

* Supported by an unrestricted educational grant from Novartis Pharmaceuticals Corp, East Hanover, NJ.

References

(1.) Drake LA, Scher RK, Smith EB, et al: Effect of onychomycosis on quality of life. J Am Acad Dermatol 1998; 38:702-704

(2.) Elewski BE: The effect of toenail onychomycosis on patient quality of life. Int J Dermatol 1997; 36:754-756

(3.) Schein JR, Gause D, Stier DM, et al: Onychomycosis: baseline results of an observational study. J Am Podiatr Med Assoc 1997; 87:512-519

(4.) Rich P, Schein JR, Lubeck D: Onychomycosis: symptoms and quality of life associated with this medical condition (Abstract). Presented at meeting of the American Academy of Dermatology, Chicago, Ill, July 31-August 4, 1998