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By: N. Cole, M.B.A., M.B.B.S., M.H.S.
Vice Chair, Midwestern University Arizona College of Osteopathic Medicine
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Bioaccumulation of heavy metals in thionic fluvisols by a marine polycheate: the role of metal studies. The abundance of some elements in hair and nail from the Machakos District of Kenya. A study of the distribution of lead, cadmium and copper between water and kaolin, bemtonite and a river sediment. Comparison of groundwater and surface water for patterns and levels of contamination by toxic substances. Copper neurotoxicity is dependent on dopamine mediated copper uptake and one-electron reduction of aminochrome in a rat substantia nigra neuronal cell line. The effect of copper on (H)-tryptophan metabolism in organ cultures of rat pineal glands. Bioavailability of metals and arsenic to small mammals at a mining waste-contaminated wetland. Food chain analysis of exposures and risks to wildlife at metals-contaminated wetland. Iron, copper and zinc status in rats fed on diets containing various concentrations of tin. Mineral content of foods and total diets: the selected minerals in foods survery, 1982-1984. Copper transport from ceruloplasmin: Characterization of the cellular uptake mechanism. Vomitting and diarrhea are the most common symptoms in children who drink water with high levels of copper. Copper in drinking water: not a strong risk factor for diarrhoea among young children. Growth modulating plasma tripeptide may function by facilitating copper uptake into cells. Selenium and copper in vegetables and fruits grown on long-term impacted soils from Valparaiso region, Chile. Cadmium, copper and lead in soils and garden produce near a metal smelter at Flin Flon, Manitoba. In vitro study of percutaneous absorption, cutaneous bioavailability and bioequivalence of zinc and copper from five topical formulations. Gastrointestinal effects associated with soluble and insoluble copper in drinking water. Bioavailability of heavy metals in terrestrial and aquatic systems: A quantitative approach. Zinc administration restores the impaired immune response observed in mice receiving excess copper by oral route. Trace element reference values in tissues from inhabitants of the European community. Review of trace elements in blood, serum and urine and critical evaluation of reference values for the Danish population.
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A urine and serum the dermis with a lymphocytic infiltrate reporting a rare complication of a black protein electrophoresis was also obtained. The repeat biopsy demonstrated a super this case, the lymphocytic infiltrate was ficial and deep, mixed lymphoid infil plasma-cell predominant. This is known Case Report trate with numerous mature plasma cells, to occur especially in the early develop an increased number of eosinophils, and mental stage of morphea. Immunohistochemical on our patient suggested the progression clinic for evaluation of a rash involving his staining demonstrated a kappa/lambda to a later-stage morphea, with hyalinized right upper extremity. It was described as a light-chain ratio of 2:1, consistent with a collagen bundles and a paucity or decrease warm, itchy and tender rash that had been reactive plasma-cell infiltrate. His and serum protein electrophoresis revealed tion, there is a marked decrease in cellular past medical history was notable for diabe no monoclonal gammopathy or light ity, especially when compared to the first tes, hypertension and hyperlipidemia. This progression is noted by com denied any significant history of alcohol, was interpreted as morphea arising within paring the early biopsy in Figure 2 to the tobacco or drug use. Unfortunately, lowing medications: pravastatin, metfor interpreted as an exuberant inflammatory the biopsy did not include the subcuticu min, glipizide, lisinopril, insulin detemir, response to the tattoo pigment. He had no tion of symptoms within his tattoo, we adverse reactions and complications being adverse reactions to the initial tattoo place speculate his findings were secondary to reported in the literature. These include ment and one year later had a second tat an inflammatory reaction to the pigment, infections, granulomatous reactions, aller too placed just proximal to it. Ours is an inter with a firm sclerodermoid patch on his to which he failed to respond. Laser tat esting case of a morpheaform reaction right upper extremity within a black-ink too removal at the present time would not arising in a tattoo, mimicking a cutaneous tattoo (Figure 1). A trial of dapsone was given for its anti-inflammatory effect, and thus far, the patient has had mild improvement in his plaque. High power showing a dense plasma cell infiltrate in biopsy obtained from indurated tous reaction to tattoos. Low power showing a dense plasma cell infiltrate in biopsy obtained from indurated plaque involving dark pigmented tattoo. Demonstration of Tattoo pigment in the Dermis with surrounding inflammatory cells. Demonstration of Tattoo pigment indurated plaque involving dark pigmented in the Dermis with surrounding inflammatory tattoo. Dermatoscopy may aid in the early diagnosis when features of dark brown or black asymmetrically pigmented follicular openings, slate-gray dots/granules (dermatoscopic regression), streaks, and rhomboidal structures are identifed. Case Report the differential diagnoses in this case included malignant melanoma in situ (len A 56-year-old white male presented tigo maligna) or a solar lentigo. Derma with a brown, irregular lesion on his right toscopically, the lesion had the malignant cheek. Clinically the lesion was a flat, ill features of asymmetric, pigmented fol defined, light and dark brown macule licular openings, focal gray-brown dots, approximately 9 mm in diameter (Figures and blue-gray pigmentation.
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Providers who wrote significant numbers of prescriptions filled by the pilot pharmacies and located within geographic proximity to each of the pilot pharmacies were identified. Then, the pharmacists made follow-up phone calls to the provider offices to establish a personal connection. Originally, the pharmacists were planning to visit the providers in person, but schedules and workflow made this not feasible. As a result of the outreach efforts, written contact was made with 54 provider offices. In some cases the pharmacists were not able to make contact with the provider offices after repeated phone calls. Based on the number of completed calls and the number of providers in each practice, the indirect impact was with 103 physicians, 17 physician assistants, 15 nurse practitioners, six nurses and 112 other office personnel. Reasons that practices did not want to be on the referral list included the following: not carrying the vaccine; working in a closed system that does not accept outside patients; working with a different chain pharmacy and having their patients come back directly for the second and third doses. Ten of seventeen provider offices that responded to the question said they would be willing to refer patients to the pharmacy. Reasons for not being willing to refer patients to the pharmacy include the following: they are doing just fine with having their patients complete the series; the pharmacy is too far away; they use nursing visits so patients just stop by and they prefer to administer the follow-up doses in their own office. Unfortunately, not all of the interactions with the provider offices were pleasant. Some offices were unreceptive to the calls and would not allow the pharmacist to speak to anyone beyond the receptionist. Some offices were even offended by the phone calls and felt the pharmacists should not be asking them any questions about their immunization practices. An unexpected barrier was actually being able to get past the receptionist or office manager in the physician practices to speak with other providers about partnership for this project. Since an introductory letter was sent first and then the pharmacists followed up with a phone call, the expectation was an enhanced ability to establish a relationship and partnership. Given the relatively short duration of the pilot project, it may not have been enough time to build the community connections. Perhaps the relationship development cycle for partnership is longer than anticipated and better relationships could have been established given more time. Other ideas for approaching this differently might be for the pharmacists to go to a local or state medical society meeting to introduce the concept of partnering on a larger level and then ask for partners and others to help disseminate the project to other members. Another strategy might be to have a pharmacist team up with a local industry representative who has an existing (and hopefully positive) relationship with the physician practices. Perhaps a joint effort could help start the conversation and get past that initial entry barrier. This possibility was discussed but was not executed during the pilot project due to time constraints. Pharmacists and pharmacy technicians involved in the pilot program received significant education since they would be providing direct patient care. A flyer was mailed to 2,550 pharmacist members notifying them about the new website resources.
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