Thrombosis at venous insertion sites after inferior vena caval filter placement

Color Doppler flow imaging or compression ultrasound (US) was used to prospectively determine frequency of thrombosis at 54 venous insertion sites (47 in common femoral veins, seven in right internal jugular veins) after percutaneous placement of Greenfield filters for interruption of the inferior vena cava. Fifty-one filters were successfully placed in 51 patients with a dilator set or a balloon angioplasty catheter. Nine focal thrombi were detected in the common femoral vein (19%) and one in the right internal jugular vein (14%). Use of dilators induced eight thrombi (24%), compared with two (10%) from balloon catheters. The left common femoral vein had a high frequency of thrombosis, regardless of dilation technique (five of nine). Of nine patients with acute common femoral vein thrombosis, four became symptomatic within 10 days after the procedure. Patients may remain asymptomatic or have delayed symptoms; thus, US is valuable for determining patients at risk of thrombosis of the common femoral vein.     

Does fetal acidosis develop with maternal glucose infusion during normal labor?

The actual effects of glucose infusion on fetal acid-base status were studied during 125 normal deliveries in which plasma glucose and acid-base parameters were determined after maternal infusion of either 10% glucose or Ringer's solution. After 80 minutes, mean (+/- SD) plasma glucose levels were significantly higher in the glucose group (N = 59) than in the Ringer's group (N = 66), both for the mother (183.6 +/- 46.8 versus 95.3 +/- 18.0 mg/dL) and the fetus (108.4 +/- 41.4 versus 64.8 +/- 16.2 mg/dL). Fetal plasma lactate concentrations did not differ between the glucose and the Ringer's groups, but were significantly lower in the fetuses delivered by elective cesarean section in both groups. With glucose administration, fetal pCO2 was higher and pH values were lower than in the Ringer's group. However, the magnitude of acid-base status changes, indicated by both pH and pCO2 shifts (ie, the difference between umbilical artery and scalp values), failed to differ between the two groups. In fetuses with progressing hypoxia, no differences in any of the acid-base parameters were observed between glucose and Ringer's administration. These data indicate that at a glucose infusion rate of 30 g/hour, fetal acidosis, when it occurs, results from hypoxia rather than from maternal glucose administration.     

Are there two biological parts in the second stage of labor?

In 228 patients, fetal blood pH, pCO2 and lactic acid were measured in two distinguishable parts of the second stage of labor. The 'first' part begins at full cervical dilatation and ends when the mother starts her first voluntary bearing down efforts. In our study, the fetal acid-base status did not change in this part, regardless of a late developing hypoxia. In contrast, higher levels of lactic acid and pCO2 and lower pH values were observed in the 'final' part of the second stage, indicating increasing acidosis. In this 'final' part, the fetuses with clinical signs of distress, as defined by an ominous Apgar score at birth, showed quicker and larger acid-base shifts than did the normal fetuses. Thus the two parts of the second stage of labor actually differ in their potential to stimulate fetal acidosis. Since such fetal acidosis may develop especially during the 'final' part of labor, we have concluded that special particular attention should be devoted to this part.     

Granuloma faciale

Granuloma faciale is characterized by indurated, red-brown papules and plaques that usually occur on the face. We present a 52-year-old man with typical clinical and histologic features of this condition. A review of treatment options is presented.     

A processive versus a distributive mechanism of action correlates with differences in ability of normal and xeroderma pigmentosum group A endonucleases to incise damaged nucleosomal DNA

A DNA endonuclease, isolated from the nuclei of normal human and xeroderma pigmentosum complementation group A (XPA) cells, which recognizes predominately pyrimidine dimers, was examined for the mechanism by which it locates sites of damage on UVC-irradiated DNA. In reaction mixtures with low ionic strengths (i.e. lacking KCl), the normal and XPA endonuclease locate sites of UV damage on both naked and reconstituted nucleosomal DNA by different mechanisms. On both of these substrates, the normal endonuclease acts by a processive mechanism, meaning that it binds non-specifically to DNA and scans the DNA for sites of damage, whereas the XPA endonuclease acts by a distributive one, meaning that it randomly locates sites of damage on DNA. However, while both the normal and XPA endonucleases can incise UVC irradiated naked DNA, they differ in ability to incise damaged nucleosomal DNA. The normal endonuclease showed increased activity on UVC treated nucleosomal DNA compared with naked DNA, whereas the XPA endonuclease showed decreased activity on the damaged nucleosomal substrate. Since a processive mechanism of action is sensitive to the ionic strength of the micro-environment, the KCl concentration of the reaction was increased. At 70 mM KCI, the normal endonuclease switched to a distributive mechanism of action and its ability to incise damaged nucleosomal DNA also decreased. These studies show that there is a correlation between the ability of these endonucleases to act by a processive mechanism and their ability to incise damaged nucleosomal DNA; the normal endonuclease, which acts processively, can incise damaged nucleosomal DNA, whereas the XPA endonuclease, which acts distributively, is defective in ability to incise this substrate.      

Palpable lymph nodes of the neck in Swedish schoolchildren

We studied 3592 Swedish schoolchildren, 8 or 9 years old, examined for palpable submandibular, cervical and supraclavicular lymph nodes. All children were skin tested with 2 TU PPD RT23 and with 0.1 μ g of Mycobacterium avium sensitin or 0.1 μ g of M. scrofulaceum sensitin. A total of 991 children had palpable lymph nodes in any of the three locations. Among them, 811 had lymph nodes in one location, 162 in two locations and 18 in three. In 312 children, the lymph nodes were ± 5 mm in size in any location. The most common location was submandibular. Boys had a significantly higher prevalence of palpable lymph nodes than girls. There was also seasonal variation. Children infected by atypical mycobacteria (sensitin reaction ±6 mm) did not have a higher prevalence of palpable lymph nodes than those not infected.     

Therapeutic decision making in the therapy of actinic keratoses

Actinic keratoses (AKs) represent the second most common reason to visit a dermatologist in the United States and their therapy has become a major portion of most dermatologists' practice. An ever-increasing array of therapeutic options exist for the therapy of actinic keratoses, offering physicians and patients a greater number of choices than ever before. Patient expectations and needs seem to be changing at the same time, thus effecting therapeutic decision-making. While destructive therapies with resultant wounds, time for wound healing, and possible hypopigmentation or scarring were acceptable in the past, many patients from the baby-boom generation are now developing AKs and have little tolerance for any time for wound healing or any cosmetic changes. This paper will raise some fundamental questions regarding AKs and their management.     

Studies using releasing factors in Klinefelter's Syndrome: The responses of LH and FSH to luteinizing hormone-releasing hormone and of prolactin and TSH to thyrotropin-releasing hormone before and after testosterone

(1) During an investigation of their pituitary function, the TSH prolactin (PRL) and gonadotropin, (LH, FSH) response to TRH was measured in four patients with documented euthyroid Klinefelter's syndrome. (2) In all four patients, the serum testosterone was low, the gonadotropins were elevated and thyroid antibodies undetectable. (3) The identical study was repeated after each patient had received intramuscular testosterone cypionate 200 mg bi-weekly for three doses. This raised the serum testosterone at least four-fold. (4) Basal TSH was normal in all four patients but its response to TRH was blunted (mean peak TSH 9.6 μU/ml), compared with normal controls (mean peak TSH 18 μU/ml). Following testosterone this response to TRH was further suppressed to a mean peak of 3.4 μU/ml TSH. (5) Basal PRL levels were also normal and the mean peak response to TRH, 28 ng/ml. When repeated after testosterone, TRH produced a mean peak PRL of 58 ng/ml. (6) LH and FSH, both elevated basally, did not change with TRH administration, but both were stimulated by LHRH 100 μg i.v., LH briskly, FSH more variably. (7) FSH was suppressed sharply but LH only partially with testosterone therapy. (8) Our studies indicate that the TSH response to TRH in Klinefelter's syndrome is blunted and further suppressed with short term testosterone replacement. The PRL response to TRH under these same circumstances, however, is enhanced. Previous reports of abnormal LH feedback control are confirmed. (9) Klinefelter's syndrome is associated with subtle abnormalities in hypothalamic pituitary regulation not expected in typical primary hypogonadism.