STUDIES ON THE TREATMENT OF IDIOPATHIC GYNAECOMASTIA WITH PERCUTANEOUS DIHYDROTESTOSTERONE

We have studied clinical and endocrine parameters in a group (group A) of forth men referred to us because of persistent idiopathic gynaecomastia (of more than 18 months duration), before and during the administration of percutaneous dihydrotestosterone (DHT). The endocrine parameters (testosterone (T), 17 beta-oestradiol (E2), DHT, gonadotrophins (FSH and LH) and prolactin (PRL), were compared to those of control groups of 12 healthy men on DHT therapy (group B) and 10 on placebo (group C). Local administration of DHT was followed by the complete disappearance of gynaecomastia in 10 patients, partial regression in 19 and no change in 11 patients after 4 to 20 weeks of percutaneous DHT (125 mg twice daily). Before treatment the T + DHT/E2 ratio was significantly (P less than 0.001) lower in group A 244 +/- 21 (SEM) than in groups B and C (361 +/- 21) while T, DHT and E2 concentrations were all within the normal range. During DHT treatment plasma hormone levels were measured in 26 patients from group A: DHT levels increases significantly (day 0: 1.63 +/- 0.14 nmol/l; day 15: 12.8 +/- 1.6 nmol/l, P less than 0.001) while T and E2 levels fell significantly (T: day 0: 22.6 +/- 1.2 nmol/l; day 15: 11.0 +/- 1.5 nmol/l, P less than 0.001; E2: day 0: 110.5 +/- 7.12 pmol/l; day 15: 86.79 +/- 9.4 pmol/l, P less than 0.01). The T/E2 ratio decreased from 231 +/- 20 to 164 +/- 27 (P less than 0.05) while the T + DHT/E2 ratio increased significantly (P less than 0.02) to a normal mean value (day 15: 354 +/- 57).(ABSTRACT TRUNCATED AT 250 WORDS)     

Patient-management problems as a learning tool for the continuing medical education of general practitioners

The value of Patient-Management Problems (PMPs as a learning tool for continuing medical education was studied by using two frequently seen cardiovascular problems (angina and high blood pressure) and a province-wide sample of full-time general practitioners. The results indicate that PMPs can be a motivating and effective means of CME for the general practitioner; that knowledge was gained through the successive resolution of three pmps; that corrective feedback enhanced learning; and, that most of the knowledge gained on the paper cases was transferred to practice as reported by the participants on a questionnaire. Furthermore, while cueing may be a confounding factor when PMPs are used for evaluation purposes, it was shown to facilitate learning in the present learning context.     

Plasma lipids in kidney transplanted children and adolescents: influence of pubertal development, dietary intake and steroid therapy

Abstract. Plasma triglycerides and/or cholesterol were significantly increased in twenty-four of thirty kidney transplanted children and adolescents with stable renal function, at least one year after the last rejection crisis who received low dose prednisone therapy. The cholesterol increment was related to both low density and high density lipoproteins. However, similar to findings in adult allograft recipients, these increases were very variable: six subjects had normal levels, eight had increased triglycerides, five increased triglycerides and cholesterol, and eleven increased cholesterol. No influence of renal function was found in this series of patients all of whom had plasma creatinine below 160 μmol/1. Subjects who had achieved sexual development had lower cholesterol values. An insignificant difference was observed between patients receiving daily and alternate-day steroid therapy, but a significant negative correlation was found between plasma triglycerides and fractional urinary excretion of 17 OH corticosteroids in the first 6 h after an oral dose of prednisone. Finally, no correlation was found between energy intake and triglycerides; but a significant correlation was observed between protein intake and plasma cholesterol.
In conclusion, some patients show a high level of triglycerides and/or cholesterol after renal transplantation, possibly due to a different individual response to steroid therapy.     

Decreased ability of high density lipoproteins to transfer cholesterol esters in non-insulin-dependent diabetes mellitus

Abstract. Esterified cholesterol transfer (ECT) from high density lipoproteins (HDL) to very low (VLDL) and low density lipoproteins (LDL) may be abnormal in situations at high risk for atherosclerosis. It has been shown to increase in insulin-dependent diabetes and to decrease in non-insulin-dependent diabetes (NIDD). Since the net transfer of esterified cholesterol (EC) results from a bidirectional exchange between HDL and VLDL/LDL, we developed a transfer assay specifically designed to measure the unidirectional transfer of EC from HDL to lipid emulsions according to first-order kinetics. Our results show that in NIDD the rate constant of HDL-dependent ECT is decreased by 30% by comparison with control subjects. Analysis of HDL composition revealed that, in both groups, HDL-dependent ECT was positively correlated with the free cholesterol/phospholipid ratio (r = 0^.94; P < 0.001) and negatively correlated with the triglycer-ide/EC ratio (r=-0.85; P<0.001). It is concluded that, besides the known defect of acceptor lipoproteins, the abnormality of ECT in NIDD is also caused by a decreased ability of HDL to act as an EC donor, presumably because of a change in composition. In addition, our work shows that the amount of EC lost by HDL during the reaction transfer is counterbalanced by a reciprocal equimolar transfer of triglycer-ides.     

Acute allergic contact dermatitis due to para-phenylenediamine after temporary henna painting

The use of temporary natural henna painting for body adornment and hair dyeing is very common in several countries of the Indian subcontinent, Middle East, and North Africa, and the fad is spreading in other parts of the world. Several cases of para-phenylenediamine (PPD) contaminated, temporary traditional/natural henna induced sensitization and acute allergic reaction have been reported, along with occasional serious long term and rare fatal consequences. We report here a 17-year-old girl with blisters over her hands of five-days duration that appeared within 72 hours of applying a temporary henna paint to her hands during a social occasion. Similar lesions were noted on her face. She had previously applied black henna only once, a year earlier without developing any lesions. Clinical diagnosis of acute allergic contact dermatitis (ACD) was made. After a short course of oral corticosteroids, topical mometasone furaote 1.0% cream, and oral antihistamines, the lesions healed completely over the next four weeks leaving post-inflammatory hypopigmentation. Patch testing done with standard European battery, PPD 1% in petrolatum, and commercially available natural henna powder revealed a 3+ reaction to PPD at 48 hours. No reaction was seen at the natural henna site. Awareness of the condition among physicians and the public and regulation regarding warnings of the risks of using such products is urgently warranted.     

Hypertrophic lupus erythematosus treated successfully with acitretin as monotherapy

Hypertrophic lupus erythematosus (HLE) is a distinct and rare subset of chronic cutaneous lupus erythematosus characterized by verrucous lesions which are chronic in course and resistant to treatment (1). We describe the successful use of acitretin in a patient with HLE who had multiple hyperkeratotic verrucous plaques over the dorsa of his hands, feet, and legs and who failed to respond to local steroids and antimalarials.     

Serological diagnosis of bullous pemphigoid (BP): comparison of the sensitivity of indirect immunofluorescence on salt-split to immunoblotting

Specialized immunological assays are required for the accurate diagnosis of bullous dermatoses such as bullous pemphigoid (BP), epidermolysis bullosa acquisita and bullous lupus erythematosus. The aim of this study was to analyse and compare the sensitivity of indirect immunofluorescence (IF) on salt-split skin and immunoblotting for the detection of circulating autoantibodies in BP. Of the BP patients selected for the study, 74/79 (94%) had circulating autoantibodies detected by at least one of the two methods. Both methods had comparable sensitivity and detected BP-specific autoantibodies in 82-85% of the patients. Because 20% of the patients were found to be positive by only one of the methods, both methods should be used in the diagnosis of BP. Indirect IF on salt-split skin is easier to perform and is preferable in routine analysis, but Western blotting may be used as a complementary assay with sera showing no reactivity on salt-split skin.     

Involvement of macrophages in the pathology of toxic epidermal necrolysis

In toxic epidermal necrolysis (TEN), as in the 'epidermal type' of erythema multiforme, the necrotic epidermis is infiltrated with mononuclear cells. We studied the epidermal infiltrate in seven cases of TEN. About half the cells obtained from pieces of cleaved epidermis dissociated by trypsin were non-epithelial. On cytologic analysis, 80% of these foreign cells exhibited markers of macrophages, 15% were granulocytes and only 5% were lymphocytes (almost exclusively OKT8 T lymphocytes). Semi-thin sections of early prenecrotic lesions showed exocytosis of mononuclear cells within the epidermis with features of satellite cell necrosis and formation of colloid bodies. Almost all these mononuclear cells were macrophages as evidenced by endogenous peroxidase-positive granules. These findings suggest that some kind of macrophage-mediated cytotoxicity may play a role in the necrosis of epidermal cells during TEN.