Epilation of hair-bearing urethral grafts using the neodymium:YAG surgical laser

Nonhair-bearing skin should be used when grafting is necessary during urethroplasty for stricture or hypospadias repair. Occasionally, this is not possible or hair-bearing skin is used inadvertently. Traditionally, electrocoagulation has been the method used for epilation when intraluminal hair has become a problem, such as interfering with flow, as a focus for recurrent urinary tract infection or acting as a nidus for calculus formation. Electrocautery also is performed during grafting in an attempt to prevent the growth of hair when hair-bearing skin is used. Unfortunately, due to lack of penetration the hair follicles are not destroyed and the epilating procedure fails or is only partially successful. The neodymium:YAG surgical laser can photocoagulate tissue to a depth up to 5.0 mm, and thus, has the ability to destroy hair follicles. We report 4 cases presenting with clinical problems directly related to hair-bearing urethral grafts successfully treated by neodymium:YAG laser epilation.     

Screening for type 2 diabetes mellitus in children and adolescents: attitudes, barriers, and practices among pediatric clinicians.

OBJECTIVE: The American Diabetes Association (ADA) recommends screening children at risk for type 2 diabetes with a fasting plasma glucose test or an oral glucose tolerance test. The purpose of this study was to describe attitudes, barriers, and practices related to type 2 diabetes screening in children among pediatric clinicians. METHODS: Pediatricians, nurse practitioners and physician assistants from a multispecialty, group practice in Eastern Massachusetts completed a mailed survey. To assess screening practice, three vignettes were presented representing pediatric patients with low, moderately high, and high risk for type 2 diabetes. The moderately high-risk and high-risk patients met ADA criteria for screening. ADA-consistent practice was defined as only screening the moderately high-risk and high-risk patients; lower-threshold practice was defined as also screening the low-risk patient; and higher threshold practice was screening only the high-risk patient. RESULTS: Sixty-two of 90 clinicians responded (69%). Based on intent to screen in the 3 vignettes, 21% of respondents reported ADA-consistent screening practice, 39% lower-threshold, and 35% higher-threshold screening practice. Five percent had incomplete or nonclassifiable responses. Many clinicians ordered screening tests other than those recommended by the ADA; few (< or =8% in any vignette) ordered only an ADA-recommended test. Preferences for nonfasting tests were influenced by nonmedical factors such as access to or cost of transportation. Inadequate patient education materials and unclear recommendations for appropriate screening methods were the most frequently reported moderate/strong barriers to screening. CONCLUSIONS: Most respondents reported type 2 diabetes screening practices that differed from current ADA recommendations. Our findings suggest that type 2 diabetes screening tests must be practical for clinicians and patients if they are to be used in pediatric practice. Further study of the benefits and cost-effectiveness of type 2 diabetes screening in children is warranted to clarify the role and optimal methods for screening in pediatric primary care.     

Branch retinal vein occlusion. A clinicopathologic case report

The eyes of a 72-year-old woman with a history of two branch retinal vein occlusions involving the left eye, were obtained postmortem and studied histopathologically. Prior to her death, she had been enrolled in the multicentered, prospective, randomized clinical trial on branch vein occlusion and treated with peripheral argon laser photocoagulation for disc neovascularization. Routine fluorescein angiograms and fundus photographs were available for clinical correlation. Despite photocoagulation, the patient had frequent recurrent episodes of vitreous hemorrhage. On histologic examination, both venous occlusions were found at arteriovenous crossings and associated with moderately sclerotic retinal arterioles. One occlusion was recanalized. Retinal inner ischemic atrophy was observed distal to the site of both venous occlusions and corresponded to areas of nonperfusion. Cystoid macular edema was not present. Three areas of neovascularization were found; one at the optic nerve head, one at the peripapillary retina, and one at the fovea. It is likely the patient's repeated vitreous hemorrhages were from one or all three areas of neovascularization demonstrated histopathologically.     

A comparison of cocaine, lidocaine with epinephrine, and oxymetazoline for prevention of epistaxis on nasotracheal intubation

The alpha-adrenergic agonist oxymetazoline was compared to cocaine and to lidocaine with epinephrine with respect to prevention of epistaxis on nasotracheal intubation. The nares of three groups of 14 patients each were topically pretreated with 4% lidocaine with 1:100,000 epinephrine (group 1), 10% cocaine (group 2), or 0.05% oxymetazoline (group 3) prior to nasotracheal intubation. After intubation, epistaxis was estimated on a scale of 0 to 3, with 0 indicating no bleeding, 1 representing blood on the nasotracheal tube only, 2 indicating blood pooling in the pharynx, and 3 representing blood in the pharynx sufficient to impede intubation. Only 29% of the patients in group 1 displayed no bleeding, whereas 57% of those in group 2 and 86% of those in group 3 had no bleeding. Nonparametric analysis showed a statistically significant difference (p less than 0.013) between oxymetazoline and lidocaine with epinephrine. In addition, heart rate (HR) and blood pressure (BP) were examined prior to administration of the medications; at 5 minutes, 10 minutes, and 15 minutes after administration of the medications; and after intubation. No significant differences were noted (p greater than 0.05) between the medications except for a slightly higher systolic BP for cocaine than for lidocaine with epinephrine at 15 minutes. The results of this double-blind, randomized trial demonstrate that the alpha-adrenergic agonist oxymetazoline is as effective as cocaine, and more effective than lidocaine with epinephrine, for the prevention of epistaxis associated with nasotracheal intubation.     

Use of vascular clips to approximate skin grafts

During excisions of acute burn wounds, attention to aesthetic detail often is secondary to the goal of rapid gross coverage. Expeditious approximation of adjacent skin grafts has long presented a problem to surgeons. Some surgeons simply place the grafts next to each other, relying on the intervening areas to "scar in". Others use staples to hold grafts together. These staples, however, can become buried under healed grafts and can cause "foreign body" reactions in the months and years ahead. In addition, staples cause bleeding beneath the newly placed grafts, contributing to hematoma formation. Still other surgeons suture or tape adjacent pieces of skin graft together, a tedious exercise. The cosmetic result of these techniques is often less than optimal resulting in the unfortunately familiar "patchwork quilt" appearance of grafts interweaved among scars. Vascular clips have proven to be useful for holding adjacent pieces of skin graft together.     

The effect of stimulus velocity on the response of movement sensitive neurons of the frog's retina

Summary 1. By means of metal-filled micropipettes the action potentials of 4 different classes of optic nerve fibers were recorded in Rana esculenta. The relationship between the angular velocity of the stimuli and the neuronal response was determined.2. If an object smaller than the excitatory receptive field (ERF) was moved through the receptive field of the different classes of retinal units the response depended on the angular velocity, contrast and size of the stimulus. The response was measured as the average impulses frequency (R) during the traverse of the ERF. Between R and the angular velocity (v) the equation R=k·v ^c [impulses · sec^–1] was found. The exponent c was 0.5 for class 1 neurons, 0.7 for class 2 neurons, and 0.95 for class 3 neurons. In class 4 neurons the response to large stimuli increased linearly with the increase of the angular velocity, while no systematic relationship between R and v was valid for small moving stimuli (<5°)3. If the contrast or the size of the stimuli was changed the exponent c was not changed; but k depended on both parameters and on the direction of the contrast against the background. The power function was no longer valid if stimuli considerably larger than the ERF were used. The exponent c was independent of the type of the movement (linear, non-linear, irregular movement); it was also independent of the direction of the motion.4. A model of the receptive field is demonstrated. In this model an RC-filter function within the bipolar cells is assumed. The bipolar cells with different filter function activate different classes of ganglion cells. Different time constants of the bandpass filter at the bipolar cell level are the main cause for the different exponents of the power function between angular velocity and neuronal response.     

Loss of heterozygosity mutations of tumor suppressor genes in cytologically atypical areas in chronic lymphocytic thyroiditis

The relationship between chronic lymphocytic thyroiditis (CLT) and papillary thyroid carcinoma (PTC) is a subject of controversy. Some investigators suggest a causal relationship, whereas others regard the two as only a coincidental occurrence. An additional complicating factor is the presence of atypical nuclei frequently found within lymphoid infiltrates in CLT, which resemble those in PTC. The finding of the RET-PTC translocations in CLT has been reported by two independent groups of investigators, suggesting that the areas of nuclear atypia in CLT are neoplastic rather than reactive. In the present study, we report additional molecular findings that support the hypothesis that the atypical nuclear changes in CLT may be preneoplastic or neoplastic. We microdissected small areas with atypical nuclei in glands with CLT and observed loss-of-heterozygosity mutations of tumor suppressor genes. These genetic mutations are evidence of clonal preneoplastic or neoplastic changes in the follicular cells of CLT. The clinical malignant potential of these minute foci is likely to be very small but remains to be determined.     

Microdissection genotyping of mixed glial and primitive neuroectodermal central nervous system neoplasm

A 22-year-old man with previous radiation treatment for childhood astrocytoma underwent resection of a right parietooccipital lesion. Histopathology revealed a malignant neoplasm with areas of astrocytic and primitive neuroectodermal components. To resolve the relationship and cellular origin, representative tissue was microdissected from several targets, obtaining a balanced mixture of each element. Nonneoplastic brain parenchyma was separately microdissected to determine polymorphic marker informativeness and to serve as an internal negative control. Despite the relatively small quantity of tissue removed for each microdissection target, sufficient material was available for reliable, balanced, polymerase chain reaction-format genotyping encompassing a panel of tumor suppressor genes and genetic loci associated with these forms of neoplasia. The findings revealed distinct discordant genotypic profiles for each of the neoplastic components. The efficacy of the approach used for molecular analysis of this complex neoplasm and the implication of the genotypic findings are discussed.