Comparison of single versus multiple dose regimens for the human chorionic gonadotropin stimulatory test.

PURPOSE: Human chorionic gonadotropin (HCG) has a stimulatory effect on testicular steroidogenesis and has been widely used for evaluating male Leydig cell function. However, considerable variability exists in the protocols for HCG stimulation tests. In the most commonly used protocols HCG is administered daily for several days. We examine the circulating androgen response after 1 and 3-dose HCG regimens. MATERIALS AND METHODS: We evaluated 77 prepubertal boys diagnosed with hypospadias, cryptorchidism or micropenis. In 60 boys who underwent 1 dose of 100 IU/kg. or 5,000 IU/1.7 m.(2) HCG serum testosterone and dihydrotestosterone were sampled at 72 (28) and 96 (32) hours after injection, while in 17 who underwent 3 daily age adjusted doses hormone levels were determined on day 4. All blood specimens were obtained and injections were performed at 8:00 to 9:00 a.m. and all specimens were evaluated at the same endocrine reference laboratory. RESULTS: Nonstimulated testosterone levels were prepubertal in all groups. In the 1-dose groups post-stimulation testosterone was elevated 22 to 29-fold from baseline after a weight based and 34 to 35-fold after a body surface area based dose. Testosterone increased 20-fold baseline in the multi-dose group. No significant differences were observed in 72 versus 96-hour hormone levels. CONCLUSIONS: Evaluating Leydig cell function by HCG stimulation is an important adjunct to the diagnosis of various urological conditions. A single weight or body surface area based HCG dose with androgen measurement after 3 or 4 days is a practical, reliable and cost saving change in testicular evaluation.

Juvenile dermatomyositis: a retrospective review of a 30-year experience.

BACKGROUND: Children with juvenile dermatomyositis (JDMS) have variable initial presentations. OBJECTIVE: Our purpose was to evaluate the epidemiology trends, presenting clinical features, laboratory data, and outcome of patients with JDMS. METHODS: A total of 16 patients were identified at Geisinger Medical Center by a 30-year retrospective chart review. RESULTS: Sex ratio, age at diagnosis, and outcome were similar to data published in previous studies. However, certain trends were noted. The most common initial physical examination findings were an extremity rash (94%) and periungual erythema (75%). New associations of JDMS that were uncovered included the findings of pruritus (38%) and a psoriasiform scalp dermatitis (25%). Nonspecific laboratory elevations were the most common initial laboratory changes (erythrocyte sedimentation rate, lactate dehydrogenase, and aspartate aminotransferase). Tubuloreticular inclusions as found on electron microscopy of muscle biopsy specimens were present in all 3 patients tested. One patient with tubuloreticular inclusions had otherwise normal muscle biopsy findings on hematoxylin-and-eosin staining. Two of the 16 patients had cutaneous findings of JDMS but did not exhibit muscle involvement after long-term follow-up at 4 and 5 years. CONCLUSION: Our study confirms that the initial physical and laboratory findings in patients with JDMS may be nonspecific. The heliotrope rash and Gottron papules classically associated with dermatomyositis appeared less commonly than an extremity rash and periungual erythema. Creatinine kinase and aldolase levels may not be elevated on initial presentation. Pruritus, a psoriasiform scalp dermatitis, and tubuloreticular inclusions found on muscle biopsy electron microscopy should be additional factors to consider. The long-term follow-up in 2 patients without muscle involvement lends support to the existence of amyopathic dermatomyositis.

Leg ulcers [bibliography].

This report reflects the best data available at the time the report was prepared, but caution should be exercised in interpreting the data; the results of future studies may require alteration of the conclusions or recommendations set forth in this report.

Hyperreninemia and congenital mesoblastic nephroma: case report and review of the literature.

A 32-week estimated gestational age female infant had elevated systolic blood pressure at birth and a palpable left abdominal mass. Radiologic evaluation revealed a left upper pole renal mass. The renin level was significantly elevated. Left nephrectomy confirmed a diagnosis of congenital mesoblastic nephroma. The postoperative renin level normalized along with the blood pressure. Histologic analysis identified renin production from either the mesoblastic nephroma or secondarily from compression or ischemia. Mesoblastic nephroma should be considered as part of the differential diagnosis for hypertension in the young. The renin concentration and a renal ultrasound scan should be obtained as part of the evaluation.

Unenhanced helical computed tomography in the evaluation of acute flank pain.

Noncontrast helical computed tomography has rapidly replaced other imaging modalities in the evaluation of patients with acute flank pain. New studies from multiple centers have compared helical computed tomography directly with intravenous urography in large numbers of patients, confirming the value of the former. It is highly sensitive and specific for the diagnosis of ureterolithiasis, including the visualization of ureteral calculi and secondary signs of obstruction. It can evaluate alternate diagnoses, improving the utility of noncontrast helical computed tomography as a diagnostic tool in the evaluation of acute flank pain.

Time to stone passage for observed ureteral calculi: a guide for patient education.

PURPOSE: We analyze the natural history of stone passage in patients with ureterolithiasis, and define factors predictive of spontaneous passage. MATERIALS AND METHODS: A total of 75 patients with ureteral calculi were prospectively followed for stone passage. Clinical data included patient gender and age, stone size and location, pain medication requirements and interval to stone passage. Of the 75 patients 13 (17%) required intervention and 62 (83%) were followed until spontaneous stone passage. Stones requiring intervention were not included in the time to passage analysis. RESULTS: Of the 75 patients 41 (55%) had ureteral stones 2 mm. or smaller with an average time to stone passage of 8.2 days and only 2 (4.8%) required intervention, 18 (24%) had stones between 2 and 4 mm. with an average time to stone passage of 12.2 days and 3 (17%) required intervention, and 16 had stones 4 mm. or greater with an average time to stone passage of 22.1 days and 8 required intervention. For 95% of stones to pass it took 31 days for those 2 mm, or less, 40 days for those 2 to 4 mm. and 39 days for those 4 to 6 mm. Multivariate analysis revealed that size, location and side were statistically related to stone passage interval (p = 0.012). Stones that were smaller, more distal and on the right side were more likely to pass spontaneously and required fewer interventions. CONCLUSIONS: Interval to stone passage is highly variable and dependent on stone size, location and side. Degree of pain, and patient gender and age had no bearing on the time to stone passage. Of ureteral stones 95% 2 to 4 mm. pass spontaneously but passage may take as long as 40 days. Intervention may be required in 50% of ureteral calculi greater than 5 mm.

Facial orf.

Orf is an occupational dermatosis caused by a poxvirus that infects sheep or goats. Human transmission typically occurs in people in contact with the infected animals or by handling contaminated animal products such as wool or meat. The infection in humans is classically characterized by a solitary papule on the fingers or hands. Involvement of the face or head has rarely been reported. We report orf in a young woman with multiple nodules on the face.

Paget's disease of the male breast associated with intraductal carcinoma.

Paget's disease of the breast is a rare condition with an incidence of 3% to 5% of all mammary malignancies. Of all malignant breast cancer, 1% occurs in male patients, and thus, Paget's disease of the male breast is extremely rare. We present a case of intraductal carcinoma of the male breast presenting as Paget's disease.

Prospective comparison of unenhanced spiral computed tomography and intravenous urogram in the evaluation of acute flank pain.

OBJECTIVES: To prospectively compare the diagnostic ability of unenhanced spiral computed tomography (NCCT) and intravenous urogram (IVU) in the evaluation of adults with acute flank pain. METHODS: After giving informed consent, 106 adult patients with acute flank pain suspected of having urolithiasis underwent NCCT followed by IVU. Subsequent follow-up was scheduled within 72 hours in the Urology Clinic. Each NCCT was read by a single radiologist who was unaware of clinical history and IVU results. Each IVU was read by a different radiologist who was unaware of clinical history and NCCT results. Sensitivity, specificity, and positive and negative predictive values were determined for NCCT and IVU. RESULTS: The diagnosis of ureterolithiasis was defined as unequivocal evidence of urolithiasis on either NCCT or IVP. Seventy-five of 106 patients evaluated were diagnosed with ureterolithiasis. Clinical follow-up was available in 74 (98%) stone patients and in 31 (100%) of 31 non-stone patients. In 72 of the 75 patients diagnosed with ureteral calculi, the NCCT made the diagnosis. IVU made the diagnosis in 65 of the 75 patients. Of the 31 patients without ureterolithiasis, the NCCT was negative in all cases. IVU was negative in 29 of the 31 cases. Unenhanced spiral CT was 96% sensitive and 100% specific (P <0.001). IVU was 87% sensitive and 94% specific (P <0.001). Compared with IVU, using the log odds ratio and Fisher's exact test, NCCT was significantly better able to predict the presence of urolithiasis (P=0.015). CONCLUSIONS: NCCT accurately diagnoses ureterolithiasis in patients presenting with acute flank pain. NCCT is significantly better than IVU in determining the presence of urolithiasis.

Erosive adenomatosis of the nipple: a benign imitator of malignant breast disease.

We present the case of a 66-year-old white woman with erosive adenomatosis of the nipple, in which an initial diagnosis of Paget's disease was considered. Diagnosis of erosive adenomatosis of the nipple was made by the characteristic histologic findings on a biopsy specimen. This essentially benign condition is generally unilateral, with erythema, crusting, and hardening of the nipple. Histologic findings of erosive adenomatosis of the nipple eliminate the diagnosis of invasive carcinoma or Paget's disease, which can have clinical features similar to those of erosive adenomatosis of the nipple.

Ulcerative sarcoidosis. Case report and review of the literature.

BACKGROUND: Sarcoidosis is a chronic granulomatous multisystem disease of unknown origin. Cutaneous manifestations are common but ulcerative skin lesions rarely occur. We report a case of generalized ulcerative sarcoidosis in a patient with fatal multisystem involvement. A review of the literature revealed only 34 other cases of ulcerative sarcoidosis, 5 of which were generalized. We reviewed the clinicopathologic spectrum of the disease and available treatment options. OBSERVATIONS: Ulcerative sarcoidosis affects women (23 of 35 cases) and blacks (18 of 30 cases) most commonly and occurs in young adulthood. Cutaneous sarcoid lesions, including ulcers (11 of 26 cases), were the presenting complaint in 26 of 35 cases. Ulcers developed both de novo and within other sarcoid lesions. The lower extremities were most often involved (29 of 35 cases). A histological diagnosis was made using skin biopsy specimens in all cases. Corticosteroid therapy seems most effective for treatment of ulcerative sarcoidosis, with methotrexate a proven alternative for refractory cases. CONCLUSIONS: Dermatologists most often make the initial diagnosis of sarcoidosis in patients with ulcerative lesions. In the proper clinical setting, a skin biopsy of ulcerative lesions establishes the diagnosis and prompt treatment reduces morbidity.

Association of scabies with a bullous pemphigoid-like eruption.

We describe a patient with scabies who had an associated bullous pemphigoid-like eruption. Previous reports of this association have appeared in the literature. However, most case reports have described negative or nonspecific findings with direct immunofluorescence in contrast to the intense linear homogenous band of IgG and C3 found in our patient.

Penile squamous cell carcinoma arising from balanitis xerotica obliterans.

Squamous cell carcinoma arising from balanitis xerotica obliterans is rarely reported. We describe an 83-year-old man in whom metastatic penile squamous cell carcinoma developed after 18 years of observation for balanitis xerotica obliterans. It is important to recognize the possibility of this uncommon complication of balanitis xerotica obliterans, because survival of patients with squamous cell carcinoma depends on early diagnosis and treatment.

Essentials of pressure ulcer treatment. The diabetic experience.

BACKGROUND: Diabetes accounts for over half of the lower extremity amputations in the United States. However, ulcers of the diabetic foot can often be treated successfully and amputations avoided. OBJECTIVE: To review treatment of diabetic foot ulcers. RESULTS: Physicians must recognize the critical clinical and diagnostic features of ischemic and neuropathic ulcers. Therapy is directed towards vascular repair in the ischemic ulcer and relief of weight bearing through casting and shoes with molded insoles in the neuropathic ulcer. Sound principles of wound care apply to all ulcers. CONCLUSION: For successful preventive foot care patients and physicians need to understand how and why ulcers form and the rationale for the types of footwear and care necessary to prevent ulcers.