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Background: Limitations in antiemetic options have resulted in increased use of intravenous promethazine. However, this drug has significant sedative effects with its standard dosage of 25 mg, especially when used in conjunction with narcotic analgesics. While studies have revealed the bioavailability of enteric promethazine to be 25%, current dosing references suggest identical dosing regardless of the route of administration. Objective: To compare the antiemetic efficacy and sedative effects of low-dose intravenous promethazine (6.25 or 12.5 mg) with intravenous ondansetron 4 mg. Methods: We assessed inpatients with noncritical conditions at Anne Arundel Medical Center who were treated for nausea or vomiting from any cause except chemotherapy or pregnancy. Forty-six patients received low-dose promethazine and 41 received ondansetron. Statistical analysis was carried out for significant differences in efficacy and sedation. Results: For patients who received intravenous promethazine 6.25 or 12.5 mg, nausea and vomiting were relieved at one hour in 74% and 68%, respectively, compared with 59% for intravenous ondansetron 4 mg. Results at 3 hours were 67% and 80% for promethazine and 71% for ondansetron. Median sedation scores at one hour were equal at 3 for promethazine and ondansetron (4 = fully awake); at 3 hours, the median scores were 4 and 3.5, respectively. There were no statistically significant differences among any of these results. Conclusions: Low-dose (6.25 mg) intravenous promethazine relieves nausea and vomiting as effectively as intravenous ondansetron 4 mg.

Objective: Our aim was to review the clinical behavior of human papillomavirus (HPV)-associated digital squamous cell carcinoma (SCC). Specifically, we examined evidence for the tumor's (1) infectious origin and spread, (2) response to therapy, and (3) prognosis and metastatic risk. Design: We reviewed and performed data tabulation of all 51 reported cases in the English-language literature and a case series of 23 cases (21 of them not previously reported). We present 2 of the cases in depth. Setting: We used previously reported cases from MEDLINE and a case series from a single dermatologic operation practice from 1985 to 1999. Results: (1) Of all cases, 10% (7/72) had an antecedent genital dysplasia or carcinoma containing the same HPV subtype as the digital SCC. (2) The rate of recurrence after general surgical therapy was 43% (6/14). After Mohs micrographic surgery the recurrence rate was 13% (2/16) for the cases in the literature, and 26% (6/23) for our case series. (3) Of tumors, 3% (2/72) have been observed to metastasize. Conclusions: (1) This suggests the possibility of genital-digital spread as a mechanism of tumor genesis. (2) HPV-associated digital SCC is more likely to recur after surgical treatment than previously reported. This rate of recurrence greatly exceeds that for cutaneous SCCs in general and may be caused by residual postsurgical HPV. (3) The rate of metastasis, however, appears to be low. (J Am Acad Dermatol 2003;48:385-93.)

We describe a patient in whom angiosarcoma developed at the site of a hemangioma that was treated during infancy with radiation for refractory thrombocytopenia. Our findings, along with those of the 10 reported cases from the world literature, are summarized. One third of angiosarcomas arise in the skin. They most often show one of three clinical patterns. First and most common is occurrence as a bruiselike lesion on the scalp or face of an elderly person. Second in frequency is the Stewart-Treves syndrome. Third and least common is angiosarcoma developing as a sequela of previous radiation therapy. The prognosis in general is poor, with a mean survival length of 24 months and a 5-year survival rate of 10%. Effective treatment relies on early diagnosis and wide-margin surgical excision.

Skin metastasis from solid tumors is uncommon. Several series have reported the frequency to be 0.7% to 9.0%.lm6 A recent large series reported an incidence of approximately lO%.7 This disparity is probably due to several factors. First, an autopsy commonly exposes greater numbers and sites of metastasis than the premortem examination. Second, reports with greater (or lesser) numbers of women may have differing results because breast cancer is common and is frequently associated with cutaneous metastases. Similarly, the tumor types included in the analysis alter the reported incidence of distant skin involvement. Melanoma, for example, commonly metastasizes to skin. The most frequent noncutaneous olid tumors implicated are tumors of breast, lung, and colon. Osteogenic sarcoma is the most common primary malignancy of bone in children and adolescents.* The mode of metastasis is mainly hematogenous; the most frequently involved organs are the lung and distant bone. Regional lymph node metastasis occurs in approximately 10% of patients.g Osteosarcoma with metastasis to skin is rare, and to our knowledge this phenomenon has been seldom reported. We describe a patient treated with radiation for Hodgkin’s disease in whom a right clavicular osteosarcoma with multiple skin metastases later developed.

Neuraminidase production has been found to vary among individual strains of type III group B streptococci (GBS). The production of neuraminidase has been shown to be affected by different environmental factors. In this study, oxygen concentration was found to influence the amount of enzyme produced. The effect of oxygen on enzyme production was examined in a highneuraminidase-producing strain and a low-neuraminidase-producing strain. With the batch culture technique, the following trend of neuraminidase production was observed: Maximum enzyme production occurred at oxygen concentrations of 5% and 10%, intermediate production occurred at 0%, and lowest production occurred at 15% and 20%. Continuous culture technique confirmed these findings at 5% and 15% oxygen concentrations. Since neuraminidase is believed to be a virulence factor in GBS syndrome in neonates, it is possible that maximum enzyme production may occur at oxygen levels similar to those found in neonatal blood.

Described is a safe and efficient technique for open reduction of the subcondylar fracture. The technique utilizes a Risdon incision to expose the fracture site and a stab incision in the preauricular region. A University of Tennessee drill guide or bone screw is introduced through the stab incision to facilitate placement of drill holes in the fragments, threading of the transosseous wires, and repositioning of the condyle within the fossa.