[Pityriasis rubra pilaris after COVID-19 vaccination: causal relationship or coincidence?]

Seit der Markteinführung der COVID-19-Impfstoffe werden regelmäßig kutane Nebenwirkungen dieser Vakzine beschrieben. Diese beinhalten unter anderem lokale Impfreaktionen (insbesondere den sog. COVID-Arm), urtikarielle, makulopapulöse und pityriasiforme Exantheme oder vorübergehende Exazerbationen einer vorbestehenden chronisch entzündlichen Hauterkrankung. Wir berichten über 3 Fälle einer Pityriasis rubra pilaris, die in engem zeitlichen Zusammenhang mit der Verabreichung eines COVID-19-Impfstoffs erstmals aufgetreten sind.

Patterns of care and follow-up care of patients with uveal melanoma in German-speaking countries: a multinational survey of the German Dermatologic Cooperative Oncology Group (DeCOG)

Purpose

Uveal melanoma (UM) is an orphan cancer of high unmet medical need. Current patterns of care and surveillance remain unclear as they are situated in an interdisciplinary setting.

Methods

A questionnaire addressing the patterns of care and surveillance in the management of patients with uveal melanoma was distributed to 70 skin cancer centers in Austria, Germany and Switzerland. Frequency distributions of responses for each item of the questionnaire were calculated.

Results

44 of 70 (62.9%) skin cancer centers completed the questionnaire. Thirty-nine hospitals were located in Germany (88.6%), three in Switzerland (6.8%) and two in Austria (4.5%). The majority (68.2%) represented university hospitals. Most patients with metastatic disease were treated in certified skin cancer centers (70.7%, 29/41). Besides, the majority of patients with UM were referred to the respective skin cancer center by ophthalmologists (87.2%, 34/39). Treatment and organization of follow-up of patients varied across the different centers. 35.1% (14/37) of the centers stated to not perform any screening measures.

Conclusion

Treatment patterns of patients with uveal melanoma in Germany, Austria and Switzerland remain extremely heterogeneous. A guideline for the treatment and surveillance is urgently needed.

Medical error analysis in dermatology according to the reports of the North Rhine Medical Association from 2004-2013

BACKGROUND

Patient safety is a central issue of health care provision. There are various approaches geared towards improving health care provision and patient safety. By conducting a systematic retrospective error analysis, the present article aims to identify the most common complaints brought forth within the field of dermatology over a period of ten years.

METHODS

The reports of the Expert Committee for Medical Malpractice Claims of the North Rhine Medical Association (from 2004 to 2013) on dermatological procedures were analyzed (n =  247 reports in the field of dermatology).

RESULTS

Expert medical assessments in the field of dermatology are most frequently commissioned for nonsurgical therapies (e.g. laser therapy, phototherapy). While suspected diagnostic errors constitute the second most common reason for complaints, presumed dermatosurgery-related errors represent the least common reason for commissioning expert medical assessments.

CONCLUSIONS

The most common and easily avoidable sources of medical errors include failure to take a biopsy despite suspicious clinical findings, or incorrect clinicopathological correlations resulting in deleterious effects for the patient. Furthermore, given the potential for incorrect indications and the inadequate selection of devices to be used as well as their parameter settings, laser and phototherapies harbor an increased risk in the treatment of dermatological patients. The fourth major source of error leading to complaints relates to incorrect indications as well as incorrect dosage and administration of drugs. Analysis of expert medical assessment reports on treatment errors in dermatology as well as other medical specialties is helpful and provides an opportunity to identify common sources of error and error-prone structures.

Fluorescence in situ hybridization, a diagnostic aid in ambiguous melanocytic tumors: European study of 113 cases

Some melanocytic tumors are ambiguous, so the reproducible histopathological diagnosis of benign or malignant lesion is difficult. This study evaluated the contribution of fluorescence in situ hybridization (FISH) first in 43 non-equivocal melanomas and nevi, and then in 113 ambiguous melanocytic tumors selected by expert pathologists from six different European institutions. We included two groups of ambiguous tumors: patients without recurrence (5-year minimal follow-up) and with metastases. An independent triple-blind histopathological review was performed to classify tumors as 'favor benign' (A-) or 'favor malignant' (A+). A four-color probe set targeting 6p25, 6q23, 11q13 and CEP6 was used for FISH. In the 43 non-equivocal melanomas and nevi, sensitivity was 85% and specificity 90%. Ninety out of 95 ambiguous melanocytic tumors included were FISH interpretable (67 FISH negative and 23 FISH positive). Of the 90 patients, 69 presented no recurrence and 21/90 exhibited metastases. These ambiguous tumors were mostly spitzoid tumors (45/90). Histopathological reviewers classified these tumors as favor malignant (49/90) and favor benign (32/90), whereas nine cases had a discordant diagnosis. By comparison with outcome, the sensitivity and specificity of histopathological review were 95 and 52%, and the sensitivity and specificity of FISH were 43 and 80%. Compared with histopathological review, the sensitivity and specificity of FISH were 34.5 and 91%. Interestingly, by combining the histopathological diagnosis with FISH results, the diagnosis was optimized, especially by increasing specificity (76% instead of 52% for expert diagnosis alone) and by improving sensitivity compared with FISH alone (90 vs 43% for FISH result alone). The value of this FISH test is to add a reproducible demonstration of malignancy to the histopathological diagnosis, especially in doubtful/ambiguous melanocytic tumors. A positive FISH test reinforces the diagnosis of melanoma, allowing such tumors (particularly thick tumors) to be managed as melanomas.

Histopathology of anti-laminin 5 mucous membrane pemphigoid

BACKGROUND

Anti-laminin 5 mucous membrane pemphigoid (MMP) is an autoimmune blistering disease characterized by autoantibodies against the major basement membrane component laminin 5 (laminin 332, epiligrin).

OBJECTIVE AND METHODS

We reviewed 17 biopsy specimens from 9 patients with anti-laminin 5 MMP in an attempt to define typical histopathologic features of the disease.

RESULTS

Fifteen specimens showed subepidermal blister formation, while two biopsy specimens revealed an epithelial ulcer. In 11 biopsies a sparse to moderate inflammatory infiltrate composed of lymphocytes and neutrophils with some eosinophils was observed. Four biopsies showed a dense infiltrate dominated by neutrophils in two cases and by eosinophils in one case. The remaining biopsy revealed a dense lymphoplasmacellular infiltrate without granulocytes. Scarring of the upper dermis was present only in 5 specimens. Immunohistochemical analysis localized type IV collagen to the dermal side of the blister, suggesting that split formation occurred within the lamina lucida of the cutaneous basement membrane.

LIMITATIONS

The number of patients studied was relatively small.

CONCLUSIONS

Histopathology of anti-laminin 5 MMP is characterized by subepidermal blistering and a sparse to moderate superficial lymphohistiocytic infiltrate with neutrophils and/or eosinophils. Both infiltrate density and composition may vary, making anti-laminin 5 MMP indistinguishable from other autoimmune subepidermal blistering diseases by histopathology alone. Scarring is present only in a minority of cases and is not a sensitive clue to the diagnosis of anti-laminin 5 MMP.

Complicated grief after traumatic loss: a 14-month follow up study

The traumatic loss of an unborn child after TOP due to fetal malformation and/or severe chromosomal disorders in late pregnancy is a major life-event and a potential source of serious psychological problems for those women. To obtain information on the course of grief following a traumatic loss, 62 women who had undergone TOP between the 15th and 32nd gestational week were investigated in a longitudinal study design and compared with 65 women after spontaneous delivery of a full-term healthy child. Grief, posttraumatic stress, depression, anxiety and psychiatric disorders were evaluated 14 days, 6 months and 14 months after the event, implementing validated self-report and clinician rated instruments. Compared to women after spontaneous delivery, women after induced TOP were significantly more stressed regarding all psychological outcomes at all three measuring points. Especially, 14 months after TOP 13.7% of the women fulfilled all criteria of a complicated grief diagnoses following Horowitz et al. (1997, Am J Psychiat 154:7904-7910). 16.7% were diagnosed as having a manifest psychiatric disorder according to DSM-IV. All in all, 25% of these women were critically affected by the traumatic loss. TOP for fetal anomaly is to be seen as a major life event, which causes complicated grief reactions and psychiatric disorders for a substantial number of women.

Gorham-Stout disease--stabilization during bisphosphonate treatment

A 45-year-old woman presented with recent onset of left-sided chest pain. On clinical examination, these symptoms seemed to be strictly localized to a region that was marked by a long-standing cutaneous erythematous lesion. Laboratory results showed no gross abnormalities. Radiological imaging including conventional X-ray, MRI scans, and 3D CT reconstruction of the rib cage revealed circumscript destruction of the left lateral ribs 9-11. Histological analysis of a rib biopsy showed angiomatous hypervascularization and intracortical fibrosis. In keeping with these findings, the patient's condition was diagnosed as Gorham-Stout disease, a rare condition with localized, often unilateral, bone destruction. Monotherapy with bisphosphonates (pamidronate 30 mg i.v. every 3 months) was initiated, leading to rapid disappearance of local pain. Follow-up over 24 months documented a stable clinical and radiological picture without evidence of progressive bone destruction.

Maternal posttraumatic stress response after the birth of a very low-birth-weight infant

OBJECTIVE

For parents, the premature birth of a child represents a traumatic event for which they are poorly prepared. To date, the focus of scientific interest has been on maternal psychological stress responses, such as anxiety and depression, or on appropriate coping mechanisms, whereas only scant attention has been paid to the traumatic aspect of the maternal experience after very low-birth-weight (VLBW) birth. The present study is the first to investigate the posttraumatic stress response of mothers after the birth of a VLBW infant in a prospective longitudinal study.

METHODS

Fifty mothers of VLBW infants were examined at four measuring time points (1-3 days pp, 14 days pp and 6 and 14 months pp) with respect to posttraumatic symptoms [Impact of Event Scale (IES-R)], psychiatric diagnosis (SKID I for DSM-IV) and the extent of depression [Beck Depression Inventory (BDI) and Montgomery Asberg Depression Scale (MADRS)] and anxiety [State-Trait Anxiety Inventory (STAI) and Hamilton Anxiety Scale (HAMA)]. The control group comprised a group of 30 mothers after the uncomplicated spontaneous birth of a healthy child.

RESULTS

At all four measuring timepoints (except 6 months pp), the mothers of the premature infants recorded significantly higher values for traumatic experience and depressive symptoms and anxiety compared with the controls. In contrast to the mothers in the control group, the mothers of the premature infants displayed no significant reduction in posttraumatic symptoms (IES-total), even 14 months after birth.

CONCLUSION

The results indicate that the situation of a mother who has given birth to a VLBW infant is a complex, with long-term traumatic event necessitating ongoing emotional support extending beyond the period immediately after the birth.

[Chronic prostatitis. Chronic pelvic pain syndrome]

The symptom complex called prostatitis represents a multifactorial problem of unclear etiology. Standardized diagnostic and therapeutic approaches do not exist. Controlled studies which fulfil evidence-based medical criteria are missing. A review of the currently available literature leads to the conclusion that a multimodal therapy concept should be developed and examined.

[Dysfunctional syndromes: their diagnostics and treatment]

If a patient presents with symptoms of a functional somatic pain syndrome in the primary care setting, it is important to confirm the diagnosis based on a thorough history and physical examination including selected diagnostic tests to exclude somatic diseases with a similar clinical presentation. Important aspects of psychosomatic medicine in the primary care setting are to discuss the diagnosis, treatment options, and prognosis of the functional psychosomatic pain syndromes with the patient in detail. Patients who present with a functional somatic pain syndrome to secondary or tertiary care centers, should be screened for additional functional pain syndromes. A psychiatric-psychosomatic evaluation might be indicated. Based on criteria of evidence-based medicine, psychotherapy and/or tricyclic antidepressants seem to be the most promising treatment approaches for the functional somatic pain syndromes.

[Functional somatic pain syndromes-nomenclature]

A significant number of pain syndromes to be found in all medical specialties, including pain therapy, can be ascribed to a group that according to the classification of the International Association for the Study of Pain (IASP) is referred to as "pain syndromes with dysfunctional etiology," or according to internal medical terminology as "functional somatic syndromes" (functional disorders), or based on psychiatric nomenclature as "somatoform disorders." Frequent syndromes exhibiting pain as the major symptom include fibromyalgia syndrome (FMS), irritable bowel syndrome (IBS), chronic pelvic pain (CPP), tension headache, chronic myoarthropathies of the masticatory system (MAP), and prostatodynia. It is important for practitioners of both somatic and psychosocial medicine to be aware of the terminology used in other fields and the frequency of comorbidities of the individual syndromes. To improve communication between somatic and psychosocial medicine as well as with patients, the authors recommend that pain therapists base their diagnosis on the ICD-10 classification and refrain from using a separate pain therapy nomenclature.

[Diagnostic criteria and therapeutic strategies of abdominal pain syndromes]

Abdominal pain syndromes can be categorised into acute or chronic manifestations. In general, diagnostic work-up is targeted upon identification of structural lesions that cause the symptoms and allows therapeutic measures that permanently cure the cause of symptoms. If no structural or biochemical abnormality can be identified upon utilising the necessary diagnostic measures, a functional disorder as the cause of symptoms is assumed. For these disorders no cure is currently available and treatment is targeted towards relief of symptoms only.

[Clinical characteristics and pathophysiology of pelvic pain in women]

Chronic pelvic pain is a common and debilitating problem that can significantly impair the quality of life of a woman. Patients with chronic pelvic pain are usually evaluated and treated by gynecologists, gastroenterologists, urologists, and internists. Although these patients seek medical care because they are looking for help to alleviate their pelvic discomfort and pain, in many cases the only focus is on finding and possibly treating the underlying pelvic disease.However, often the examination and work-up remain unrevealing and no specific cause of the pain can be identified. At this point patients are frequently told, that no etiology for their chronic pain syndrome can be found and that nothing can be done. In these cases it is important to recognize that pain is not only a symptom of pelvic disease, but that the patient is suffering from a chronic pelvic pain syndrome. Knowledge of the clinical characteristics of visceral pain will guide the health care provider in making a diagnosis of chronic pelvic pain and in sorting it out from the lump diagnosis of idiopathic pain. Once the diagnosis of chronic pelvic pain is made, treatment should be directed towards symptomatic pain management.This conceptualization of chronic pelvic pain is very important, because chronic pelvic pain is a treatable condition! Effective treatment modalities are available to lessen the impact of pain and offer reasonable expectations of an improved functional status.

Subacute prurigo variant of bullous pemphigoid: autoantibodies show the same specificity compared with classic bullous pemphigoid

We describe a 76-year-old white woman with a 6-month history of intensive pruritus and excoriated papules resembling subacute prurigo. Histopathology showed signs of chronic dermatitis, whereas findings by direct and indirect immunofluorescence microscopy were compatible with bullous pemphigoid (BP). The patient's serum contained IgG autoantibodies that recognized epitopes on both BP180 and BP230 by Western blot analysis of epidermal extracts. In addition, we found strong reactivity with recombinant NC16A, an immunodominant region of BP180 targeted in the majority of BP sera, whereas no antibodies against the keratinocyte-derived soluble BP180 ectodomain (LAD-1) or the recombinant intracellular domain of BP180 were detected. The patient's disease responded well to oral methylprednisolone and mycophenolate mofetil. Disease activity correlated with enzyme-linked immunosorbent assay reactivity of antibodies to BP180 but not with titers of antibodies to the dermoepidermal junction as determined by indirect immunofluorescence on salt-split skin. Our findings suggest that the subacute prurigo form of BP is a true variant of BP.

Interstitial cystitis: a chronic visceral pain syndrome

Interstitial cystitis (IC) has remained an unresolved problem in clinical urology. The etiology and pathophysiologic mechanisms of IC are still undetermined, and to date the diagnosis is based on the clinical characteristics of the disease and the exclusion of other diseases and pathology that can mimic the symptoms of IC. In clinical practice, much emphasis has been placed on finding a specific etiology and specific pathologic markers for the disease and on identifying specific events that precipitate IC; however, those have not been identified with certainty. In this review, an additional approach is proposed, taking into account the observation that IC shares many features with other chronic nonmalignant visceral pain syndromes. This approach is based on the conceptualization of 3 hypotheses: (1) a spectrum of different insults can lead to chronic visceral pain in patients with IC; (2) different underlying pathogenic pain mechanisms may require different pain treatment strategies for patients diagnosed with IC; and (3) multiple different pathogenic pain mechanisms may coexist in the same patient requiring several different pain treatment strategies (perhaps concomitantly) to successfully treat chronic visceral pain associated with IC. This concept is likely to lead to new insights into the pathophysiologic mechanisms of IC and to novel treatment avenues for patients with IC and-in a broader view-also for patients with other chronic visceral pain syndromes.

Neurogenic inflammation and chronic pelvic pain

Chronic pelvic pain is a puzzling disease entity. The pathophysiological mechanisms of chronic pelvic pain are not clear and current treatment strategies are often not successful, leaving patients as well as health care providers frustrated. In a subgroup of patients with chronic pelvic pain (e.g., interstitial cystitis, irritable bowel syndrome, vulvar vestibulitis, prostatodynia/prostatitis, and loin pain/hematuria syndrome) inflammatory changes are observed, for which no etiology has been identified. These inflammatory changes might be due to neurogenic inflammation. Applying the concept of neurogenic inflammation to chronic pelvic pain provides new insights into the pathophysiological mechanisms of these pain syndromes, makes it possible to account for the heterogeneity and variability observed in the clinical presentation, and might lead to the development of novel therapies.

Pelvic pain: a chronic visceral pain syndrome

Patients with chronic pelvic pain are usually evaluated and treated by gynecologists, gastroenterologists, urologists, and internists. In many patients with chronic pelvic pain the examination and work-up remain unrevealing and no specific cause of the pain can be identified. In these cases it is important to recognize that pain is not only a symptom of pelvic disease, but that the patient is suffering from a chronic pelvic pain syndrome. Once the diagnosis of chronic pelvic pain is made, treatment should be directed to symptomatic pain management. This article outlines treatment options currently available. Despite the challenge inherent in the management of chronic pelvic pain, many patients can be treated successfully using a multidisciplinary pain management approach. The first important step is to recognize that patients with chronic pelvic pain might suffer from a chronic visceral pain syndrome.

[Termination of pregnancy for fetal abnormality--a traumatic experience?]

The diagnosis of a lethal anomaly of the fetus can affect a pregnant woman in a traumatic way. Almost immediately she has to decide whether she wishes the pregnancy to be terminated or not. Literature shows that such a loss is very difficult to cope with, and can lead to social isolation and depression. Contrary to popular belief the loss felt by the woman is at least the same to that following a stillbirth. Problems arise when the woman has difficulties in expressing her feelings, has a lack of self-esteem or receives very little social support. The prenatal diagnosis evokes an acute grief reaction. Only few studies are available regarding length, course and severity of grief in this case. Although an abortion through a fetal anomaly is a traumatic experience, research is vague on the trauma caused. Present day research of the psychological sequelae after the termination will be summarized. In respect to the current trauma-research lies the question of which psychiatric conditions arise from such a traumatic experience.

Molecular cytogenetic analysis of Spitz nevi shows clear differences to melanoma

Spitz nevus is a benign neoplasm of melanocytes that can be difficult or impossible to distinguish from melanoma by clinical and histopathologic examination. We studied genomic DNA from 17 Spitz nevi by comparative genomic hybridization (CGH). Thirteen lesions showed no chromosomal aberrations, three cases had a gain involving the entire p-arm of chromosome 11, and one case showed a gain of chromosome 7q21-qter. Fluorescence in situ hybridization (FISH) on lesional tissue with a probe for the p-arm of chromosome 11 showed 6-10 p-arm signals per nucleus in those cases with a CGH-detected gain of chromosome 11p. One case with a normal CGH profile also showed increased copy number of 11p by FISH. Thus, the majority of Spitz nevi have a normal chromosomal complement at the level of CGH resolution; however some may contain gains, with 11p apparently being the most frequently involved location. These findings differ significantly from the previously reported changes in primary cutaneous melanoma, which show frequent deletions of chromosomes 9p (82%), 10q (63%), 6q (28%), and 8p (22%), as well as gains of chromosomes 7 (50%), 8 (34%), 6p (28%), 1q (25%) by CGH analysis. These clear differences in the location and frequencies of chromosomal aberrations in Spitz nevi and primary cutaneous melanomas could represent a basis for developing adjunctive techniques for refining accuracy in the difficult differential diagnosis of spitzoid melanocytic neoplasms.

Autoantibodies in lichen planus pemphigoides react with a novel epitope within the C-terminal NC16A domain of BP180

Lichen planus pemphigoides is an autoimmune subepidermal blistering disease. The finding of immunoglobulin G antibodies directed against the basement membrane zone differentiates it from bullous lichen planus. The aim of this study was to identify the target antigen of lichen planus pemphigoides autoantibodies. Sera from lichen planus pemphigoides patients (n = 4) stained the epidermal side of NaCl-split human skin in a pattern indistinguishable from that produced by bullous pemphigoid sera. In bullous pemphigoid, the autoimmune response is directed against BP180, a hemidesmosomal transmembrane collagenous glycoprotein. We previously demonstrated that bullous pemphigoid sera predominantly react with a set of four epitopes (MCW-0 through MCW-3) clustered within a 45 amino acid stretch of the major noncollagenous extracellular domain (NC16A) of BP180. By immunoblotting and enzyme-linked immunosorbent assay, lichen planus pemphigoides sera were also strongly reactive with recombinant bullous pemphigoid 180 NC16A. The lichen planus pemphigoides epitopes were further mapped using a series of overlapping recombinant segments of the NC16A domain. All lichen planus pemphigoides sera reacted with amino acids 46-59 of domain NC16A, a protein segment that was previously shown to be unreactive with bullous pemphigoid sera. Two lichen planus pemphigoides sera, in addition, reacted with the immunodominant antigenic region associated with bullous pemphigoid. In conclusion, there are now five bullous diseases that are associated with an autoimmune response to BP180: bullous pemphigoid; pemphigoid/herpes gestationis; cicatricial pemphigoid; linear immunoglobulin A disease; and lichen planus pemphigoides. In addition, we have identified a novel epitope within the BP180 NC16A domain, designated MCW-4, that appears to be uniquely recognized by sera from patients with lichen planus pemphigoides.

History of the neurobiology of the pelvis

The contemporary clinical management of a variety of pelvic disorders has benefited greatly from both basic science research discoveries and clinical observations in pelvic neurobiology. The foundation of this scientific discipline emanates from historical advances in the neuroanatomy and neurochemistry of the pelvic region. These advances, many of which were controversial when introduced, have served to shape currently accepted views regarding the neuroregulatory basis of pelvic functions. This report highlights the major contributions in the history of pelvic neurobiology, providing both an overview of the evolution of scientific thought in this discipline and insight into the role of this discipline in the development and practice of medicine and surgery related to the pelvic region.

Paraneoplastic pemphigus treated with dexamethasone/ cyclophosphamide pulse therapy

Paraneoplastic pemphigus (PNP) is an autoimmune, mucocutaneous bullous disease associated with underlying malignancies. We report a patient with Waldenström's macroglobulinemia who developed clinical, histological and immunopathological features typical of PNP. The patient was treated twice with i.v. dexamethasone and cyclophosphamide pulse therapy (day 1: cyclophosphamide 500 mg i.v.; day 1-3: dexamethasone 100 mg i.v.) at 3-week intervals. Therapy was continued with oral cyclophosphamide (50 mg/d). Two weeks after initiation of treatment, significant improvement of the cutaneous and mucosal lesions was noted. The therapy also had beneficial effects on the macroglobulinemia in terms of a marked reduction of the IgM lambda serum level. Three months after the second pulse, severe stomatitis recurred but the patient rejected any further systemic therapy. The initial response of the usually recalcitrant mucosal and skin lesions of PNP makes dexamethasone/cyclophosphamide pulse therapy an interesting therapeutic option.

Eosinophilic globules in spitz nevi: no evidence for apoptosis

Eosinophilic globules are commonly found in Spitz nevi and can be of help in the differential diagnosis with melanoma. Despite their use as a diagnostic marker, there are conflicting concepts concerning the mechanism of the formation of these globules. Because pyknotic nuclei are often present in the cells surrounding the globules, many believe that apoptotic cell death of keratinocytes and melanocytes is an important mechanism in their formation. We studied nine Spitz nevi containing 21 eosinophilic globules for apoptotic cell death around and within Kamino bodies using the TUNEL method (TdT-mediated dUTP-x nick end-labeling method). In none of the cases were positive cells seen in the vicinity of the globules. Single apoptotic cells were found only sporadically in the melanocytes of the neoplasms (one to four per section) and were scattered throughout the entire lesion. The absence of apoptosis-specific labeled cells in the vicinity of eosinophilic globules and the rare occurrence of positive stained cells in other parts of the tumors makes apoptotic cell death unlikely to be relevant in the formation of eosinophilic globules.

Uterine inflammation as a noxious visceral stimulus: behavioral characterization in the rat

We have developed a model of uterine inflammation in the rat. The purpose of this study was to characterize the behavioral manifestations of uterine pain. Mustard oil was injected into one uterine horn to produce chemical inflammation. Control rats were sham-operated. Non-stop videotape recording was performed for 7 days to monitor rat behavior. Rats with uterine inflammation showed abnormal behavior during the first 4 days (hunching, hump-backed position, licking of the lower abdomen, repeated waves of contraction of the ipsilateral oblique musculature with inward turning of the ipsilateral hindlimb, stretching, squashing of the lower abdomen against the floor) suggestive of visceral pain and evidence of flank muscle hyperalgesia over 7 days indicative of referred visceral pain. This model resembles closely a state of inflammatory uterine pain and will allow to gain further insight into the neural processes which contribute to visceral nociception.

[Pain syndromes in AIDS]

Pain is a major, but largely neglected problem in AIDS patients. The aim of this article is to review the etiology of pain manifestations in AIDS patients in different organ systems and to discuss appropriate treatment strategies. The most common pain symptoms in AIDS patients are headache, oral cavity pain, dysphagia and adynophagia, chest pain, abdominal pain and pain related to peripheral neuropathy. Symptomatic pain treatment should be started while diagnostic work-up is still in progress, so that the patient does not suffer. If etiological treatment is possible, specific treatment pain treatment tapered as tolerated. If etiological treatment is not possible, symptomatic pain treatment should be continued. In view of the multiple organs involved in the presentation of AIDS requiring multiple drugs, careful attention to side effects, contraindications and drug interactions is warranted, when administering pain medications. Fear of the complexity of these issues should, however, not prevent effective pain management for these patients, who suffer from a fatal disease. A multidisciplinary approach to pain in AIDS patients, similar to the approach in patients with cancer, is desirable.

The dynias

The "dynias" are a group of chronic, focal pain syndromes with a predilection for the orocervical and urogenital regions. They include glossodynia, carotidynia, vulvodynia, orchidynia, prostatodynia, coccygodynia, and proctodynia. In some cases, the dynias occur secondarily, but more often, despite an exhaustive evaluation, no etiology is found and in these remaining cases, the cause of the pain remains enigmatic. The controversy that surrounds this group of disorders, which ranges from questioning their existence to suggesting that they are purely psychosomatic, is counterbalanced by an extensive literature attesting to their organicity. The approach to the patient begins with acknowledging that the symptom is well described, searching for a secondary cause, and performing a careful psychologic assessment. Treatment is empirical and patients can often be helped with medications used to treat neuropathic pain, all the while providing psychologic support and exercising caution toward invasive and irreversible therapeutic procedures.

Galactorrhea and hyperprolactinemia in schizophrenic patients on neuroleptics: frequency and etiology

The frequency of galactorrhea and the subjective response to it were investigated in 150 schizophrenic patients. The incidence rate was 14% and the prevalence rate 19%. The latency periods between start of neuroleptic medication and manifestation of galactorrhea were subject to substantial scatter, as were the prolactin values. Patients who had undergone neuroleptic relapse prevention prior to the index episode and/or had been pregnant were affected significantly more frequently by galactorrhea.

Galactorrhea: subjective response by schizophrenic patients

The frequency of galactorrhea and the subjective response to it were investigated in 150 schizophrenic patients. The incidence rate was 14% and the prevalence rate 19%. More than half the women experienced galactorrhea in connection with their femininity, with this side effect of neuroleptic therapy being rated more often as a positive effect, especially as a reinforcement of feminine identity or as an expression of the ability to conceive children. The overall response to galactorrhea was positive among 43% and negative among 20%, with the remaining patients tending towards indifference.

Laser effects on myelinated and nonmyelinated fibers in the rat peroneal nerve: a quantitative ultrastructural analysis

We have recently shown that Nd:YAG laser irradiation of rat peripheral nerve differentially impairs action potential transmission in small, slowly conducting sensory fibers compared to fast conducting afferents. In addition, the number of small sensory neurons of the A-delta- and C-fiber group labeled with HRP is significantly reduced after laser irradiation, while the number of labeled large sensory neurons and motoneurons was not affected. To further evaluate this laser-induced injury, we examined three distinct regions of the laser-irradiated rat peroneal nerve using ultrastructural morphometric methods. These regions were the site of laser irradiation and zones 10 mm proximal and 5 mm distal to the injury. The contralateral nerve was sham treated. Our results indicate that for the small nonmyelinated fibers, there was a significant increase in both mean fiber size and the number of microtubules per fiber, but a decrease in the number of neurofilaments. In contrast, the number of myelinated and nonmyelinated fibers is not significantly altered at 7 days following laser irradiation, and the mean diameter and frequency distribution of myelinated nerve fibers was unchanged. This study demonstrates that selective functional alterations in laser-irradiated nerves (nerve conduction velocity, HRP transport properties) are accompanied by ultrastructural changes of axonal organelles in nonmyelinated fibers. Nd:YAG laser light might ultimately prove to be a powerful tool to selectively alter functional properties in small, slowly conducting afferent fibers, without causing degeneration at the ultrastructural level at the site of irradiation. We hypothesize further that the laser-induced functional alterations might be related to differential thermally mediated changes.