Topical nitroglycerin: an alternative in the conservative treatment of biliary fistula

A patient with post-laparoscopic cholecystectomy cystic duct leak successfully treated with conservative treatment is presented. The cystic duct leak was diagnosed through a CPRE where a Oddy sphyncter spasm was noted. The use of a topic Nytroglicerine resulted in a sphincter release and resolution of the fistula. A literature review of the importance of CPRE in the diagnosis and treatment of biliary injuries was carried out. In patients with nondilated bile ducts where the sphincterotomy or endoprothesis undergo with high morbidity, the use of topic nitroglycerine could be an effective alternative procedure.     

Evidence of androgen receptor expression in lichen sclerosus: an immunohistochemical study

OBJECTIVE: While topical androgen administration is widely used in the treatment of lichen sclerosus of the vulva, localization and level of expression of androgen receptor (AR) have not been described previously. METHODS: Thirty-nine paraffin-embedded punch biopsies of patients with lichen sclerosus of the vulva were examined. Androgen receptor, estrogen receptor (ER), and progesterone receptor (PR) expression in lichen sclerosus and in normal vulvar skin were investigated by immunohistochemistry. RESULTS: Five tissue specimens (12.8%) of lichen sclerosus showed nuclear staining with anti-AR in the parabasal cell layers of the epidermis. Median age of patients with positive nuclear staining for AR versus women without AR expression was 71 (range, 63-78) and 66.5 (range, 38-91) years, respectively. Estrogen receptor expression was present in only one patient. Nuclear staining reaction for PR expression was absent in all cases. Four of the five AR-positive women reported no complaints and therefore received no topical testosterone therapy. CONCLUSION: Our results suggest a lack of complaints in AR-positive lichen sclerosus patients. Our findings could justify a larger study comparing symptoms of patients with and without AR expression.     

Apropos of lichen sclerosus of the vulva

Among the very rare intracerebral lipomas, those of the corpus callosum are the most frequent. Due to the advanced technology and the frequent use of ultrasonography these lesions are diagnosed more and more often. A female neonate was admitted to our hospital because of a progressive thrombocytopenia. Pregnancy was complicated by an autoimmune thrombocytopenia of the mother. While there were no remarkable findings on clinical presentation, a sonogram of the brain revealed an area of increased echogenicity in the midline which was interpreted as an intracerebral hemorrhage. In absence of any respective clinical signs a magnet-resonance-tomography of the brain was performed leading to the hypothesis of a lipoma of the corpus callosum (LCC) that could be verified by a densitometry in a cranial computer tomography (CT). Obviously, the initially performed sonogram was misinterpreted as an intracerebral hemorrhage due to the coincidence with the thrombocytopenia. At last the discrepancy of clinical and ultrasonographical findings led to the diagnosis by magnet-resonance-tomography and CT scan. Knowledge of the typical sonographic appearance of an LCC may be helpful for the differential diagnosis of this rare lesion even in fetal ultrasound.     

Vulvar squamous cell hyperplasia and lichen sclerosus et atrophicus: clinical picture, morphology and treatment

The term evidence-based practice is becoming increasingly common within the health care sector. This is not only because of a search for quality, but also because of economic factors which demand more effective use of resources. This article will present some of the arguments which both support and oppose evidence-based practice. These arguments may at times appear to be contradictory in nature. The implications of evidence-based practice, for both patients and health care workers, is considered.     

Histological comparison of morphea and lichen sclerosus et atrophicus

To clarify the role of the lens capsule in cataract formation, changes in the protein conformational structure of immature cataractous lens capsules from patients with systemic hypertension or glaucoma have been investigated, as compared to normal lens capsules. The protein secondary structure and composition of these capsular samples were determined using Fourier transform infrared microspectroscopy with second-derivative, deconvolution and curve-fitting methods. We found that the composition of both random coil and beta-type (beta-sheet and beta-turn) structures in the immature cataractous human lens capsules was increasingly induced by systemic hypertension or glaucoma, but alpha-helix content clearly decreased, leading to the alteration of protein conformational structures in lens capsules. A possible pathway of cataract formation exacerbated by systemic hypertension or glaucoma is discussed. According to the results, we propose that systemic hypertension or glaucoma induce changes in the protein conformational structures of the lens capsule, then cause alteration of membrane transport and permeability for ions, and finally increase intraocular pressure, resulting in the exacerbation of cataract formation. The effect on the conformational structure of cataractous human lens capsules is more pronounced for systemic hypertension than for glaucoma. The present study implies that systemic hypertension or glaucoma can exacerbate cataract formation in senile patients by modifying the protein secondary structures in the lens capsule.     

Behavioral activation as an alternative treatment approach for Latinos with depression.

Depression is one of the most commonly diagnosed psychological health problems and a major cause of disability in this country. Very little attention, however, has been given to depression among Latinos. To address this issue, the authors provide a review of the literature on psychosocial factors that contribute to depression within the Latino adult population. In addition, the authors argue that Behavioral Activation (BA), as an alternative treatment approach, may be as effective as, if not more effective than, Cognitive Behavioral Therapy because of BA's focus on environmental conditions and behavior change rather than beliefs and underlying attitudes. More importantly, components of BA can be easily adapted to accommodate specific Latino cultural values. Its application is illustrated in a case example. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rare case of lichen sclerosus et atrophicus associated with morphea

A rare case of lichen sclerosus et atrophicus coexisting with morphea in the foot was presented. Orthotic therapy was required to alleviate an antalgic gait.     

Coexistence of generalized morphea with hisotological changes in lichen sclerosus et atrophicus and lichen planus

A morphometric study has shown that 10% of the fibers of the ulnar nerve should suffice to reinnervate the biceps muscle in brachial plexus palsies. The aim of this study was to evaluate, by a morphometric study using computerized microanalysis, the cross-sectional surface areas of the different collateral and terminal branches of the ulnar nerve. This was expressed in terms of percentage of the cross-sectional surface area of the main trunk of the ulnar nerve. The study revealed that the branch to the flexor digitorum profundus bellies to the ring and little fingers formed 9.5% of the cross-sectional area of the ulnar nerve. Thus use of these fascicles destined for the flexor digitorum profundus, identified by intra-operative nerve stimulation, at the level of the arm would be sufficient for neurotisation of the nerve to the biceps. This has been confirmed by the initial clinical results in patients operated upon using this technique.     

Infantile pyramidal protrusion as a manifestation of lichen sclerosus et atrophicus

BACKGROUND: A perineal infantile lesion previously described as "skin tag/fold" had recently been named infantile perianal pyramidal protrusion. It appears on the perineal median raphe of girls as a pyramidal soft tissue swelling, covered by smooth, red or rose-colored skin. Its pathogenesis is unknown. As in the case of other perianal lesions, knowledge about it is important, as concern about signs of child abuse grows. OBSERVATIONS: Four girls, 2 of them sisters, with infantile perianal pyramidal protrusion were studied. Three of these girls showed subtle clinical evidence of classic lichen sclerosus et atrophicus on first examination. The other girl developed vulvar lesions of lichen sclerosus et atrophicus months after the diagnosis of infantile perianal pyramidal protrusion. All 4 protrusions disclosed histopathological findings diagnostic of lichen sclerosus et atrophicus. CONCLUSIONS: Infantile perianal pyramidal protrusion is, at least in some patients, a peculiar form of lichen sclerosus et atrophicus that can precede other, more characteristic manifestations. We suggest changing the name to the more precise infantile perineal protrusion. Knowledge of this hitherto unrecognized clinical form of lichen sclerosus et atrophicus can help to explain anogenital symptoms and avoid its misinterpretation as a sign of sexual abuse.     

Midpalmar approach to the carpal tunnel: an alternative to endoscopic release

OBJECTIVE: To determine whether hysteroscopic adhesiolysis improves reproductive outcome in women with Asherman's syndrome and pregnancy failure. SUBJECTS: Ninety consecutive women who had undergone hysteroscopic adhesiolysis of intrauterine adhesions during a 5-year period. Only women in whom at least two previous pregnancies had ended with either a spontaneous abortion or a premature delivery accompanied by fetal or neonatal mortality and a hysteroscopic diagnosis of intrauterine adhesions were enrolled. RESULTS: Whereas pregnancy outcome prior to the operation was 18.3% term deliveries, 3.3% premature deliveries, 62.4% first-trimester abortions, and 16.0% late abortions, after hysteroscopic adhesiolysis pregnancy outcome was 68.6% term deliveries, 9.3% premature deliveries, 17.4% first-trimester abortions, and 4.7% late abortions. In women with two previous unsuccessful pregnancies, the operative success rate measured by delivering a healthy newborn improved from 18.3% preoperatively to 64% postoperatively. In women with three or more unsuccessful pregnancies the success rate improved from 18.3% to 75%. Successful outcome of adhesiolysis was observed in 61.9% of mild (stage I) and in 70.6% of moderate to severe cases (stages II and III) of intrauterine adhesions. CONCLUSION: Hysteroscopic adhesiolysis in women with Asherman's syndrome and poor reproductive performance contributes significantly to a successful reproductive outcome.     

G proteins and hypertension: an alternative candidate gene approach

Hypertension affects approximately 20 to 30% of individuals in industrialized countries, and is commonly believed to develop on the basis of both genetic and environmental factors. The identification of genes susceptible to the most frequent form of hypertension, commonly referred to as "essential" hypertension, is hampered by the fact that blood pressure is a poorly defined phenotype that is modulated by multiple factors, such as gender, race, body mass etc., and that the definition of hypertension depends on a rather arbitrarily chosen cut-off value. Hence, more progress has been made in the identification of genes responsible for rare autosomal dominant forms of hypertension, such as Liddle's disease. This review focuses on an experimental approach that attempts to define candidate genes for essential hypertension using immortalized cells from well characterized normotensive and hypertensive subjects. From the presently available results, one attractive speculation is that an increased intracellular signal transduction caused by an enhanced reactivity of Gj-type G proteins represents a genetically fixed trait that renders affected individuals susceptible to essential hypertension.     

Iontophoresis: an alternative in the treatment of dental caries?

Celiac sprue (CS) is frequently complicated by malignancy, most commonly small intestinal lymphoma. Our study was performed in an area with a high prevalence of CS to define the clinical features, response to treatment, and outcome of this tumor. Of a total of 31 lymphomas complicating CS identified, 30 case records and 24 tumor specimens were reviewed. Overall 1-year survival was 9 of 29 (31%) and 5-year survival 3 of 27 (11%). Seven previously diagnosed celiac patients developed lymphoma; length on gluten-free diet ranged from 12 to 252 months (median 44 months). In this group, presentation was nonspecific, diagnosis difficult, and survival poor (lymphoma diagnosed in life in four of seven, mean survival 2.25 months). Twenty-three patients had CS and lymphoma diagnosed during the same illness. In this group, 14 of 23 presented with a surgical emergency and were treated with tumor resection and chemotherapy. Nine are disease-free and alive or died of another cause after 10-196 months (mean 74 follow-up). Celiac-associated lymphoma is a frequent, difficult to diagnose, and commonly fatal complication of CS. An aggressive diagnostic approach, including laparoscopy, is recommended. Long-term survival can be expected in a significant number of these patients and in our series was almost exclusively confined to those treated with chemotherapy.     

Documenting informed consent for treatment with neuroleptics: an alternative to the consent form

Clinicians can comply with Ohio state regulations for documenting patients' informed consent for treatment with neuroleptic medication by checking a box in the medical record stating that a periodic discussion of informed consent has occurred and writing a note about the discussion in the narrative record. The authors discuss clinicians' experience with this alternative to the conventional consent form in a large community support agency. Although the approach has been largely successful, implementation has been hindered by some clinicians' incomplete understanding of the informed consent process. Continued training is needed to bring the ideal of informed consent into clinical practice.     

Holistic approach to analysis of medical data: vulvar cancer

Calpains are calcium-dependent intracellular nonlysosomal proteases that are believed to participate in signal transduction. In vertebrates, five different calpains have so far been identified, of which three, mu-, m-, and mu/m-calpain, are ubiquitously expressed while the other two, nCL-1 (p94) and nCL-2, exhibit a restricted tissue distribution. We have identified two new vertebrate calpain genes, Capn5 and Capn6. The human and mouse amino acid sequences of these new calpains are the most divergent of the vertebrate calpains identified. They possess most of the residues conserved in calpain family members but the C-terminal region lacks any homology to the calmodulin-like domain of other vertebrate calpains. They both exhibit significant homology over the entire coding region to the protein encoded by the gene tra-3, involved in nematode sex determination, and Capn5 may represent its vertebrate orthologue. The predicted Capn6 protein lacks critical active site residues and may not be proteolytically active. Both genes are differentially expressed in human tissues with highest RNA levels for Capn5 occurring in the testis, liver, trachea, colon, and kidney, while Capn6 is highly expressed only in the placenta sample of the 50 tissues examined. Phylogenetic analysis suggests that the vertebrate calpains arose through a series of gene duplication events that began before the initial divergence of the vertebrate and invertebrate lineages. The discovery of these two new calpains highlights a hitherto unknown complexity of the calpain family with subclasses perhaps possessing different modes of regulation.