Three cases of bullous morphea: histopathologic findings with implications regarding pathogenesis

Bullous morphea is a rare variant and is not frequently reported. We present three cases of bullous morphea. Although lymphangiectases have been suggested as the most likely mechanism for the development of the bullae in cases of morphea, none of the cases presented with lymphangiectases. To the contrary, all of our cases showed hemorrhagic content in the bullae, which suggests local trauma as a mechanism involved in bulla formation.     

Porocarcinoma with areas of mucinous differentiation suggesting multilineage differentiation

Porocarcinoma is an infrequent malignant adnexal carcinoma, with some histopathological variants described, such as the clear cell, the sarcomatoid or the pigmented porocarcinoma. We report an invasive porocarcinoma showing areas of tumor cells floating in prominent dermal mucin, simulating mucinous carcinoma, that we consider a new histopathological variant of porocarcinoma. We report a 74‐year‐old male with previous history of multiple basal cell carcinomas that presented a nodule on his left temple. Histopathologic study showed a large ulcerated multilobular tumor composed of thickened cords of cells emanating from a hyperplastic epidermis and showing a mixed infiltrative and pushing pattern in the dermis. Poroid differentiation was observed in most of the neoplasm, both in intraepidermal and dermal invasive component. Within the neoplasm a prominent area where these small nests with clear formation of ducts were floating in mucinous pools with few septa intermingled was observed, simulating a primary cutaneous mucinous carcinoma. Cytology, immunohistochemistry and the presence of both neoplastic areas as closely related and with multiple points of connectivity favors the consideration of a composite tumor in this peculiar case. Other differentials are discussed.     

An analysis of the survival outcomes of simultaneous pancreas and kidney transplantation compared to live donor kidney transplantation in patients with type 1 diabetes: a UK Transplant Registry study

Transplant options for patients with type 1 diabetes and end‐stage renal disease (ESRD) include deceased donor kidney, live donor kidney (LDK) and simultaneous pancreas‐kidney (SPK) transplantation. The aim of this study was to compare outcomes between LDK and SPK for patients with type 1 diabetes and ESRD in the UK. Data on all SPK (n = 1739) and LDK (n = 385) transplants performed between January 2001 and December 2014 were obtained from the UK Transplant Registry. Unadjusted patient and kidney graft survival were calculated using the Kaplan–Meier method. Multivariate analysis of kidney graft and patient survival was performed using Cox proportional hazards regression. There was no significant difference in patient (P = 0.435) or kidney graft survival (P = 0.204) on univariate analysis. On multivariate analysis there was no association between LDK/SPK and patient survival [HR 0.71 (0.47–1.06), P = 0.095]. However, LDK was associated with an overall lower risk for kidney graft failure [HR 0.60 (0.38–0.94), P = 0.025]. SPK recipients with a functioning pancreas graft had significantly better kidney graft and patient survival than LDK recipients or those with a failed pancreas graft. SPK transplantation does not confer an overall survival advantage compared to LDK. However, those SPK recipients with a functioning pancreas have significantly better outcomes.     

Hemodynamics "au contraire" despite diastolic flow reversal and angiographically severe aortic regurgitation

One of the commonly used parameters for evaluating aortic regurgitation is the rate of pressure decay data obtained from echocardiographic evaluation or cardiac catheterization. The measurement of the rate of equalization of pressure between the aorta and the left ventricle and its utility in the setting of aortic insufficiency has been validated. Intuitively, the Doppler equivalent, pressure half-time, is inversely related to the severity of regurgitation. However, this is a phenomenon dependent on multiple variables including blood pressure, heart rate, compliance of the receiving chamber, effects of vasopressors and the volume status of the patient. We report a case of unique hemodynamics obtained during cardiac catheterization due to low filling pressures that was further confounded by elevated systemic vascular resistance in a critically ill patient with angiographically severe aortic regurgitation.     

Arthroscopic lavage speeds reduction in effusion in the glenohumeral joint after primary anterior shoulder dislocation: a controlled randomized ultrasound study

Recent studies have shown that arthroscopic lavage of the glenohumeral joint within 10 days following a primary anterior dislocation significantly lowers the recurrence rate when compared with a nonoperative regime. We hypothesize that the lavage reduces distension in the joint and thereby facilitates adaptation and healing of the soft tissue lesion. Using ultrasound, we assessed the hemarthrosis in the glenohumeral joint weekly in 16 consecutive patients after traumatic primary anterior shoulder dislocation. The patients were randomized into two groups for treatment with either arthroscopic lavage or a nonoperative regime. Except for the lavage the two groups followed an identical rehabilitation program. Transversal dorsal ultrasound of the glenohumeral joint was performed, in which the joint effusion was assessed as the distance between the humeral head and the glenoid. Prior to the lavage the two groups had a similar amount of excessive joint effusion. The effusion declined to a steady state level within 3–7 weeks. The joint effusion decreased more rapidly (33%) in the group treated with arthroscopic lavage (P = 0.02) than in the nonoperated group. Received: 10 December 1998 /Accepted: 2 July 1999     

Ureteric complications in recipients of kidneys from donation after circulatory death donors

A large increase in the use of kidneys from donation after circulatory death (DCD) donors prompted us to examine the impact of donor type on the incidence of ureteric complications (UCs; ureteric stenosis, urinary leak) after kidney transplantation. We studied 1072 consecutive kidney transplants (DCD n=494, live donor [LD] n=273, donation after brain death [DBD] n=305) performed during 2008‐2014. Overall, there was a low incidence of UCs after kidney transplantation (3.5%). Despite a trend toward higher incidence of UCs in DCD (n=22, 4.5%) compared to LD (n=10, 3.7%) and DBD (n=5, 1.6%) kidney transplants, donor type was not a significant risk factor for UCs in multivariate analysis (DCD vs DBD HR: 2.33, 95% CI: 0.77‐7.03, P=.13). There was no association between the incidence of UCs and donor, recipient, or transplant‐related characteristics. Management involved surgical reconstruction in the majority of cases, with restenosis in 2.7% requiring re‐operation. No grafts were lost secondary to UCs. Despite a significant increase in the number of kidney transplants from DCD donors, the incidence of UCs remains low. When ureteric complications do occur, they can be treated successfully with surgical reconstruction with no adverse effect on graft or patient survival.     

Port-A-Cath in Children During Long-Term Chemotherapy: Complications and Outcome

Complications related to Port-A-Cath were studied prospectively during a period of 32 months in 31 patients, aged 1-18years, with leukemias and solid tumors. There were 34 Port-A-Cath inserted, and the cumulative time for these catheters kept in place was 5899 days. No complications occurred in 18 patients (19 catheters) kept in place for a cumulative time of 3998 days with an average duration of 210 days (12-550 days). In 13 patients (15 catheters) there were 14 events of systemic infections; seven events were treated successfully with antibiotics, four events necessitated the extraction of the catheter (in one patient a combination of systemic and local infection), and in three events the catheters were kept unused, as the patients were in terminal stages. Nonsystemic complications occurred with five catheters; two local infections, two obstructions (catheters removed), and one local bleeding (catheter kept unused). Appropriate antimicrobial treatment of systemic infections enables the immunocompromised child to keep the Port-A-Cath in place for a long time.     

Acute and chronic gastrointestinal manifestations associated with Yersinia enterocolitica infection. A Norwegian 10-year follow-up study on 458 hospitalized patients.

The aim of the present study was to elucidate the gastrointestinal manifestations of yersiniosis. During the period 1974 to 1983, Yersinia enterocolitica infection was diagnosed in 458 patients, by isolation from fecal samples or by antibody response. At first admission, 184 patients had abdominal pain; 200, diarrhea; 45, vomiting; and 36, weight loss. Ulcerative colitis was diagnosed in 7 patients, Crohn's disease in 2, and unspecific colitis in 11. Mesenteric lymphadenitis or ileitis were found in 43 of 56 patients at laparotomy. The patients were followed for 4 to 14 years (1987). Thirty-eight patients were readmitted with abdominal pain and 28 with diarrhea; these symptoms were significantly correlated with the corresponding symptoms at first admission. Chronic colitis was diagnosed in 4 patients, chronic weight loss in 12. A follow-up inquiry (380 patients) indicated that patients with right iliac fossa pain during the acute infection less frequently developed chronic abdominal complaints. Gastrointestinal symptoms are common in both the acute and chronic states of yersiniosis. The correlations between acute and chronic symptoms indicate that yersiniosis is a chronic disease. Immunologically competent individuals may profit by fighting the infection in the right iliac fossa. The relationship between yersiniosis and inflammatory bowel diseases may still not be settled.     

A single‐centre experience of Roux‐en‐Y enteric drainage for pancreas transplantation

Exocrine drainage following pancreas transplantation can be achieved by drainage into the bladder or bowel, the latter typically by direct duodeno‐jejunostomy; the use of Roux‐en‐Y enteric drainage is uncommon. We report a retrospective analysis of a single‐centre experience of Roux‐en‐Y enteric drainage following pancreas transplantation. Over a 14‐year period (2001–2015), 204 consecutive adult pancreas transplants were performed (96.6% simultaneous pancreas and kidney transplants), of which 26.0% were from donors after circulatory death (DCD). During a median follow‐up of 67 months (range 13–183 months), 14 (6.9%) recipients experienced complications related to their enteric drainage. Complications during follow‐up included early enteric anastomotic haemorrhage (five patients), non‐anastomotic enteric bleeding (one patient), small bowel obstruction (four patients) and graft duodenal perforation (two within 6 weeks, five beyond 12 months). No recipient lost their graft as a direct result of complications related to enteric drainage. Patient and pancreas graft survival at 1 year was 99.0% and 94.0% and at 5 years 91.3% and 84.9%, respectively. We conclude that Roux‐en‐Y enteric drainage following pancreas transplantation is a safe and effective procedure and facilitates graft salvage in the event of graft duodenal perforation.