Immunohistochemical characterization of the 'intimal proliferation' phenomenon in Sneddon's syndrome and essential thrombocythaemia

Cellular changes were immunocytochemically characterized in skin vessels of five patients with idiopathic generalized racemose livedo (Sneddon's syndrome), and one patient with localized racemose livedo associated with essential thrombocythaemia. Antibodies against α-smooth muscle-actin, tropomyosin, desmin, vimentin, factor VIII-related antigen, human endothelial cells (CD31), human macrophages (CD68), and HLA-DR positive cells (CR3/43) were used. Conventional light microscopy showed, in all cases, intimal thickening of ascending arteries and arterioles as a result of an accumulation of cells and extracellular hyalinized material. None of the specimens showed infiltration with polymorphonuclear leucocytes or macrophages. The cells in the region of the intimal hyperplasia showed intense positive immunostaining for α-smooth muscle actin and tropomyosin. Staining for the intermediate filament desmin was localized to the resident smooth muscle cells of the media, whereas staining for vimentin was found in all types of cells in both the intima and media. Positive immunostaining for factor VIII-related antigen and CD31 was strictly confined to the endothelial cells lining the narrowed lumina of the vessels. No positive staining with either antibody was observed in totally occluded vessels. Cells in the subintimal space did not show reactivity for CD68 in any of the specimens, but two cases showed solitary cells with positive staining for HLA-DR in this region. There were no differences in staining pattern between Sneddon's syndrome and essential thrombocythaemia with any of the antibodies. Our results support the assumption that the ‘intimal proliferation’ in both diseases is caused by colonization of the subendothelial space with contractile cells of possibel smooth muscle origin. The similarities in histopathology and immunocytochemistry might indicate that in both diseases platelet-derived factors play a causative role.     

Elephantiasis nostras verrucosa: beneficial effect of oral etretinate therapy

Elephantiasis nostras verrucosa is characterized by chronic secondary, non-filarial lymphoedema due to recurrent lymphangitis, dermal fibrosis, and epidermal changes consisting of hyperkeratotic, verrucous and papillomatous lesions. Histologically, there is pseudoepitheliomatous hyperplasia. Therapeutic efforts should aim to reduce lymph stasis, which will also lead to improvement of the cutaneous changes. In this study, rapid disappearance of the hyperkeratotic and verrucous lesions, remarkable flattening of the papillomatous nodules and improvement of lymphoedema occurred in three obese patients treated with etretinate in an initial dose of 0.6-0.75 mg/kg/day for 4-6 weeks. Monitoring of plasma concentrations of etretinate, acitretin and 13-cis-acitretin by HPLC revealed sufficient short-time absorption (4 h) and bioavailability of the drug (30 days; two out of three patients). Long-term maintenance therapy in one patient produced a remarkable improvement in the lymphoedema; another patient relapsed after discontinuation of the etretinate and responded again after this was reintroduced. In the third patient treatment was withdrawn because of an increase in triglycerides, but improvement persisted 6 months later. The clinical side-effects of oral retinoid therapy were moderate and well tolerated.     

Relapse rates in chronic hepatitis B naïve patients after discontinuation of antiviral therapy with entecavir

Registration studies show entecavir (ETV) to be effective and safe in NUC‐naïve patients with chronic hepatitis B, but relapse rates after treatment discontinuation have not been well established. Relapse rates and predictors of relapse were evaluated in naïve HBeAg‐positive and HBeAg‐negative patients treated with ETV. Treatment duration was defined according to international guidelines. Virological relapse was defined as reappearance in serum of hepatitis B virus (HBV) DNA to >2000 IU/mL after discontinuation of treatment. A hundred and sixty‐nine consecutive patients were treated for a median 181 weeks. 61% were HBeAg positive, 23% had cirrhosis, and mean HBV DNA level was 6.88 ± 1.74 log₁₀ IU/mL. Ninety‐two per cent became HBV DNA negative; 71% of HBeAg+ve patients became HBeAg negative and 68% anti‐HBe positive; 14% became HBsAg negative and 13% anti‐HBs positive. At the end of the study, 36 patients discontinued treatment: one due to breakthrough associated with resistant variants and 35 (20%) due to sustained virological response; 33 of these patients developed HBeAg seroconversion and 18 HBsAg seroconversion. Median off‐treatment time was 69 weeks. Nine patients (26%), all HBeAg positive at baseline, developed virological relapse after a median 48 weeks off‐treatment, 3 of them showed HBeAg reversion and 4 lost anti‐HBe. No patient with HBsAg seroconversion relapsed. HBeAg clearance after week 48 of treatment was associated with an increase risk of relapse. After ETV discontinuation, HBsAg seroconversion was maintained in 100% of the patients, HBeAg seroconversion maintained in 90%, and virological relapse rate was 24%.     

Incidence, clinical significance and prognosis of ventricular fibrillation in the early phase of myocardial infarction

Of 1265 patients admitted to the CCU with the diagnosis of acuteMI, 96 (7.6%) developed ventricular fibrillation within 72 hoursfollowing admission. Of these 96, 35 (36.5%) had secondary VFassociated with left ventricular failure; they had a high in-hospitalmortality of 57.1%. The remaining 61 (63.5%) had primary VF,i.e. VF occurring in the absence of significant LV failure.Fourteen of these (23%) died in hospital: 9 due to PVF (3 duringthe first episode, 6 during a recurrence). This mortality figurewas significantly higher (P<0.001) than the mortality of10% seen among patients who did not experience VF. Primary VFshowed a recurrence rate of 20%. Compared with the 1061 patientswho left the hospital without primary VF, the 61 subjects withthis rhythm disorder were older, had larger infarcts and morefrequent complications, such as pericarditis, conduction abnormalities,frequent ventricular premature contractions and signs of rightventricular failure. These findings, in contrast with a widelyheld view, suggest that primary VFmay carry a guarded prognosis.     

DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS (DISH) OF THE SPINE: A CAUSE OF BACK PAIN? A CONTROLLED STUDY

This is the first controlled study of the frequency of backpain in a European caucasian population with diffuse idiopathicskeletal hyperostosis (DISH). Elderly patients admitted to hospital for reasons other thanback pain were assessed for the presence of spinal DISH usingthe routine lateral chest radiograph films. A total of 106 probands(82 males, 24 females) with a mean age of 70 years fulfilledthe criteria for DISH as defined previously. One hundred andseventyeight patients (117 males, 61 females) not meeting thesecriteria were used as controls. The prevalence of back painwas assessed by a blinded interviewer using a structured questionnaire.Our primary hymthesis was that spinal DISH positive probandshad not had back pain more often than controls. The controlledstudy showed no statistically significant difference in painfrequency between spinal DISH positive probands and controlsat any spinal level. We conclude that back pain does not occur more often in radiographicallydefined DISH positive probands than in controls. The radiologicalfinding of spinal DISH, as far as it does not lead to stenosisof the spinal canal or dysphagia, thus seems to be a findingwithout clinical relevance. KEY WORDS: Spine, Radiographs, Pain, Osteoarthritis, Forestier's disease, Ankylosing vertebral hyperostosis