[Angina pectoris in a 47-year-old athletic man with psoriasis vulgaris]. / Pektanginöse Beschwerden bei einem 47-jährigen athletischen Patienten mit Psoriasis vulgaris.

A 47-year-old man presented with angina pectoris complaints in the chest pain unit. Due to psoriasis and psoriatic arthritis he had been systemically treated for 4 years. Because of an increased cardiovascular risk profile, coronary heart disease (CHD) was suspected and an invasive coronary diagnosis was performed. In the cardiac catheterization, CHD could be detected and treated in the same session. The risk of CHD in patients with psoriasis is increased due to a higher incidence of risk factors but also the disease itself. Patients with psoriasis should regularly undergo cardiovascular risk screening.

Laparoscopic transperitoneal inguinal hernioplasty (TAPP) after radical open retropubic prostatectomy: special features and clinical outcomes.

Purpose Laparoscopic transperitoneal endoscopic (TAPP) and totally extraperitoneal (TEP) hernia repair have been well established in primary and recurrent inguinal hernias [1]. Only few studies [2-5] evaluate the surgical outcome of patients with inguinal hernias after radical prostatectomy, using the TAPP or TEP procedure. But controversies remain including its feasibility, safety and recurrence rate. The mesh size to be used and the necessity of a complete dissection of the scared retropubic space are discussed controversially. Long-term follow-up studies are missing.Methods After introducing the technique of a laparoscopic transperitoneal endoscopic hernioplasty (TAPP) at the hospital in October 1992, this approach had been recommended to all adult patients with inguinal and femoral hernias. In our single-center study, the medical records of all 5,764 patients with 7,010 inguinal and femoral hernias, operated from 1993 until 2009, were enrolled in a retrospective analysis. A TAPP procedure was performed in 6,582 hernias (Peitsch, Surg Endosc 28:671-682, 2014). During that period, 48 patients with 55 inguinal hernias on average of 3.7 years (3 months-14 years) after prior open radical retropubic prostatectomy underwent hernia surgery (92.7% TAPP). The age of these patients, time required for surgery, hernia location (medial, lateral, combined and bilateral), the perioperative (30-day complications "Clavien Classification") and late complications with a median postoperative follow-up time of 8.0 years (2-17 years) were analyzed and compared with the data of the control group (all TAPP procedures for inguinal and femoral hernias).Results Patients with inguinal hernias after radical open retropubic prostatectomy were older as patients of the control group (70.3 vs. 59.1 years) and the medial time required for surgery was significantly longer (72.9 vs. 41.3 min). Less frequent were bilateral inguinal hernias (25.5 vs. 35.8%), medial inguinal hernias (Hernia classification Nyhus Type 3A) with 5.5 vs. 17.9% and femoral hernias (0 vs. 4.9%). No hernia patient after radical prostatectomy and only 0.1% of the control group (n = 6582 hernias) had a conversion to an anterior open repair. One patient after radical prostatectomy needed a laparoscopic drainage of a hemato-seroma 48 h postoperatively (1/51). The rate of late postoperative complications was low. 4.8% of patients reported of groin pain and 2.4% of testicular pain longer than 28 days postoperatively. The hernia recurrence rate of 2.4% (1/42 TAPP) was not significantly different from the control group (1.8%, 16/896 hernias).Conclusions In the hands of surgeons with large experiences in endoscopic laparoscopic hernia repair, the laparoscopic transperitoneal hernioplasty (TAPP) after previous radical open retropubic prostatectomy is safe and effective with low intra- and postoperative complications and low hernia recurrences (2.4%). A TAPP technique with closure of hernia gaps larger than 1 × 1 cm with non-absorbable surgical sutures and a mesh-size of 13 × 13-15 cm is requested. A complete sharp dissection of the retropubic scared tissue for mesh implantation is not mandatory.

[Psoriasis in special localizations]. / Psoriasis in besonderen Lokalisationen.

A large proportion of patients with plaque psoriasis suffer from psoriatic lesions of the scalp, nails, and intertrigines. These locations can also be soley or predominantly affected. Scalp psoriasis, nail psoriasis, and inverse psoriasis are often perceived as particularly stigmatizing. Involvement of these parts of the body is associated with an increased risk of psoriatic arthritis. Location-specific features must be considered when choosing treatment. Evidence for topical therapy of scalp psoriasis with steroids and combinations of steroids and vitamin D analogues is high. These agents are regarded as safe and effective treatments of first choice. Efficacy of TNF antagonists and apremilast is well documented for refractory scalp psoriasis. Nail psoriasis often responds insufficiently to topical therapy. Several effective systemic medications including methotrexate and TNF antagonists are available for treatment of severe forms. Controlled trials for treatment of inverse psoriasis are scarce. Topical steroids, vitamin D analogues, dithranol, and off-label calcineurin inhibitors are used in clinical practice. This review provides a survey on the clinical presentation and current evidence for treatment of psoriasis in challenging locations.

Matching physicians' treatment recommendations to patients' treatment preferences is associated with improvement in treatment satisfaction.

BACKGROUND: Dissatisfaction with treatment is common among those with psoriasis. While incorporating patients' preferences into the process of treatment decision-making may improve satisfaction, this relationship has not been clearly established. OBJECTIVE: To assess the extent to which matching physicians' treatment recommendations to patients' treatment preferences is associated with improvement in treatment satisfaction in patients with moderate-to-severe psoriasis. METHODS: This prospective cohort study design examined change from baseline to 3-month follow-up in four subscales of an established measure of treatment satisfaction. Separate multivariate regression models investigated the association of change in these subscale scores with an index measuring the match between physicians' treatment recommendations and patients' treatment preferences at the initial study visit. RESULTS: A closer match between physicians' recommendations and patients' preferences was associated with greater improvement in treatment satisfaction over time in each of the four subscales: effectiveness (ß = 0.53, P < 0.001), side-effects (ß = 0.25, P = 0.009), convenience (ß = 0.78, P < 0.001) and global satisfaction (ß = 0.49, P < 0.001). Adjusted models explained as much as 76% of the variation in change in treatment satisfaction subscales over 3 months. CONCLUSIONS: Further efforts to incorporate patients' preferences in treatment decision-making appear justified given the strength of independent associations between preference matching and improved treatment satisfaction and the extent to which our models explained variation in this relationship. An approach based on preference matching shows promise for increasing satisfaction in the management of other chronic diseases.

Patient preferences for psoriasis treatments: impact of treatment experience.

BACKGROUND: Patient preferences for psoriasis treatments can impact treatment satisfaction and adherence and may therefore influence clinical outcome. OBJECTIVE: To assess the impact of treatment experience (satisfaction with current treatment, number of prior visits, disease duration, number of preceding therapies and currently prescribed treatment modalities) on treatment preferences. METHODS: A computer-based conjoint analysis experiment was conducted to analyse preferences of patients with moderate or severe psoriasis (n = 163) treated at a German University Medical Center for outcome (probability, magnitude and duration of benefit; probability, severity and reversibility of side effects) and process attributes (location, frequency, duration, delivery method, individual cost) of psoriasis treatments. Relative importance scores (RIS) were calculated for each attribute and compared using anova, post hoc test and multivariate regression analysis. RESULTS: Participants with longer disease duration attached significantly greater importance to duration of benefit (ß = 0.206, P = 0.018), whereas participants on oral therapy were more concerned about magnitude of benefit by trend (ß = 0.218, P = 0.058). Participants receiving injectables not only set higher value to probability of benefit (RIS = 32.80 vs. 21.89, P = 0.025) but also to treatment location (RIS = 44.74 vs. 23.03, P = 0.011), delivery method (RIS = 43.75 vs. 19.29, P = 0.019), treatment frequency (RIS = 31.24 vs. 16.89, P = 0.005) and duration (RIS = 32.54 vs. 16.57, P = 0.003) when compared with others. Treatment satisfaction was significantly higher in participants on infusions or injections compared with those on phototherapy and mere topical therapy. CONCLUSIONS: Treatment preferences may change over time course and with treatment experience. Participants on injectables attach great importance to efficiency and convenience of therapies, and are highly satisfied with their treatment.

P-cadherin expression in Merkel cell carcinomas is associated with prolonged recurrence-free survival.

BACKGROUND: Merkel cell carcinoma (MCC) is a highly aggressive skin cancer, associated with advanced age, immunosuppression and Merkel cell polyomavirus (MCV) infections. As development and progression of cancer can be promoted by changes in cell adhesion proteins, we have previously analysed homo- and heterotypic cell-cell contacts of normal Merkel cells and MCCs and obtained indications for cadherin switching. OBJECTIVES: To examine the prevalence and prognostic relevance of E-, N- and P-cadherin in MCCs. METHODS: Paraffin-embedded MCC samples (n = 148) from 106 different patients were analysed by double-label immunostaining and immunofluorescence microscopy. MCV status was determined by real-time polymerase chain reaction. The cadherin repertoire and MCV status were correlated to clinical data, including tumour stage and recurrence-free survival. RESULTS: Ninety-one per cent of all MCC were positive for N-cadherin whereas only 61·6% and 70·3% expressed E- and P-cadherin, respectively. P-cadherin was significantly more frequent in primary tumours than in lymph node metastases (81·9% vs. 40·9%, P = 0·0002). Patients with P-cadherin-positive primary tumours were in earlier tumour stages at initial diagnosis (P = 0·0046). Both in log-rank tests (P = 0·0474) and in multiple Cox regression analysis including age, sex, immunosuppression, stage at initial diagnosis and MCV status (hazard ratio 0·193, P = 0·0373), patients with P-cadherin-positive primary MCCs had significantly prolonged recurrence-free survival (mean 25·2 vs. 10·6 months; median 9·0 vs. 4·0 months). MCV DNA was detected in 78·2% of all MCC, more frequently in P-cadherin-positive MCC (P = 0·0008). CONCLUSION: P-cadherin expression in MCCs predicts prolonged recurrence-free survival and may therefore indicate favourable prognosis.

[Exulcerated, nodular tumor on the occiput of a 29-year-old patient]. / Exulzerierter, nodulärer Tumor am Hinterkopf eines 29-jährigen Patienten.

Cranial fasciitis is a rare variation of nodular fasciitis that occurs in the region of the capillitium. We report on a 29-year-old patient who presented with a 2-month history of a tumor progressively increasing in size located on the occiput. Histological examination revealed a tumor, consisting of tightly packed spindle-shaped cells with underlying myxoid stroma, which extended from the dermis to the subcutis. Actin and vimentin were detected by immunohistochemistry. We established a diagnosis of cranial fasciitis and excised the tumor. Especially when a child or young adult presents with a tumor in the skull area, consideration should be given to cranial fasciitis in the differential diagnosis to avoid unnecessary and possibly very invasive treatment approaches.

[Caterpillar dermatitis. An increasing dermatologic problem in warmer regions of Germany]. / Lepidopterismus. Ein zunehmendes Hautproblem in klimatisch wärmeren Regionen Deutschlands.

Caterpillar dermatitis or lepidopterism (Lepidoptera = butterflies) is a toxic-irritant, or rarely allergic, reaction triggered by the release of histamine, thaumetopoein and other kinins from the hairs of butterflies and caterpillars. In Central Europe, the two main causes of caterpillar dermatitis are the oak and pine processionary caterpillar. In addition to cutaneous reactions, patients may develop conjunctivitis, bronchitis and even anaphylactic reactions. We describe the cutaneous aspects of caterpillar dermatitis based on two case reports.

[Hematogenous contact dermatitis after intravesicular instillation of mitomycin C]. / Hämatogenes Kontaktekzem nach intravesikaler Instillation von Mitomycin C.

Mitomycin C is an alkylating chemotherapeutic agent which is instilled intravesically to prevent recurrence of superficial bladder carcinomas. After several cycles of mitomycin C, our patient developed a pruritic genital dermatitis and palmar desquamation. Following exclusion of a fungal infection, we performed patch tests using the standard series, the major basic ointment ingredients, disinfectants, and mitomycin C in concentrations of 0.001 to 0.1%; the resulting diagnosis was allergic contact dermatitis due to delayed-type hypersensitivity to mitomycin C. The skin rash rapidly resolved with application of topical steroids, and the intravesical chemotherapy was changed to doxorubicin. Eczematous skin reactions are quite common side effects after intravesical instillation of mitomycin C. In the majority of cases, they are caused by delayed-type hypersensitivity reactions, presumably elicited by hematogenous spread of the allergen, and not by irritation. The sensitization most likely occurs via the bladder mucosa. In order to differentiate between allergic and toxic contact dermatitis, patch tests with the above-mentioned mitomycin C concentrations are useful. In cases of mild allergic contact dermatitis the intravesical chemotherapy might be continued with concomitant topical steroids.

[Hypereosinophilic dermatitis. An overlooked diagnosis?]. / Hypereosinophile Dermatitis. Ein verkanntes Krankheitsbild?

BACKGROUND: The idiopathic hypereosinophilic syndrome is a rare systemic disease characterized by blood and tissue eosinophilia of unknown etiology, in which multiple organs may be affected. In hypereosinophilic dermatitis the only affected organ besides the blood is the skin. PATIENTS: We present a series of seven patients with hypereosinophilic dermatitis who were treated in our hospital between 2002 and 2003. RESULTS: All patients initially showed characteristic, therapy-resistant, polymorphic skin lesions, presenting with a combination of erythematous, pruritic and urticarial papules and plaques. All had blood eosinophilia without evidence of allergic, parasitic or other causes. The histology showed tissue eosinophilia only in half of the cases; the other histological findings were non-specific. We observed a good response to therapy with systemic corticosteroids, dapsone and light therapy, applied as UVA-1 irradiation or as shower photochemotherapy. CONCLUSIONS: The diagnosis "hypereosinophilic dermatitis" should be based primarily on the characteristic clinical picture together with "idiopathic" peripheral eosinophilia, whereas the histological findings are not always indicative. Because of the multiplicity of possible differential diagnoses and the often non-revealing histology, we assume that the diagnosis "hypereosinophilic dermatitis" is often overlooked.

Drebrin particles: components in the ensemble of proteins regulating actin dynamics of lamellipodia and filopodia.

Drebrin, an actin-binding 70-kDa protein with an unusually slow SDS-PAGE mobility corresponding to approximately 120 kDa, containing a proline-rich, profilin-binding motif, had originally been reported from neuronal cells, but recently has also been found in diverse other kinds of tissues and cell lines. In biochemical analyses of various cells and tissues, employing gel filtration, sucrose gradient centrifugation, immunoprecipitation and -blotting, we have identified distinct states of soluble drebrin: a approximately 4S monomer, an 8S, ca. 217-kDa putative trimer, a 13S and a > 20S oligomer. In the 8S particles only [35S]methionine-labelled drebrin but no other actin-binding protein has been detected in stoichiometric amounts. By immunofluorescence and immunoelectron microscopy, drebrin-positive material often appeared as "granules" up to 400 nm in diameter, in some cell types clustered near the Golgi apparatus or in lamellipodia, particularly at leading edges, or in dense-packed submembranous masses at tips (acropodia) or ruffles of leading edges, in filopodia and at plaques of adhering junctions. We conclude that these drebrin complexes and drebrin-rich structures allow the build-up and maintenance of high local drebrin concentrations in strategic positions for the regulation of actin filament assembly, thereby contributing to cell motility and morphology, in particular local changes of plasticity and the formation of protrusions.

Cryptococcosis in patients with cancer.

Records of 31 patients with cancer who did not have known human immunodeficiency virus infection and who developed culture-proven cryptococcosis during the period of 1989-1999 (incidence of 18 cases per 100,000 admissions) were retrospectively reviewed. Several presentations of cryptococcosis were seen, including pulmonary in 19 patients (13 of which were symptomatic), disseminated in 6, meningeal in 3, and other, less common manifestations in 3. Hematologic malignancy (in 20 patients [65%]) was the most common underlying disease. Lymphopenia was present in 19 patients (61%). Previous steroid use was noted in 16 patients (51%). The diagnosis of cryptococcosis was rarely suspected; lung and brain malignancy were frequent initial impressions. Cryptococcosis was diagnosed postmortem in only 2 cases (6%). In cases of both pulmonary and meningeal cryptococcosis, the yield of invasive diagnostic procedures was good. Antifungal treatment was heterogeneous, but only 18% of patients who received it had treatment failure. Fluconazole monotherapy was successful in 92% of patients. In conclusion, cryptococcosis is rare in patients with cancer and appears to have a relatively good diagnostic yield and therapeutic outcome.

Drebrin is a widespread actin-associating protein enriched at junctional plaques, defining a specific microfilament anchorage system in polar epithelial cells.

Using immunoblotting, immunprecipitation with subsequent fragment mass spectrometry, and immunolocalization techniques, we have detected the actin-binding ca. 120-kDa protein drebrin, originally identified in - and thought to be specific for - neuronal cells, in diverse kinds of human and bovine non-neuronal cells. Drebrin has been found in numerous cell culture lines and in many tissues of epithelial, endothelial, smooth muscle and neural origin but not in, for example, cardiac, skeletal and certain types of smooth muscle cells, in hepatocytes and in the human epithelium-derived cell culture line A-431. By double-label fluorescence microscopy we have found drebrin enriched in actin microfilament bundles associated with plaques of cell-cell contact sites representing adhering junctions. These drebrin-positive, adhering junction-associated bundles, however, are not identical with the vinculin-containing, junction-attached bundles, and in the same cell both subtypes of microfilament-anchoring plaques are readily distinguished by immunolocalization comparing drebrin and vinculin. The intracellular distribution of the drebrin- and the vinculin-based microfilament systems has been studied in detail by confocal fluorescence laser scanning microscopy in monolayers of the polar epithelial cell lines, MCF-7 and PLC, and drebrin has been found to be totally and selectively absent in the notoriously vinculin-rich focal adhesions. The occurrence and the possible functions of drebrin in non-neuronal cells, notably epithelial cells, and the significance of the existence of two different actin-anchoring junctional plaques is discussed.

A novel type of adhering junction in an epithelioid tumorigenic rat cell culture line.

Two major types of plaque-bearing adhering junctions are commonly distinguished: the actin microfilament-anchoring adhaerens junctions (AJs) and the desmosomes anchoring intermediate-sized filaments (IFs). Both types of junction usually possess the common plaque protein, plakoglobin, whereas the other plaque proteins and the transmembrane cadherins are mutually exclusive. For example, AJs contain E-, N-, or P-cadherin in combination with alpha- and beta-catenin, vinculin and alpha-actinin, whereas in desmosomes, desmogleins and desmocollins are associated with desmoplakin and one or several of the plakophilins (PP1-3). Here we describe a novel type of adhering junction comprising proteins of both AJs and desmosomes and the tight junction (TJ) plaque protein, ZO-1, in a newly established, liver-derived tumorigenic rat cell line (RMEC-1). By immunofluorescence microscopy, cell-cell contacts are characterized by mostly continuous-appearing lines which are usually resolved by electron microscopy as extended arrays of closely spaced small plaque subunits. These plaque-covered regions are positive for plakoglobin, alpha- and beta-catenin, the arm-repeat protein p120, vinculin, desmoplakin and protein ZO-1. They are positive for E-cadherin in cultures early on in passaging, but tend to turn negative for all known cadherins in densely grown cultures. On immunoblotting SDS-PAGE-separated proteins from dense-grown cell monolayers, "pan-cadherin" antibodies have reacted with a band at approximately 140 kDa, identified as N-cadherin by peptide fingerprinting of the immunoprecipitated protein, which for reasons not yet clear is modified or masked in immunolocalization experiments. The exact histological derivation of RMEC-1 cells is not known. However, the observations of several endothelial markers and the fact that all cells are rich in IFs containing vimentin and/or desmin, while only subpopulations also reveal IFs containing CKs 8 and 18, is suggestive of a mesenchymal, probably endothelial origin. We discuss the molecular relationship of this novel type of extended junction with other types of adhering junctions.

Budd-Chiari syndrome as the primary manifestation of a fibrolamellar hepatocellular carcinoma.

An 18-year-old female patient was admitted with ascites, right upper abdominal tenderness and peripheral edema. Angiography showed complete occlusion of the vena cava inferior up to the level of the right atrium. By open heart surgery, masses of thrombotic material were pulled out of the v. cava inferior/vv. iliacae which histologically contained tumor cell populations consistent with a hepatocellular carcinoma. Celiacography showed a highly vascularized tumor in the right hepatic lobe. Histologically, it proved to be fibrolamellar subtype hepatocellular carcinoma.