Histopathologic analysis of dermal lymphatic alterations in chronic venous insufficiency ulcers using D2-40.

BACKGROUND: Chronic venous insufficiency (CVI) ulcers represent a major medical problem worldwide. Current theories concerning the pathogenesis of CVI ulcers focus on abnormalities in the blood vascular system. Other abnormalities, such as chronic leg edema, may also play pathogenic roles in CVI ulcer development and further understanding of such alterations may lead to better treatments. OBJECTIVE: To gain insight into lymphatic abnormalities occurring in CVI, we compared dermal lymphatics in histologic sections from CVI ulcers and normal controls. METHODS: We compared global and architectural features of dermal lymphatics in D2-40-stained histologic sections from CVI ulcer tissue and from normal controls. D2-40 recognizes podoplanin, a transmembrane glycoprotein that is constitutively expressed in lymphatic endothelial cells, allowing us to distinguish dermal blood vessels from lymphatic vessels. RESULTS: Our analyses reveal that CVI ulcer specimens have more dermal lymphatic vessels per unit area than controls (5.71 vs 4.08 per mm(2), respectively; P = .0281); a higher percentage of lymphatic vessels with collapsed lumina compared with controls (30.5% vs 8.1%, respectively; P < .0001); and a higher percentage of competent lymphatic vessels displaying open inter-endothelial junctions compared with controls (5.7% vs 2.9%, respectively; P < .0369). LIMITATIONS: Our study is limited by its retrospective nature and relatively small sample size. CONCLUSIONS: Lymphatic vessels in CVI ulcer specimens display global and architectural differences compared with lymphatic vessels in control specimens. These findings further implicate lymphatic dysfunction in the pathogenesis of CVI ulcers and allow for the formulation of a hypothesis concerning lymphatic changes that may be tested in future studies.

Tumor necrosis factor-α in vitiligo: direct correlation between tissue levels and clinical parameters.

BACKGROUND: Experimental evidences have shown that tumor necrosis factor (TNF)-α may play a role in the pathogenesis of nonsegmental vitiligo, and successful cases of vitiligo treated with TNF-α inhibitors have been recently reported. MATERIALS AND METHODS: Two cases of refractory generalized vitiligo, which showed high tissue levels of TNF-α, were commenced anti-TNF-α antibody etanercept 50 mg weekly. A retrospective study, considering chart review and immunohistochemical staining for TNF-α, was then carried out on eight additional patients affected by untreated vitiligo. RESULTS: Etanercept achieved improvement of vitiligo in two patients at 6-month follow-up. Five out of eight specimens showed a strong cytoplasmic staining for TNF-α. Considering all 10 cases, patients with a strong TNF-α staining were characterized by a higher vitiligo disease activity score than patients with a weak staining. DISCUSSION: These findings, albeit limited in significance by the low number of cases and the retrospective nature of the study, confirm a probable role of TNF-α in the pathogenesis of vitiligo. The intensity of TNF-α staining in vitiligo lesions may be worth to be further studied as a biomarker for potentially successful anti-TNF-α treatment of nonsegmental vitiligo in cases refractory to conventional treatment.

Molecular markers of micrometastasis in oral cavity carcinomas.

OBJECTIVE: To examine the expression of candidate markers for micrometastasis. STUDY DESIGN: Cross-sectional analysis of subjects with oral cavity carcinomas who underwent sentinel lymph node biopsy (SLNB) and subsequent immunohistochemical (IHC) analysis. SUBJECTS AND METHODS: Two groups were identified based on SLNB status: negative SLNB (19/30) and positive SLNB (11/30). Specimens underwent IHC using conjugated monoclonal antibodies for membrane type-1 matrix metalloproteinase (MT1-MMP), CD44, focal adhesion kinase-1, and E-cadherin. Staining results were evaluated to determine if a particular marker was associated with SLNB status or other histopathologic prognosticators. RESULTS: For MT1-MMP, 21 percent (3/14) of evaluable specimens stained positively in the SLNB(-) group and 67 percent (4/6) stained positively in the SLNB(+) group (P=0.12). No statistically significant association was seen between any marker's staining pattern and SLNB status alone. When MT1-MMP staining was evaluated in tumors with SLNB(+) or perineural invasion (PNI) present on histopathology, six of nine specimens (67%) stained positively for MT1-MMP, vs one of 11 (9%) in specimens lacking either negative prognosticator (P=0.016, RR=7.33). CONCLUSION: Preliminary results suggest that MT1-MMP positivity in primary tumor specimens may identify aggressive tumor types, evidenced by the presence of micrometastasis or PNI.

Qualitative evaluation of a young carers' initiative.

This focus of this article is a qualitative, evaluative study of three Crossroads young carers projects. Focus group discussions took place with 24 young people aged 11-16 years. Data were analysed using a thematic content analysis approach. The themes of the research were: experiences of being a young carer, peer support, opportunities for time out and purposeful activities. The personal characteristics of the participants give rise to a number of worrying conclusions, that relatively young people were found to be undertaking primary caring roles over long periods of time. However, the groups were found to provide opportunities for young carers to experience a positive environment, participate in purposeful activities and have the chance to develop new friendships. Nevertheless, the literature suggests that provision of such projects is inadequate and under-resourced, which may disadvantage further a group of young people who are known to come from lower income families.

Tumor necrosis factor-alfa in nonhealing venous leg ulcers.

BACKGROUND: Venous leg ulcers are responsible for more than half of all lower extremity ulcerations, affecting more than one million Americans annually. Studies have demonstrated alterations in levels of proinflammatory cytokines in patients with chronic wounds, including tumor necrosis factor-alfa (TNFalpha), which may be implicated in wound chronicity. OBJECTIVE: To test the hypothesis that recalcitrant venous leg ulcers have increased local tissue TNFalpha as compared to normal skin. METHODS: Five patients with nonhealing healing chronic venous leg ulcers were recruited. Two 4-mm punch biopsy specimens were obtained: one from the wound margin and one from noninvolved, non-sun exposed normal skin on the flexor aspect of the forearm. Tissue samples were processed using fixed with formalin stained by immunohistochemistry for TNFalpha. Qualitative and quantitative comparisons were made for the presence of TNFalpha receptor in all tissue samples, specifically comparing the presence of TNFalpha in nonhealing venous leg ulcer samples versus normal skin. RESULTS: The overall staining score for nonhealing venous leg ulcers was significantly higher compared to respective normal skin samples (P = .01). In addition, immunostaining for TNFalpha was significantly less in the two nonhealing venous leg ulcers that were present for the shortest duration compared to the other ulcers of longer duration (P = .048). LIMITATIONS: The small sample size may mitigate the clinical implications of findings. CONCLUSIONS: Increased levels of TNFalpha in nonhealing venous leg ulcers, especially those of longer duration, implies that excessive inflammation may be causal in wound chronicity and suggests potential therapeutic alternatives.

Herpes simplex virus: a histopathologic study of the depth of herpetic wounds.

BACKGROUND: Herpes is a prevalent, infectious disease that can occur anywhere on the body; it is found primarily on the face and genitalia. Herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2) are the DNA viruses that cause human herpes. Clinically, HSV-1 and HSV-2 infections produce lesions generally located on the mucocutaneous junctions of the face and genitalia. At times, vesicular lesions may ulcerate, leaving recalcitrant wounds that are challenging to treat. Until now, the basis of treatment has been related to the eradication of the viral infection. Little attention has focused on the consequence of the viral infection and the resulting wounds, specifically whether this represents an epidermal or dermal injury. METHODS: Using 10 herpetic lesions from different individuals, we studied the depth of the injury via routine hematoxylin and eosin stains, as well as periodic acid-Schiff (PAS) and type IV collagen stains, which demonstrate the presence of the basement membrane. RESULTS: In all cases, we found an inflammatory infiltrate in the dermis and selective disruption of the basement membrane. CONCLUSION: This suggests that herpetic lesions involve the dermis and are best classified as partial-thickness wounds.

Treatment of herpes simplex virus infection: rationale for occlusion.

Orofacial herpes is a widespread benign malady that is also commonly known as herpes labialis or cold sores. Herpes of this type is generally caused by herpes simplex virus type 1 (HSV-1) and, to a lesser degree, herpes simplex virus type 2 (HSV-2), both of which are DNA viruses. The clinical presentation of herpetic lesions is normally located on mucocutaneous areas of the face and may eventually erode and ulcerate, leaving wounds that are known to be difficult to successfully treat. Focus of treatment has been related to treatment of the viral infection, and limited attention has focused on the resultant wounds. Clinical observation and recent histologic evaluation has demonstrated these wounds to extend through a disrupted cutaneous basement membrane into the dermis, suggesting that HSV is capable of causing partial-thickness wounds. This observation suggests a role for occlusion in the treatment of herpetic-induced partial-thickness wounds because occlusion is well recognized as the treatment of choice for other types of partial-thickness wounds.

Strengthening an academic nursing center through partnership.

Nurse-managed health centers offer holistic health care and patient-centered health promotion and disease prevention. These goals are particularly well suited to the needs of children and their families. Few reports in the literature, however, have described such practices. The purpose of this paper is to describe one practice, Valencia Health Services (VHS), a nurse-managed, academic health center providing primary care to pediatric and adolescent patients. Valencia Health Services offers interdisciplinary, comprehensive health services to ethnically diverse children and their families through an inter-university partnership and provides clinical experiences and research opportunities, under the supervision of expert faculty-clinicians, to students of nursing (advanced practice, public health, and case management), social work and psychology. Valencia Health Services is the rare nurse-managed academic health center that provides comprehensive health care to children and adolescents. The multifaceted demands of such a health center, however, present both unique opportunities for quality care and service and considerable ongoing challenges.

Exogenous peptides delivered by ricin require processing by signal peptidase for transporter associated with antigen processing-independent MHC class I-restricted presentation.

In this study we demonstrate that a disarmed version of the cytotoxin ricin can deliver exogenous CD8(+) T cell epitopes into the MHC class I-restricted pathway by a TAP-independent, signal peptidase-dependent pathway. Defined viral peptide epitopes genetically fused to the N terminus of an attenuated ricin A subunit (RTA) that was reassociated with its partner B subunit were able to reach the early secretory pathway of sensitive cells, including TAP-deficient cells. Successful processing and presentation by MHC class I proteins was not dependent on proteasome activity or on recycling of MHC class I proteins, but rather on a functional secretory pathway. Our results demonstrated a role for signal peptidase in the generation of peptide epitopes associated at the amino terminus of RTA. We showed, first, that potential signal peptide cleavage sites located toward the N terminus of RTA can be posttranslationally cleaved by signal peptidase and, second, that mutation of one of these sites led to a loss of peptide presentation. These results identify a novel MHC class I presentation pathway that exploits the ability of toxins to reach the lumen of the endoplasmic reticulum by retrograde transport, and suggest a role for endoplasmic reticulum signal peptidase in the processing and presentation of MHC class I peptides. Because TAP-negative cells can be sensitized for CTL killing following retrograde transport of toxin-linked peptides, application of these results has direct implications for the development of novel vaccination strategies.