Is the 2003 ISSVD terminology and classification of vulvodynia up-to-date? A neurobiological perspective.

This paper aims to determine if the 2003 International Society for the Study of Vulvovaginal Disease (ISSVD) terminology and classification of vulval pain is up-to-date, according to a current and widely accepted neurobiological pain classification, which divides pain into nociceptive, inflammatory and pathological pain with the latter subdivided into neuropathic and dysfunctional pain. Nociceptive pain is protective, adaptive, high-threshold pain provoked by noxious stimuli. Inflammatory pain is protective, adaptive, low-threshold pain associated with peripheral tissue damage and inflammation. Pathological pain is non-protective, maladaptive, low-threshold pain caused by structural damage to the nervous system (neuropathic pain) or by its abnormal function (dysfunctional pain). The 2003 ISSVD vulval pain classification should be revised in terms of current neurobiological pain information. Inflammatory vulval pain occurs as a result of specific infectious, inflammatory and neoplastic disorders. Neuropathic vulval pain arises following a specific neurological disorder, responsible for structural damage to the nervous system. Vulvodynia is dysfunctional vulval pain, caused by abnormal function of the nervous system itself.

Provoked vestibulodynia: inflammatory, neuropathic or dysfunctional pain? A neurobiological perspective.

This paper aims to clarify the nature of the pain in provoked vestibulodynia (PV). It reviews published data about the nature of the pain in PV, employing a recent pain classification, which divides pain from a neurobiological perspective, into nociceptive, inflammatory and pathological pain, with the latter subdivided into neuropathic and dysfunctional pain. Nociceptive pain is high-threshold pain provoked by noxious stimuli; inflammatory pain is adaptive, low-threshold pain associated with peripheral tissue inflammation; pathological pain is maladaptive, low-threshold pain caused by structural damage to the nervous system (neuropathic) or by its abnormal function (dysfunctional). Most of the published data show that in PV, there is no active peripheral tissue inflammation. Similarly, no neural damage has been demonstrated. It is reasonable to consider PV as dysfunctional pain induced by exposure to acute physical or psychological precipitating events in the presence of an individual predisposition to produce or maintain abnormal central sensitisation.

Ectopic lingual thyroid tissue and acquired hypothyroidism: case report.

Ectopic thyroid tissue with thyroid gland in its normal location is an extremely rare phenomenon. We present a case of a 38-year-old woman who was referred to our hospital with symptoms of hypothyroidism. Thyroid hormone measurement revealed clinical hypothyroidism with elevated anti-thyroid antibodies, neck ultrasonography showed a small tissue with the characteristic of Hashimoto thyroiditis, while the scintigraphy demonstrated only a lingual thyroid. Treatment consisted in L-thyroxine replacement to the euthyroid state. We reviewed the literature with respect to the embryological background and the clinical management of such cases.

Long-term clinical outcomes in critical limb ischemia--A retrospective study of 181 patients.

OBJECTIVE: Critical limb ischemia (CLI) is the most severe manifestation of the peripheral arterial disease. To date, several prognostic factors have been identified but the data of long-term follow-up in real life setting are scarce. The aim of our study is to describe a large group of CLI patients and identify possible prognostic factors, in a long-term follow-up. PATIENTS AND METHODS: Case-control, retrospective study. 181 consecutive CLI patients with a minimum follow-up of 5 years were included in the study. RESULTS: Overall mortality was 15%, 24%, and 43% at 1, 2, and 5 years, respectively. Among known risk factors, only arterial hypertension was significantly correlated with survival rate; no differences were found between diabetics and non-diabetics. Patients treated with intravenous iloprost (46%), compared to untreated patients, showed a better (p < 0.0001) long-term outcome in terms of major amputation (6% vs. 21%), subsequent vascular surgery (4% vs. 32%) and survival rates (69% vs. 47%), at 5-year follow-up. Major amputations were significantly correlated with lower median forefoot transcutaneous values of O2 (0/3 mmHg, p < 0.001) and higher median values of CO2 (83/53 mmHg, p < 0.0001) in supine/dependent position, respectively. CONCLUSIONS: Our results confirm the poor prognosis of CLI patients in a very long-term follow-up and the severe metabolic damage caused by ischemia. A favourable role of iloprost was observed, in agreement with previous evidence in the literature.

Cost-effectiveness of fine-needle-aspiration cytology of thyroid nodules with intranodular vascular pattern using two different needle types.

OBJECTIVE: To compare the cytological findings of hypoechoic thyroid nodules with intranodular vascular pattern (pattern II) obtained by two different needles (Neolus 25 gauge, Chemil, Wenzhou, China vs Yale Spinal 25 gauge, Becton Dickinson, Madrid, Spain) in euthyroid patients and to evaluate their cost-effectiveness. METHODS: From January 2001 to December 2003, 480 euthyroid patients with a hypoechoic thyroid nodule pattern II were referred for US-FNAC. The nodules were alternatively evaluated by Neolus or by Yale Spinal with the stylet (YS+) or without the stylet (YS-), in order to evaluate if the cytological results could be due to the presence of the stylet or to the different length of the two needles. For each nodule two passes were performed and the material was obtained by capillary action. Material was smeared on slides, fixed, and stained by Papanicolaou techniques. Cytological specimens were evaluated in blind by the same experienced cytopathologist. RESULTS: Inadequate cytological specimens because of blood contamination were present in 30 (18.7%) samples by Neolus needle and in 22 (13.8%) by YS- compared to only 5 (3.1%) by YS+. In 6 (20%) cases of the 30 repeated US-FNAC by Neolus and in 4 (18%) of the 22 US-FNAC by YS-, material remained inadequate for diagnosis because of blood contamination. All the five repeated samples obtained by YS+ became adequate for diagnosis and resulted benign nodules. Direct costs of US-FNAC procedure are currently 72.30 Euro including cytological examination. The cost of Neolus and Yale needles is 0.19 Euro and 3.0 Euro, respectively. The estimated total cost to obtain a cytological diagnosis by a Neolus needle (160 + 30 repeated US-FNAC) was 13809.2 Euro vs 12919.5 Euro by Yale Spinal needle (160 + 5 repeated US-FNAC). CONCLUSION: This study demonstrates that the use of Yale Spinal needles greatly reduces inadequate cytological specimens, and therefore limits both direct and indirect costs.

Cellular atypia in vulvar dystrophies.

We studied the frequency and distribution of cellular atypia in 448 cases of vulvar dystrophy. The total frequency was 9.4%. Atypia was found almost exclusively in hyperplastic areas. Epithelial changes suggestive of human papillomavirus infection were found in 14.2% of the atypical dystrophies. During the follow-up of 78 patients with typical dystrophy, mild atypia developed in three cases, but with the continuation of medical treatment it disappeared in two cases. Eleven cases of atypical dystrophy were followed for 3-48 months; three patients with severe atypia underwent surgical treatment, and eight with mild atypia underwent medical treatment. Among the last patients, six showed regression and two, progression of the atypia.

Vulvar dystrophies in young and premenopausal women.

Eighty-six cases of vulvar dystrophy in young and premenopausal women (age range, 6-53 years) were studied clinically and histopathologically. The most frequent symptom was pruritus associated with burning. Clinical examination showed the presence of white areas in 73% of the patients, red areas in 9% and other signs (such as melanosis) in 18%. Hyperplastic dystrophy was the most frequent type of dystrophy in these patients and was observed in 63% of cases. Cellular atypia was observed in 9.8% of the cases and was found almost exclusively in hyperplastic dystrophy. Epithelial changes suggestive of human papillomavirus infection were found in 4 of the 86 cases of dystrophy, and they were observed only in atypical dystrophies.

Epithelial alterations adjacent to 111 vulvar carcinomas.

Material from 111 invasive primary vulvar carcinomas was reviewed in order to study the histopathologic changes adjacent to the neoplasia. The histopathologic characteristics of the adjacent tissue were divided into categories. Dystrophic lesions were adjacent to invasive cancer in 57.6% of the cases, carcinoma in situ (CIS) in 21.6% and epithelial changes suggestive of human papillomavirus infection in 18.9%. A spectrum of epithelial changes, ranging from hyperplastic dystrophy without atypia to CIS, was found adjacent to nine cases of invasive carcinoma (8.1%). In 40.5% of the vulvar carcinomas there were no specific alterations surrounding the neoplasia. These data show that dystrophies and CIS were adjacent to invasive carcinomas in nearly 60% and 20% of cases, respectively.

Antigens of the HLA system in women with vulvar lichen sclerosus. Association with HLA-B21.

The cause of vulvar lichen sclerosus (VLS) is unknown. An autoimmune origin has been suggested. The HLA system is responsible for the synthesis of major histocompatibility antigens and is considered a genetic marker of the risk of or resistance to some diseases. Recently, the association between some antigens of the HLA system and diseases of proven autoimmune origin has been reported. A possible association between antigens of the HLA system and VLS has been investigated by others, with contradictory results. Here we report the results of HLA typing in 68 women with histologically proven VLS. The following antigens were tested: A1, A2, A3, A9-11, A28, A29, A32, B5, B7, B8, B12-B18, B21, B22, B27, B35, B40, Cw1-4, Dr1-5 and Dr7. The results were compared with the frequency of HLA antigens in about 2,000 controls. Patients affected by VLS showed an increased frequency of HLA-B21 (22.06% vs. 9.56%, P less than .001), HLA-Dr5 (55.38% vs. 40.92%, P less than .025) and HLA-Dr7 (38.46% vs. 25.19%, P less than .025). After correction for the number of antigens tested (44) the difference in HLA-B21 frequency was significant at the P less than .05 level. This finding gives further support to the suggestion that an immune system disorder is involved in the origin of VLS.

Membranous hypertrophy of the posterior fourchette as a cause of dyspareunia and vulvodynia.

Twenty-one women were treated surgically for entry dyspareunia and vulvodynia. The ages of the patients ranged from 18 to 39 years (mean, 24.5). Physical examination showed the presence of membranous hypertrophy of the posterior fourchette with consequent stricture of the vaginal introitus in all the patients. Eighty percent of the patients had erythema and tenderness of the vestibule, particularly in the posterior part. The histologic findings were somewhat enigmatic and quite unimpressive, frequently suggestive of chronic nonspecific inflammation; in only two cases were histologic changes suggestive of human papillomavirus infection observed. All the patients underwent excision of the posterior part of the vestibule with vaginal advancement under general anesthesia. Follow-up showed elimination of the symptoms in 19 patients and an improvement in the symptoms in the remaining 2.

Psychological distress in women with nonneoplastic epithelial disorders of the vulva.

The aim of this study was to evaluate psychological distress in 44 women with vulvar squamous cell hyperplasia and 21 with vulvar lichen sclerosus in order to examine the presence of psychological factors in these dermatologic disorders. Two psychometric tests were used to evaluate depressive status and various aspects of anger. No significant depressive status was diagnosed with the former test either in patients with vulvar squamous cell hyperplasia or in patients with vulvar lichen sclerosus. Patients with squamous cell hyperplasia had two components of anger (state and internal anger) that were significantly higher and three components (trait anger, exteriorization and control of anger) significantly lower than did the controls. In patients with lichen sclerosus all the components of anger were within the normal range. These findings suggest that psychological factors may be associated with vulvar conditions, such as squamous cell hyperplasia, and may have some therapeutic implications in cases resistant to standard treatment.

Topographic distribution of groin lymph nodes. A study of 50 female cadavers.

There is a discrepancy between anatomy textbooks' description of groin node position and Way's technique of lymphadenectomy. On the one hand, anatomic studies have demonstrated that the deep femoral nodes are on the medial side of the femoral vein, lying on the deep portion of the fascia lata, and can be seen easily through the opening of the fossa ovalis. On the other hand, the standard technique of deep femoral lymphadenectomy consists of removing the fat lying lateral to the femoral artery through the incision and detachment of the fascia lata from the sartorius to adductor longus muscle. With the aim of demonstrating that a correct deep femoral lymphadenectomy does not require removal of the fascia lata, we dissected Scarpa's triangles in 50 female cadavers. The examination of 100 specimens demonstrated that the deep femoral nodes are always situated within the opening of the fossa ovalis, and no lymph nodes are distal to the lower margin of the fossa ovalis, under the fascia cribrosa. These findings suggest that deep femoral lymphadenectomy can be performed without removing the fascia lata.

Deep femoral lymphadenectomy with preservation of the fascia lata. Preliminary report on 42 invasive vulvar carcinomas.

Forty-two patients with primary invasive vulvar carcinoma were treated with radical vulvectomy and deep femoral lymphadenectomy with preservation of the fascia lata and cribriform fascia. The rationale for using this technique was based on anatomic knowledge of the topographic distribution of groin lymph nodes, which was confirmed by the study of 50 cadavers. The preliminary data show that the number of superficial and deep femoral lymph nodes removed from the 42 patients (mean number of nodes, 20; range, 8-32) was similar to the number reported in anatomy books. In addition, the five-year actuarial survival rate, 70%, was comparable to that in the literature. These preliminary results suggest that the surgical technique used in this study is as radical an oncologic procedure as Way's classic groin lymphadenectomy, which consists of removing the fascia lata and cribriform fascia.

Vulvar intraepithelial neoplasia. A clinicopathologic study of 60 cases.

Sixty cases of vulvar intraepithelial neoplasia (VIN) were analyzed clinicopathologically (24 VIN I, 9 VIN II, 27 VIN III). The ages of the patients ranged from 21 to 83 years (mean, 53.7). Colposcopic examinations showed the presence of white areas in 29 cases, red areas in 9, acetowhite areas in 6 and other alterations in 13. One-third of the lesions were multifocal. Pruritus and burning were present in 65% of the cases. Fifty-one percent of the cases showed histologic changes suggestive of human papillomavirus (HPV) infection; the mean age of those patients was significantly lower than that of patients without HPV infection. In 15 cases of VIN, HPV DNA testing was performed with Southern blot hybridization; in three (20%) of those specimens HPV 16 episomal DNA was identified. Epithelial alterations surrounding the areas of VIN were found in 24 cases (40%)-23 squamous cellular hyperplasias and 1 lichen sclerosus. Different types of treatment were performed according to the different grades of VIN: medical therapy, diathermocoagulation, local excision, hemivulvectomy and total vulvectomy. Follow-up was possible in 52 cases, with a mean of 33 months (range, 3-98). Two cases of VIN I showed progression of disease over 12-24 months.

Biologic behavior of vulvar intraepithelial neoplasia. Histologic and clinical parameters.

The aim of this study was to evaluate the role by which different factors, such as human papillomavirus (HPV) infection, age, dystrophic alterations, focal nature and size of the lesion, influence the biologic behavior of vulvar intraepithelial neoplasia (VIN). Sixty-nine cases of VIN were investigated (28 VIN 1, 9 VIN 2, 32 VIN 3). Follow-up was possible in 58 cases, with a mean of 31 months; no treatment was given to 3 patients, while 55 were treated either medically or surgically. Eighty-four percent of the patients were cured, recurrences were found in 11%, and 5% of the patients showed progression of the disease to carcinoma. The ratio between medical and surgical treatment was the same among the cured, recurred and progressed groups of patients. No differences with regard to focal nature of the lesion, presence of HPV infection or dystrophic alterations were observed between the three groups of patients. Only the mean age was higher in patients who showed progression of the lesion to carcinoma.

Histologic parameters of vulvar invasive carcinoma and lymph node metastases.

We evaluated seven histologic parameters (tumor diameter, histologic grading, depth of stromal invasion, vascular invasion, pattern of invasion, lymphoplasmocytic infiltration and amount of necrosis) of 50 cases of vulvar invasive carcinoma to assess their correlation with groin lymph node metastases. Of 50 patients, 25 had groin lymph node metastases. No lymph node metastasis was found in four cases with depth of invasion < or = 2.0 mm. Among the 31 patients with vascular invasion, 23 (74%) had positive nodes, whereas lymph nodes were metastatic only in two of the 19 patients (10%) without vascular invasion. At univariate analysis, performed with Fisher's exact method, all the parameters considered, except pattern of invasion and amount of necrosis, were significantly associated (P < .05) with lymph node metastases. However, after adjustment by multiple logistic regression for the variables statistically significant at univariate level, only the presence of vascular invasion was significantly associated with nodal involvement and tumor diameter was borderline, whereas the effect of the other variables was almost completely explained by confounding.

Vulvar intraepithelial neoplasia of low grade: a challenging diagnosis.

The authors reviewed 21 cases of "mild vulvar atypia" diagnosed from 1981 to 1990. The first 16 cases were diagnosed as hyperplastic dystrophy with mild atypia according to the 1976 ISSVD Classification of Vulvar Disease, while the last five cases were diagnosed as vulvar intraepithelial neoplasia grade I (VIN I). The review of the specimens was made by the same pathologist who gave the initial diagnosis and by a dermatopathologist unaware of the initial diagnosis. Both reviewers used the 1986 and 1989 ISSVD terminologies. The presence of "mild atypia" was confirmed in only four of the 21 specimens, that is in 19% of the cases, and two of them were found in the context of patients suffering from a lichen planus. These findings show that the diagnosis of mild atypia in vulvar tissues is a challenge and that mild vulvar atypia cannot be automatically considered a VIN I.

[Neurologic and laboratory findings in a population of an endemic area for taeniasis-cysticercosis, Lagamar, MG, Brazil (1992-1993)]. / Achados neurológicos e laboratoriais em população de área endêmica para teníase-cisticercose, Lagamar, MG, Brasil (1992-1993).

A clinic-epidemiological enquiry was conducted on in an endemic area for teniasis-cysticercosis. From the whole population 1080 (32.2%) individuals were examined. We found 198 (18.3%) individuals referring teniasis-bearing in the past, and 103 (9.5%) affirming to have had convulsions, either in the past or present. From the last group, 39 (37.8%) indicated that the crisis had begun in adulthood. From the group of patients presenting convulsions, 62 (62%) had laboratory tests performed. Computed tomography showed intracranial calcifications in 21 (33.8%) patients, variable in number and location, suggesting neurocysticercosis and no evidence of disease activity. Electroencephalograms showed abnormal waves in 21 (33.8%) patients and cerebrospinal fluid analyses were altered in 27 (43.5%) cases, having detected eosinophils only in 3 (4.8%) patients. Spinal fluid tests for cysticercosis through enzyme linked immunosorbent assay (ELISA) or indirect immunofluorescence were taken in only 26 (41.9%) patients, obtaining positive results in 6 (23%) samples. Varying upward shifts of protein levels were found in spinal fluid analysis. Assuming that all epidemiologic risk factors for teniasis-cysticercosis in the studied region and its correlation with the laboratory alterations described in convulsing crisis, a prevalence of 1.9% for neurocysticercosis was found.

Heterologous, lyophilized, non-denatured type-I collagen in dentistry.

Experience in the use of a heterologous collagen, extracted from bovine Achilles' tendon by a non-denaturing procedure, is reported. Normal tooth extraction procedures, periodontal surgery, treatment of alveolitis, oroparanasal communications and maxillary cysts, and oral surgery in patients affected by a defective haemostatic mechanism, benefit from its use.

[Vestibular papillomatosis]. / La papillomatosi vestibolare.

The aim of the present study is to re-update the clinical significance of vestibular papillomatosis. At the beginning of the eighties this condition has been related to HPV infection based on histological and/or molecular evidence of the virus presence and considered responsible of many cases of pruritus and/or vulvodynia. Based upon these findings a lot of clinicians have been treating this condition by laser ablation or by topical application of podophyllin or trichloroacetic acid. At present the majority of the authors believes that vestibular papillomatosis should be considered an anatomical variant of the vestibular mucosa not HPV related. Therefore HPV-DNA presence should be considered a causal rather than a causal agent. This evidence is important in defining the management of vestibular papillomatosis: the papillae are usually distinguishable from condylomata acuminata by clinical examination and biopsies or HPV testing are not necessary. According to the studies considering vestibular papillomatosis a non HPV related condition and on the bases of a series of 252 women examined, the Authors share the opinion that this clinical entity should be considered a normal vestibular findings. As a consequence no ablative treatment is usually required even if in presence of symptomatology or HPV molecular infection.