Systematic description of an interdisciplinary multimodal pain treatment programme for patients with chronic musculoskeletal pain, using the TIDieR checklist.

OBJECTIVE: To provide a thorough and systematic description of an interdisciplinary multimodal pain treatment programme (IMPT) for patients with chronic musculoskeletal pain (CMP), using the TIDieR checklist as a guide. RESULTS: The main goal of the 'Centre for Integral Rehabilitation (CIR) Excellent' IMPT is to improve daily functioning, participation and quality of life of patients with CMP by helping them to adapt their behaviour so as to better manage their symptoms. A combination of physical and psychosocial treatment methods is employed, including Emotional Awareness and Expression Therapy (EAET), Pain Neuroscience Education (PNE), Acceptance and Commitment Therapy (ACT), graded activity, exposure in vivo, and experiential learning through physical training. The interdisciplinary treatment team comprises physiotherapists, psychologists and a physiatrist. The programme lasts 10 weeks (61 h in total) and consists of three phases: a start (Week 1), education (Weeks 2-3), and skills learning phase (Weeks 4-10). Patients come in twice a week and participate in 2-4 sessions (3-4 h) per treatment day. The programme consists of both individual (physical and mental coaching) and group sessions (education, movement and behaviour outdoors/indoors). Individualisation through personal goal-setting is an important characteristic of the treatment, as well as frequent interdisciplinary consultation between care providers.

Immunohistochemical analysis of malignant melanomas and nevocellular nevi with monoclonal antibodies to distinct monomorphic determinants of HLA antigens.

Using an indirect immunoperoxidase technique, 20 nevocellular nevi, 5 dysplastic nevi, 14 primary cutaneous melanomas, and 24 metastatic melanomas were tested with a panel of monoclonal antibodies to monomorphic determinants of Class I (HLA-A,B,C) and Class II (la-like) major histocompatibility complex antigens. Class I HLA and beta 2-microglobulins were not detected on the majority of nevus cells but were expressed by 3 of 5 dysplastic nevi, by the majority of tumor cells in 12 of 14 primary cutaneous melanomas, and in 13 of 24 metastases. The different expression of Class I HLA and beta 2-microglobulins in primary and metastatic lesions suggests that loss of these antigens may be associated with progression of malignancy. Class II HLA were not detected in common nevi but were locally present in 1 of 5 dysplastic nevi, 7 of 14 cases of primary cutaneous melanoma, and all 24 cases of metastatic lesions tested. These findings suggest that increase in Class II HLA expression may be associated with progression of malignancy. The staining patterns obtained with monoclonal antibodies to distinct determinants of Class I HLA and Class II HLA were superimposable within each type of antigen. Therefore, the discrepancies in the literature about the expression of histocompatibility antigens by lesions of melanocytic origin are not likely to reflect the different specificity of the antibodies used by the various investigators.

DNA-cytophotometry of lymph node imprints from patients with mycosis fungoides.

To obtain objective criteria for early diagnosis of lymph node involvement in patients with mycosis fundoides, Feulgen DNA-cytophotometry was carried out in lymph node imprints from patients with mycosis fungoides. The lymph nodes of 3 patients with lymph nodes, showing partial or total replacement by atypical lymphoreticular tissue histologically, showed a polyploid and aneuploid DNA distribution. Eleven out of 22 patients with dermatopathic lymphadenopathy both with or without early involvement histologically had an abnormal DNA histogram with hypertetraploid DNA values. Four of these 11 died, 5 had a partial remission in response to therapy and 2 had sustained remission during the follow-up period of 5 yr. The other 11 patients had a normal DNA distribution. Of these 11, one died and 10 achieved sustained remission after therapy. There is a good correlation between the DNA-cytophotometric results and histology of the lymph nodes. On the basis of these results DNA-cytophotometry may be considered an additional and objective aid in the diagnosis of lymph node involvement in mycosis fungoides.

Validity of the histopathological criteria used for diagnosing dysplastic naevi. An interobserver study by the pathology subgroup of the EORTC Malignant Melanoma Cooperative Group.

Ten (dermato)pathologists studied 50 cutaneous melanocytic lesions including common naevocellular naevi, dysplastic naevi (DN), melanomas in situ and invasive primary melanomas, with emphasis on the histological criteria of DN. Using a standardised form, 20 defined histopathological features were scored (semi)quantitatively. Concordance of diagnosis, efficacy and reproducibility of features were investigated. DN were distinguished well from the other entities (mean Po 0.87). Agreement on the degree of atypia of DN was low. The reproducibility of the scoring was best for the following features: irregular nests, lymphohistiocytic infiltrate, marked junctional proliferation and large nuclei. The overall values of these features to discriminate between DN and non-DN were better than for the other features studied. Using the presence of at least three of the four features as a condition for the diagnosis of DN, values for sensitivity, specificity and positive and negative predictive values were 0.86, 0.91, 0.96 and 0.73, respectively. On the basis of the results these features seem best suited as histological criteria for the diagnosis of DN.

Accumulation and localization of gallium-67 in various types of primary lung carcinoma.

The uptake and location of Ga-67 were investigated in 15 primary pulmonary carcinomas. The accumulation in the tumor was determined by scintigraphy of the patient, grain counts over fields of tumor cells in autoradiographs of tumor-tissue samples, and gamma counts in specimens of the tumor. Good correlation was found between the results obtained with these three methods. The relationship between accumulation of Ga-67 in the tumor and the histologic type of tumor was also studied. Undifferentiated carcinomas, and tumor cells in squamous-cell carcinomas showed significantly more Ga-67 than tumor cells in adenocarcinomas. No correlation was found between the presence of inflammatory infiltrates in or around the tumor and the grade of the scintigraphic images. In the autoradiograms, lymphocytes, plasma cells, granulocytes, and macrophages showed less radioactivity than the tumor cells--or none at all. Collagen fibers appeared to have bound some Ga-67, but necrotic areas showed no uptake.

The course of Legionella pneumonia in guinea pigs after inhalation of various quantities of L. pneumophila.

The course of legionella pneumonia in guinea pigs after infection with various quantities of virulent L. pneumophila serogroup 1 organisms by aerosol exposure was investigated. The clinical course, histopathological characteristics, manifestations in the lungs and clearance of the legionella organisms from the lungs and spleen were followed. Four groups were exposed to 4.3 X 10(4), 4.7 X 10(5), 5.0 X 10(6) and 1.0 X 10(8) aerosolized legionellae, respectively. The most striking clinical symptoms were fever and weight loss, which were found in 67-94% and 33-100% of the animals, depending on the dose of L. pneumophila organisms administered. Spontaneous death occurred only in animals receiving the highest dose and always within 10 days. All animals exhibited exponential growth of legionella organisms in the lungs. Maximal growth occurred 5 to 7 days after exposure and varied from 9.3 X 10(7) to 7.4 X 10(8) organisms/both lungs. Twenty-two days after exposure, legionellae could still be cultured from lung tissue. Between 2 and 7 days after exposure, the spleen cultures were positive for legionellae in 41% of the animals receiving the lowest dose and in 83% of all other animals; legionellae could no longer be cultured from spleen tissue after day 7. Depending on the dose, peripherally localized areas of bronchopneumonia increased in size with time, tending to become confluent lobar pneumonia. The microscopic changes were not related to the number of inhaled organisms. In the cellular infiltrate, PMN predominated until day 7 and macrophages thereafter. Seroconversion was found in all animals that survived greater than 7 days. The present animal model closely mimics the course of events in human legionella pneumonia, thus enabling us to further study the factors involved in host resistance against legionella as well as the efficacy of various antimicrobial agents in normal and immunosuppressed animals.

Multiple primary melanomas in a patient with familial-type DNS during clomiphene-induced pregnancy.

A 35-year old woman developed six primary cutaneous melanomas during her third pregnancy. She had received clomiphene treatment for nearly 2 years previously. She developed two more primary melanomas 15 and 21 months after giving birth. All melanomas were histologically associated with preexisting dysplastic naevi. The patient showed the characteristic phenotype of the dysplastic naevus syndrome; a cousin and an aunt were treated for malignant melanoma and the patient's brother had histologically confirmed dysplastic naevi. The course of her first two pregnancies was not complicated by the development of melanomas. We suggest that clomiphene may have played a role in the activation or progression of these 'precursor lesions' into malignant melanoma.

Lymphomatoid papulosis and Hodgkin's disease: are they related?

Two different characteristic types of lymphomatoid papulosis (type A and type B) can be histologically distinguished, that represent the ends of a spectrum. In the present report, two patients are described. One patient with both lymphomatoid papulosis type A and type B lesions for more than 25 years developed Hodgkin's disease (nodular sclerosing type) in the para-aortic and para-iliac lymph nodes. Histologic examination of the skin lesions in the second patient, who had Hodgkin's disease (nodular sclerosing type) in many supradiaphragmatic lymph nodes, showed the characteristic features of lymphomatoid papulosis type A. These findings, together with the results of recent immunohistochemical investigations showing many similarities between the large atypical cells in lymphomatoid papulosis type A lesions and Reed-Sternberg cells in Hodgkin's disease, support the view that lymphomatoid papulosis type A and Hodgkin's disease are closely related conditions. The results of recent studies indicate a close relationship between lymphomatoid papulosis type B and the early stages of mycosis fungoides. Accordingly, the possible relationship between lymphomatoid papulosis types A and B, mycosis fungoides, and Hodgkin's disease is discussed.

Clinimetric evaluation of the pain observation scale for young children in children aged between 1 and 4 years after ear, nose, and throat surgery.

This study assessed the reliability, validity, and responsiveness of a new pain measure for children aged 1 to 4 years that was developed from the Children's Hospital of Ontario Pain Scale and its Neonatal Infant Pain Scale. Pain in 311 children, aged 1 to 4 years, was measured by two observers at fixed intervals after adenotonsillectomy (n = 114), adenotomy (n = 109), or insertion of ventilation tubes (grommets) (n = 88) until discharge using a dichotomous pain scale of 9 behavioral and physiological categories. The scale proved to be strongly homogeneous. The interobserver agreement was substantial for 7 items. On these final 7 items, the ability to distinguish between patients with differing degrees of pain and the sensitivity to detect changes over time within each patient were substantial. The resulting Pain Observation Scale for Young Children is reliable and easy to use for assessment of short- and longer-lasting pain after ear, nose, and throat surgery and may be used for assessing pain with other conditions.

Clinical and histologic differentiation between lymphomatoid papulosis and pityriasis lichenoides.

The relationship between lymphomatoid papulosis and pityriasis lichenoides is a matter of considerable debate. Differentiation between these two conditions is, however, important because patients with lymphomatoid papulosis, unlike those with pityriasis lichenoides, may develop systemic lymphoma and thus require long-term follow-up. In our study the clinical and histologic features of eighty-two patients with pityriasis lichenoides and twenty-six patients with lymphomatoid papulosis were reviewed and compared. Clinical and histologic differences were recognized, not only allowing differentiation between the two conditions, but also suggesting that they are pathogenetically distinct diseases. Finally, evidence is presented to suggest that the different views on the relationship between these diseases mainly result from differences in patient selection.

Masquerade of eyelid tumours.

Space-occupying processes in the eyelids can either be due to lesions which are specific for the eyelids, such as a chalazion or a meibomian carcinoma, or to non-specific lesions of the skin or ocular adnexa. An incorrect interpretation on clinical or histological grounds is often made; in other words, some eyelid processes masquerade as others. The correct diagnosis should be made on the basis of case history, localisation, the appearance of the tumour and the histological findings, so that adequate treatment can be given. One must be aware of the danger of mistaking one space-occupying process for another. In the Leiden Ophthalmological Clinic a study was made of the incidence of eyelid tumours in the period 1981-1987, with special attention to the most important masquerade phenomena observed. In a group of 956 eyelid tumours histological examination was necessary in 126 cases. Basal-cell carcinoma was the most frequent diagnosis, but other less common tumours such as a trichilemmoma, an eosinophilic granuloma, a haemangio-endothelioma, a metastasis from a mammary carcinoma and a granuloma annulare were also diagnosed.

Drug-induced pseudolymphomatous skin reactions.

We present two patients with generalized and three with localized skin eruptions due to various non-anticonvulsant drugs, with a histological picture of a pseudolymphoma of the skin. Cessation of the causative drugs resulted in disappearance of the lesions in all cases.

Alopecia mucinosa progressing into mycosis fungoides. A long-term follow-up study of two patients.

The present report describes two patients with alopecia mucinosa who developed mycosis fungoides 4 and 8 years after the diagnosis of alopecia mucinosa had been made. The relationship between both conditions will be discussed.

Dermatopathic lymphadenopathy and lymph node involvement in mycosis fungoides.

Lymph node involvement in mycosis fungoides (MF) is associated with a poor prognosis, Histologically, in most cases of clinical lymphadenopathy the excised lymph node shows dermatopathic lymphadenopathy (DL). The diagnosis of MF involvement can readily be made when the lymph node tissue has partly or wholly been replaced by atypical lymphoreticular tissue. Early involvement of a dermatopathic lymph node by MF may be difficult to diagnose. A histologic study was performed on 30 lymph nodes from 24 patients with MF. Most of these lymph nodes had been excised as part of the staging procedure. The maximal follow-up period was five years. A classification of lymph node involvement into four categories is suggested and correlations with clinical courses and results of DNA cytophotometry of lymph node imprints are shown. Lymph nodes showing the histologic picture of DL can be divided into two groups: a group with MF involvement (category I) and a group with MF involvement (category II). The latter group is considered to represent early involvement of lymph nodes by MF. Partial or complete replacement of lymph node tissue by atypical lymphoreticular tissue corresponds with cagegories III and IV, respectively.

A staining procedure for melanin in semithin and ultrathin epoxy sections.

Staining for melanin at the ultrastructural level may act as an important diagnostic aid by helping to identify apparently amelanotic melanomas. A modified Warthin-Starry (WS) procedure for melanin has therefore been adapted for direct application to epoxy sections. Minute amounts of melanin can thus be demonstrated in individual melanosomes, indicating a high sensitivity. Using the usual types of fixation, specificity for melanin at the ultrastructural level is high. Primary osmium tetroxide (OsO4) fixation probably induces false positive staining of lipofuscin and should not be used prior to the WS procedure, but it does not influence the results of the procedure when employed as a post-fixative. It is not improbable, however, that the positive staining of lipofuscin and also of mast cell granules is due to the presence of melanin in these structures. The WS procedure yields additional diagnostic information, especially in suboptimally preserved material, as expressed by an increase in the number of convincingly identifiable melanosomes in one completely and four partly amelanotic melanomas.

Mycosis fungoides simulating acanthosis nigricans.

In this paper, an unusual papillomatous variant of the plaque stage of mycosis fungoides with clinical similarities to acanthosis nigricans is described. In contrast to the classic plaque stage of mycosis fungoides, the dermal infiltrates in this patient showed a rather monomorphous proliferation of blast-like cells that had little or no tendency to infiltrate the epidermis.