RESUMO
AIM: To determine the mortality rate in a Danish cohort of children and adolescents diagnosed with Type 1 diabetes mellitus compared with the general population. METHODS: In 1987 and 1989 we included 884 children and 1020 adolescents aged 20 years and under, corresponding to 75% of all Danish children and adolescents with Type 1 diabetes, in two nationwide studies in Denmark. Those who had participated in both investigations (n = 720) were followed until 1 January 2014, using the Danish Civil Registration System on death certificates and emigration. We derived the expected number of deaths in the cohort, using population data values from Statistics Denmark to calculate the standardized mortality ratio. Survival analysis was performed using Cox proportional hazards model. RESULTS: During the 24 years of follow-up, 49 (6.8%) patients died, resulting in a standardized mortality ratio of 4.8 (95% confidence interval 3.5, 6.2) compared with the age-standardized general population. A 1% increase in baseline HbA1c (1989), available in 718 of 720 patients, was associated with all-cause mortality (hazard ratio = 1.38; 95% confidence interval 1.2, 1.6; P < 0.0001). Type 1 diabetes with multiple complications was the most common reported cause of death (36.7%). CONCLUSION: We found an increased mortality rate in this cohort of children and adolescents with Type 1 diabetes compared with the general population. The only predictor for increased risk of death up to 24 years after inclusion was the HbA1c level in 1989. This emphasizes the importance of achieving optimal metabolic control in young people with Type 1 diabetes.
Assuntos
Complicações do Diabetes/fisiopatologia , Diabetes Mellitus Tipo 1/complicações , Adolescente , Adulto , Biomarcadores/sangue , Criança , Estudos de Coortes , Estudos Transversais , Dinamarca/epidemiologia , Complicações do Diabetes/mortalidade , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 1/mortalidade , Diabetes Mellitus Tipo 1/fisiopatologia , Progressão da Doença , Feminino , Seguimentos , Hemoglobinas Glicadas/análise , Humanos , Masculino , Mortalidade , Estudos Prospectivos , Sistema de Registros , Análise de Sobrevida , Adulto JovemRESUMO
PURPOSE: To examine associations between retinal vascular geometry (tortuosity, branching coefficient [BC] and length-diameter ratio [LDR]) and diabetic proliferative retinopathy (PDR), nephropathy, and peripheral neuropathy in patients with type 1 diabetes mellitus (T1DM). METHODS: A cohort of patients with T1DM participated in a clinical examination in 2011. Blood and urine analyses were done and retinal images taken. PDR was defined as Early Treatment Diabetic Retinopathy Study level 61 or above, nephropathy as albumin-creatinin ratio ≥300 mg/g, and neuropathy as vibration perception threshold >25 Volt. Retinal vessel parameters were measured using semi-automated software. Multiple logistic regressions were performed to investigate correlations between retinal vascular parameters and outcomes. Models were adjusted for other variables (sex, age, duration of diabetes, systolic and diastolic blood pressure, HbA1c, and presence of microvascular complications). Odds ratios were given per standard deviation in retinal vascular parameter. RESULTS: Retinal vascular analyses were performed in 181 patients. Mean age and duration of diabetes were 37.0 years and 29.4 years respectively, and 50.8% were male. Prevalence of PDR, nephropathy, and neuropathy were 26.5%, 6.8%, and 10.1% , respectively. Patients with increased arteriolar BC had a higher risk of nephropathy (OR: 3.10, 95% CI: [1.01-9.54]). Patients with increased venular BC had a higher risk of neuropathy (OR: 2.11, 95% CI: [1.11-4.03]). No associations were found in patients with PDR. CONCLUSIONS: By analyzing the retinal vascular tree in patients with T1DM, we found a higher risk of complications in kidneys and nerves when BC was increased. This might indicate a suboptimal construction of the vascular tree in these patients.
Assuntos
Diabetes Mellitus Tipo 1/complicações , Retinopatia Diabética/diagnóstico , Microcirculação , Vasos Retinianos/patologia , Adulto , Arteríolas/patologia , Criança , Estudos Transversais , Retinopatia Diabética/etiologia , Retinopatia Diabética/fisiopatologia , Progressão da Doença , Feminino , Seguimentos , Humanos , Masculino , Vasos Retinianos/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tomografia de Coerência ÓpticaRESUMO
AIM: To evaluate current insulin pump settings in an optimally regulated paediatric population using bolus wizard. METHODS: We used a retrospective study design to analyse data from 124 children on insulin pump therapy who had optimum HbA1c levels [< 59 mmol/mol (< 7.5%)] and no history of severe hypoglycaemic events. Bolus wizard settings were used to calculate the insulin to carbohydrate factors and insulin sensitivity factors. Multiple regression analysis was used to analyse the variables associated with the calculation factors. RESULTS: Insulin to carbohydrate factor varied from 276 in the youngest group to 424 in the oldest group, and increased according to age. Insulin sensitivity factor was highest in the group aged 6 to < 12 years, with a value of 125. Age, amount of carbohydrates, number of boluses per day and insulin per kg were all significantly associated with both calculation factors. Furthermore, duration of insulin pump treatment was significantly associated with insulin sensitivity factor and percentage bolus/basal was significantly associated with insulin to carbohydrate factor. Gender, diabetes duration and BMI were not associated with any of the calculation factors. CONCLUSION: Optimum insulin pump settings at pump initiation depend on both insulin requirements and use of the pump. Settings need to be individualized because the standardized calculation factors are not constant for children. There is a need to develop specific age- and insulin dose-dependent calculation factors.
Assuntos
Diabetes Mellitus Tipo 1/tratamento farmacológico , Cálculos da Dosagem de Medicamento , Sistemas de Infusão de Insulina/normas , Insulina/administração & dosagem , Adolescente , Glicemia/análise , Peso Corporal/fisiologia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , SoftwareRESUMO
AIMS: To examine the long-term incidence of vitrectomy in young people with Type 1 diabetes. METHODS: We prospectively studied 324 people with Type 1 diabetes who participated in baseline examinations in 1995. Surgical history was obtained from the Danish National Patient Registry in April 2012. RESULTS: During the 17-year study period, 39 people (12.0%) underwent vitrectomy at least once. The mean age and diabetes duration at first vitrectomy were 29.8 and 22.9 years, respectively, and 64.1% of the participants were men. In multivariable Cox regression analysis, baseline age (hazard ratio 0.81 per 1 year increase), BMI (hazard ratio 1.21 per 1 kg/m(2) increase), HbA1c (hazard ratio 1.72 per 1% increase) and diabetic retinopathy (hazard ratio 2.85 and 6.07 for mild and moderate/severe diabetic retinopathy vs none, respectively) were independent predictors of vitrectomy (P < 0.05 for all variables). CONCLUSIONS: Vitrectomy is a relatively common procedure in young people with Type 1 diabetes, with poor glycaemic control being the strongest modifiable risk factor.
Assuntos
Diabetes Mellitus Tipo 1/epidemiologia , Retinopatia Diabética/epidemiologia , Vitrectomia/estatística & dados numéricos , Adulto , Dinamarca/epidemiologia , Diabetes Mellitus Tipo 1/cirurgia , Retinopatia Diabética/cirurgia , Métodos Epidemiológicos , Feminino , Humanos , MasculinoRESUMO
PURPOSE: To investigate microaneurysm (MA) count as a predictor of long-term progression of diabetic retinopathy (DR) in young patients with type 1 diabetes mellitus (T1DM). METHODS: We examined 185 patients with T1DM at baseline (1995) and at follow-up (2011). At baseline, mean age and duration of diabetes were 20.6 and 12.9 years, respectively. Two-field (1995) and seven-field (2011) fundus photographs were taken in accordance with the European Diabetes Study Group (EURODIAB) and the Early Treatment Diabetic Retinopathy Study (ETDRS) protocol, respectively. DR was graded in accordance to the ETDRS protocol, allowing for non-standard photography at baseline. Baseline MAs were counted; patients without DR and those with MAs only were included. Multivariable logistic regressions were performed to investigate MA-count as a predictor of two-step progression, progression to proliferative DR (PDR), and incident diabetic macula edema (DME). RESULTS: We included 138 patients (138 eyes). Of these, 58 had no retinopathy and 80 had MAs only. At follow-up, rates of two-step progression of DR, progression to PDR and incident DME were 52.9, 21.7, and 10.1 %, respectively. In logistic regression models, MA count was able to predict progression to PDR (OR: 1.51 per MA; 95 % CI: [1.04-2.20]) and DME (OR: 1.69 per MA; 95 % CI: [1.05-2.77]), but not two-step progression (OR 0.91 per MA, 95 % CI: [0.64-1.31]). CONCLUSIONS: In younger patients with T1DM, MA count predicts long-term incidence of PDR and DME. This demonstrates that early DR is a warning sign of late retinopathy complications and that the number of MAs is an important factor for long-term outcome.
Assuntos
Aneurisma/diagnóstico , Diabetes Mellitus Tipo 1/diagnóstico , Retinopatia Diabética/diagnóstico , Edema Macular/diagnóstico , Vasos Retinianos/patologia , Albuminúria/urina , Pressão Sanguínea/fisiologia , Estudos de Coortes , Dinamarca , Progressão da Doença , Feminino , Seguimentos , Hemoglobinas Glicadas/metabolismo , Humanos , Masculino , Fotografação , Estudos Prospectivos , Fatores de Risco , Tomografia de Coerência Óptica , Adulto JovemAssuntos
Infecções , Articulação do Ombro , Medula Óssea , Humanos , Leucócitos , Tomografia Computadorizada de EmissãoRESUMO
BACKGROUND: The purpose of this study was to evaluate the clinical outcomes of mosaicplasty in the treatment of osteochondritis dissecans of the distal humeral capitellum. MATERIALS AND METHODS: Between 2003 and 2007, 10 patients (6 female and 4 male patients), with a mean age at surgery of 18 years (range, 13 to 27 years), with advanced lesions of capitellar osteochondritis dissecans underwent mosaicplasties. The surgical technique involves transplanting small-sized cylindrical osteochondral grafts from the lateral periphery of the femoral condyle at the level of the patellofemoral joint to the defect of the capitellum. At a mean follow-up of 30 months, all elbows were assessed with the Mayo Elbow Performance Score and a modified functional elbow score (Constant). RESULTS: Postoperative radiographs and control magnetic resonance imaging/computed tomography images showed incorporation of the subchondral cortex in all patients. All but 2 patients were completely pain free after surgery. Of the patients, 8 (80%) had no reduction in range of motion. By use of the Mayo Elbow Performance Score, the injured elbow had a preoperative mean score of 71 points (range, 55 to 85 points) and increased significantly to a mean score of 93.5 points (range, 85 to 100 points) postoperatively (P = .0005, paired t test). The nonoperative elbows had a mean score of 100 points, whereas the operated elbows had a mean score of 93.5 points. The functional elbow score showed a mean difference of 7.5 points between the operated and nonoperative elbows. No infection or neurologic deficit developed after surgery in any case. CONCLUSIONS: Autologous osteochondral mosaicplasty for advanced lesions of capitellar osteochondritis dissecans can provide satisfactory clinical and radiographic results.
Assuntos
Atletas , Articulação do Cotovelo/cirurgia , Epífises/transplante , Fêmur/transplante , Úmero/transplante , Osteocondrite Dissecante/cirurgia , Adolescente , Adulto , Cartilagem Articular/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Osteocondrite Dissecante/etiologia , Osteocondrite Dissecante/fisiopatologia , Amplitude de Movimento Articular , Estudos Retrospectivos , Transplante Autólogo , Resultado do Tratamento , Adulto JovemRESUMO
AIMS: To examine contemporary rates of severe hypoglycemia (SH) and identify the effect of predictors of SH in a pediatric type 1 diabetes population. METHODS: The national diabetes register provided data on children residing in Denmark from 2008 to 2013 in this register-based population study. Robust Poisson regression models were applied. RESULTS: The study population [n = 2,715 (50.9 % boys), mean (SD) age at onset; 8.1 (4.0) years, diabetes duration; 5.6 (4.9) years] comprised 7,390 person-years of data and 561 events of SH. The overall incidence of SH was 7.6 per 100 person-years. The incidence rate peaked with 16.0 per 100 person-years in 2008 reaching a nadir of 4.9 in 2011. Overall, insulin pump reduced the rate of SH with 27 % compared to any pen treatment (P = 0.003). When stratifying pen treatment, premixed insulin increased the rate of SH by 1.9-fold (P = 0.0015) and NPH increased the rate by 1.6-fold (P = 0.003) versus pump treatment, whereas long-acting insulin analogues were comparable with pump treatment (P = 0.1485). We found no association of SH with glycemic control (P > 0.05). CONCLUSIONS: A nationwide halving in rates of severe hypoglycemia was observed during the study period independent of the prevailing average HbA1c level. Changes in diabetes care and successful educational programs may have influenced the lower incidence rate of severe hypoglycemia.
Assuntos
Diabetes Mellitus Tipo 1/epidemiologia , Hipoglicemia/epidemiologia , Adolescente , Criança , Pré-Escolar , Dinamarca/epidemiologia , Diabetes Mellitus Tipo 1/tratamento farmacológico , Feminino , Humanos , Hipoglicemia/tratamento farmacológico , Insulina/administração & dosagem , MasculinoRESUMO
The study aimed to identify risk markers (present at the start of the study in 1989) for the occurrence and progression of microvascular complications 6 years later (in 1995) in a Danish nationwide cohort of children and adolescents with Type 1 diabetes (average age at entry 13.7 years). Probabilities for the development of elevated albumin excretion rate (AER), retinopathy, and increased vibration perception threshold (VPT) could then be estimated from a stepwise logistic regression model. A total of 339 patients (47% of the original cohort) were studied. Sex, age, diabetes duration, insulin regimen and dose, height, weight, HbA(1c), blood pressure, and AER were recorded. In addition, information on retinopathy, neuropathy (VPT), and anti-hypertensive treatment was obtained at the end of the study. HbA(1c) (normal range 4.3-5.8, mean 5.3%) and AER (upper normal limit <20 microg min(-1)) in two, timed overnight urine collections were analysed centrally. Eye examination was performed by two-field fundus photography. Determination of VPT was assessed by biothesiometry. Increased AER (> or =20 microg min(-1)) was found in 12.8% of the patients in 1995, and risk markers for this were increased AER and high HbA(1c), in 1989 (both p<0.001). Retinopathy was present in 57.8% of patients in 1995, for which the risk markers were long duration of diabetes (p<0.0001), age (p<0.01), and high HbA(1c) (p<0.0001) in 1989. Elevated VPT (>6.5 V) was found in 62.5% of patients in 1995, for which the risk markers were male sex (p<0.05), age (p<0.0001), and increased AER (p<0.05) in 1989. This study confirms that hyperglycaemia plays a major role for the development of microvascular complications in kidneys and eyes, and emphasises the need for optimal glycaemic control in children and adolescents with Type 1 diabetes.
Assuntos
Glicemia/metabolismo , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 1/fisiopatologia , Nefropatias Diabéticas/prevenção & controle , Neuropatias Diabéticas/prevenção & controle , Retinopatia Diabética/prevenção & controle , Adolescente , Albuminúria/epidemiologia , Criança , Estudos de Coortes , Dinamarca/epidemiologia , Diabetes Mellitus Tipo 1/tratamento farmacológico , Nefropatias Diabéticas/epidemiologia , Neuropatias Diabéticas/epidemiologia , Retinopatia Diabética/epidemiologia , Feminino , Humanos , Masculino , Exame Neurológico , Percepção , Probabilidade , Fatores de Risco , VibraçãoRESUMO
This study describes the surgical technique used for reconstruction and reinforcement of the lateral collateral ligament complex in patients with posterolateral instability of the elbow and the results. A triceps tendon graft from the ipsilateral elbow which was inserted through bone tunnels and fixed with bone anchors augmented the reconstruction. The operation was performed on 18 consecutive patients with instability after an acute traumatic dislocation. The mean follow-up was 44 months (14 to 88). There were no recurrent dislocations. The elbow was stable in 14 patients; three had some minor limitation of movement. Thirteen had no or only occasional slight pain, 15 returned to their normal level of activity and 17 were satisfied with the outcome. There was only one failure.
Assuntos
Lesões no Cotovelo , Luxações Articulares/etiologia , Instabilidade Articular/cirurgia , Acidentes por Quedas , Adolescente , Adulto , Artralgia/etiologia , Criança , Ligamentos Colaterais/lesões , Ligamentos Colaterais/cirurgia , Feminino , Seguimentos , Humanos , Imobilização , Luxações Articulares/fisiopatologia , Luxações Articulares/cirurgia , Instabilidade Articular/fisiopatologia , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Cuidados Pós-Operatórios/métodos , Recidiva , Transferência Tendinosa/métodos , Resultado do TratamentoRESUMO
We studied the stabilising effect of prosthetic replacement of the radial head and repair of the medial collateral ligament (MCL) after excision of the radial head and section of the MCL in five cadaver elbows. Division of the MCL increased valgus angulation (mean 3.9 +/- 1.5 degrees) and internal rotatory laxity (mean 5.3 +/- 2.0 degrees). Subsequent excision of the radial head allowed additional valgus (mean 11.1 +/- 7.3 degrees) and internal rotatory laxity (mean 5.7 +/- 3.9 degrees). Isolated replacement of the radial head reduced valgus laxity to the level before excision of the head, while internal rotatory laxity was still greater (2.8 +/- 2.1 degrees). Isolated repair of the MCL corrected internal rotatory laxity, but a slight increase in valgus laxity remained (mean 0.7 +/- 0.6 degrees). Combined replacement of the head and repair of the MCL restored stability completely. We conclude that the radial head is a constraint secondary to the MCL for both valgus displacement and internal rotation. Isolated repair of the ligament is superior to isolated prosthetic replacement and may be sufficient to restore valgus and internal rotatory stability after excision of the radial head in MCL-deficient elbows.
Assuntos
Ligamentos Colaterais/cirurgia , Articulação do Cotovelo/cirurgia , Instabilidade Articular/etiologia , Osteotomia/efeitos adversos , Rádio (Anatomia)/cirurgia , Idoso , Artroplastia de Substituição , Articulação do Cotovelo/fisiopatologia , Feminino , Humanos , Instabilidade Articular/fisiopatologia , Masculino , Pessoa de Meia-Idade , Amplitude de Movimento Articular , Lesões no CotoveloRESUMO
The first Danish case report of a thorn-induced arthritis is presented. The symptoms and histopathology are similar to those in the cases described in foreign literature. The clinical presentation is that of transient acute synovitis, followed by an asymptomatic period, and later by a period of persistent symptoms, often after the thorn injury was forgotten. Histopathology shows granulomatous synovitis. Synovectomy and removal of the plant thorn usually results in normal joint function. The diagnosis should be remembered in undiagnosed cases of monoarticular arthritis.
Assuntos
Artrite/etiologia , Corpos Estranhos/complicações , Plantas , Sinovite/etiologia , Ferimentos Penetrantes/complicações , Artrite/diagnóstico , Pré-Escolar , Diagnóstico Diferencial , Feminino , Corpos Estranhos/diagnóstico , Humanos , Articulação do Joelho , Sinovite/diagnósticoRESUMO
Hydrops foetalis is an uncommon condition, occurring in 1/1400-1/4000 of all pregnancies. The possible etiologies to the disease are numerous and up to now the prognosis has been very dull, with a mortality-rate of 40-90%. A successfully treated case story is presented. It is concluded, that it is essential from the very beginning to treat the child aggressively to restore normal respiratory and circulatory function. When this is performed the child will have a good chance of surviving and developing normally.
Assuntos
Hidropisia Fetal/etiologia , Feminino , Humanos , Hidropisia Fetal/diagnóstico , Hidropisia Fetal/terapia , Lactente , Recém-Nascido , Recém-Nascido Prematuro , PrognósticoRESUMO
Wilsons disease is a rare autosomal recessive disorder of copper transportation, which is fatal if not treated. The disease often starts in adolescence, and most common symptoms are due to liver-and/or brain involvement. This paper deals with an adolescent with Wilsons disease. His clinical presentation was joint complaints for almost two years. The final diagnosis was made by mutation analysis. It is stressed that the clinician should consider Wilson's disease in cases of unexplained liver- and neurological involvement as well as cases of repetitive unexplained joint symptoms in the pubertal period.
Assuntos
Artrite , Degeneração Hepatolenticular , Adolescente , Artrite/diagnóstico , Artrite/genética , Dinamarca , Degeneração Hepatolenticular/diagnóstico , Degeneração Hepatolenticular/genética , Humanos , Masculino , Paquistão/etnologia , RecidivaRESUMO
Recipients of solid-organ transplants are, due to immunosuppressive treatment, disposed to opportunistic infections including tuberculosis. We report a rare case of acute intramedullary tuberculous abscess in a Danish male recipient of a liver transplant. The problems in diagnostics, medical and surgical treatment are discussed.
Assuntos
Transplante de Fígado , Tuberculose da Coluna Vertebral/etiologia , Abscesso/patologia , Antituberculosos/administração & dosagem , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Medula Espinal/patologia , Tuberculose da Coluna Vertebral/diagnóstico , Tuberculose da Coluna Vertebral/tratamento farmacológico , Tuberculose da Coluna Vertebral/imunologiaRESUMO
In this study, we evaluated patient-reported outcomes, the rate of revision and the indications for revision following resurfacing hemiarthroplasty of the shoulder in patients with osteoarthritis. All patients with osteoarthritis who underwent primary resurfacing hemiarthroplasty and reported to the Danish Shoulder Arthroplasty Registry (DSR), between January 2006 and December 2010 were included. There were 772 patients (837 arthroplasties) in the study. The Western Ontario Osteoarthritis of the Shoulder (WOOS) index was used to evaluate patient-reported outcome 12 months (10 to 14) post-operatively. The rates of revision were calculated from the revisions reported to the DSR up to December 2011 and by checking deaths with the Danish National Register of Persons. A complete questionnaire was returned by 688 patients (82.2%). The mean WOOS was 67 (0 to 100). A total of 63 hemiarthroplasties (7.5%) required revision; the cumulative five-year rate of revision was 9.9%. Patients aged < 55 years had a statistically significant inferior WOOS score, which exceeded the minimal clinically important difference, compared with older patients (mean difference 14.2 (8.8; 95% CI 19.6; p < 0.001), but with no increased risk of revision. There was no significant difference in the mean WOOS or the risk of revision between designs of resurfacing hemiarthroplasty.
Assuntos
Hemiartroplastia/métodos , Osteoartrite/cirurgia , Articulação do Ombro/cirurgia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemiartroplastia/efeitos adversos , Hemiartroplastia/instrumentação , Humanos , Prótese Articular , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Falha de Prótese , Sistema de Registros , Reoperação/estatística & dados numéricos , Resultado do Tratamento , Adulto JovemAssuntos
Aracnoide-Máter/patologia , Calcinose , Meninges/patologia , Medula Espinal/patologia , Adolescente , Adulto , Idoso , Autopsia , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
A case of solitary appendicular neurofibromatosis is presented. The neurogenous nature of the lesion was emphasized by the positive reaction for S-100 protein. Attention is directed towards the morphological differences between neurogenous hyperplasia, which is a reactive common place feature in the elderly, and the present example of neoplastic nerve growth, which produced a gigantic appendix. A review of the literature failed to disclose any previous case unassociated with von Recklinghausen's disease.
Assuntos
Neoplasias do Apêndice/patologia , Neurofibroma/patologia , Adulto , Apendicectomia , Neoplasias do Apêndice/análise , Humanos , Masculino , Neurofibroma/análise , Proteínas S100/análiseRESUMO
A series of 237 appendices was studied immunohistochemically for neurogenous hyperplasia. This was observed in 195 cases. It was possible to trace a continuum from appendices with intact lumens, featuring intramucosal neurogenous hyperplasia often with co-existent submucosal and muscular nerve growth, to obliterated specimens whose axial portions were composed of varying proportions of nerve tangles and fibrous tissue. Predominantly fibrotic specimens were considered as end-stages of this process. Stromal, argyrophilic cells lying amidst the nerve elements were prominent in the early, non-obliterated cases; their number decreased in the obliterated nerve rich specimens and such cells became inapparent in the late fibrotic stage. Repeated minimal subclinical attacks of inflammation are thought to trigger this lesion.