[Altered function of the hypothalamic-pituitary-adrenal axis in patients with acute, chronic and episodic pain]. / Funktionsstörung der hypothalamisch-hyphophysär-adrenalen Achse bei Patienten mit akuten, chronischen und intervallartigen Schmerzsyndromen.

INTRODUCTION: Complex disorders of the hypothalamic-pituitary-adrenal axis constitute phenomena whose etiopathogenetic significance is the subject of controversy. The frequent coincidence with depressive symptoms further complicates interpretation. PATIENTS AND METHODS: Daily variations in cortisol levels were measured in 20 patients with acute pain, 27 with chronic pain in the lumbar musculoskeletal system, and 44 with episodic forms of headache to determine the daily average and then correlated with differentiated algesimetric data. RESULTS: Patients with chronic and episodic pain had significantly higher scores on the McGill Pain Questionnaire and more affective items as an expression of depressive symptoms than patients with acute pain. The three groups did not however exhibit significant differences for the depression scale and list of "psychovegetative" disorders. In comparison to an age-matched pain-free control population (n=17), the average daily levels of cortisol were significantly higher in all three groups besides singularly elevated daily levels, but no correlations between the cortisol values and overall algesimetric data could be established. Chronic pain patients with high depression scores had significantly higher cortisol levels irrespective of pain intensity. DISCUSSION: Pain experiences cause increased plasma cortisol levels with significant elevation of the daily average. Whereas in cases of acute pain, a direct but unspecific stress reaction not connected with the pain seems to be likely, the underlying cause in cases of chronic and episodic pain appears to be a complex and enduring activation of the hypothalamic-pituitary-adrenal axis, likewise independent from pain, probably associated with concomitant depressive symptoms and disruption of the circadian rhythm of release controlled by the hypothalamus.

Brain lesion size and phase shift as an index of cerebral autoregulation in patients with severe head injury.

BACKGROUND: Whether the phase relationship (phase shift) between cerebral blood flow velocity as assessed by transcranial Doppler ultrasound and blood pressure at 0.1 Hz can be used to assess cerebral autoregulation (CA) in patients with severe traumatic brain injury (TBI). METHODS: In 33 healthy volunteers (mean age, SD; 37+/-17 years, range 17-65) middle cerebral artery (MCA) blood velocity (V) was recorded simultaneously with finger blood pressure (BP) over a period of 10 minutes under normocapnic and hypocapnic conditions to generate normative data. In 27 patients with severe TBI (Glasgow Coma scale score < or =8) serial close in time investigations of cranial computed tomography (CT) scanning and phase shift assessment were performed on days 1, 3, 5, and 8 after trauma. Phase shift in the MCA was compared to brain parenchyma lesion size in the MCA territory on CT scanning. Lesion size was classified into 0, normal; 1, presence of a small lesion (diameter <3 cm); 2, presence of a large lesion (>3 cm). FINDINGS: Compared to normocapnia, hypocapnia significantly increased phase shift at 0.1 Hz from 78+/-28 degrees to 101+/-25 degrees (p < 0.001). In the TBI patients, 115 comparisons between CT findings and CA results were possible. Phase shift detected a pathological CA in 31 instances, which were more frequent in CT lesion type 2 (19/42) than in group 0 (7/44) and group 1 (5/29). INTERPRETATION: When CA is intended to be assessed by use of phase shift, the hyperventilation setting needs its own reference values. In MCA territories containing a traumatic lesion greater than 3 cm in diameter phase shift at 0.1 Hz will detect a high frequency (44%) of a disturbed state of CA.

Changes in linear dynamics of cerebrovascular system after severe traumatic brain injury.

BACKGROUND AND PURPOSE: We sought to describe the dynamic changes in the cerebrovascular system after traumatic brain injury by transfer function estimation and coherence. METHODS: In 42 healthy volunteers (mean+/-SD age, 37+/-17 years; range, 17 to 65 years), spontaneous fluctuations of middle cerebral artery blood flow velocity and of finger blood pressure (BP) were simultaneously recorded over a period of 10 minutes under normocapnic and hypocapnic conditions to generate normative spectra of coherence, phase shift, and gain over the frequency range of 0 to 0.25 Hz. Similar recordings were performed in 24 patients with severe traumatic brain injury (Glasgow Coma Scale score 70 mm Hg. Each blood flow velocity/BP recording was related to the presence or absence of middle cerebral artery territory brain parenchyma lesions on cranial CT performed within a close time frame. RESULTS: In controls, hypocapnia decreased coherence (0.0 to 0.20 Hz), increased phase shift (0.0 to 0.17 Hz), and decreased gain in the frequency range of 0.0 to 0.11 Hz but increased gain at frequencies of 0.20 to 0.25 Hz (P<0.01 for all frequency ranges reported). In patients with traumatic brain injury, 102 investigations were possible. Compared with controls, coherence was increased in the frequency range <0.03 Hz and between 0.13 and 0.25 Hz in both normocapnia and hypocapnia, irrespective of the CT findings. Gain was unchanged in normocapnia and in the absence of a CT lesion. Gain was decreased in hypocapnia at frequencies >0.12 Hz irrespective of the presence/absence of a CT lesion. Phase shift decreased rapidly between 0.06 and 0.13 Hz under hypocapnic conditions and under normocapnic conditions in the presence of a CT lesion (P< 0.01). CONCLUSIONS: Use of spontaneous fluctuations of blood flow velocity and BP to assess the cerebrovascular system dynamically requires consideration of the Paco2 level. In different conditions, including severe traumatic brain injury, the cerebrovascular system behaves linearly only in parts of the investigated frequency range.

Cerebral blood flow velocity and inflammatory response after severe traumatic brain injury.

OBJECTIVES: The cerebral blood flow velocity (CBVF) was measured by transcranial Doppler sonography in patients with severe traumatic brain injury (TBI) in order to determine, whether it depends on the posttraumatic inflammatory response. MATERIAL AND METHODS: CBVF in both middle cerebral arteries (MCA) was recorded in 25 comatous TBI patients (male 20; female five; mean age +/- standard deviation (S.D.), 41 +/- 20 years) and correlated to the levels of interleukine-(IL) 6, IL-8 and IL-10 in corresponding CSF/plasma samples, to PaCO2 and to intracranial (ICP), mean arterial (MAP) and cranial perfusion pressure (CPP). RESULTS: CSF IL-6 and IL-8 were clearly higher than the corresponding plasma levels (mean CSF/plasma quotient for IL-6: 159 +/- 582; for IL-8: 143 +/- 311). CBVF did not show large side-to-side differences at each examination indicating that CBFV in both MCAs was determined mostly by systemic conditions and not by severe regional abnormalities. Since all other evaluated variables including interleukines represent also systemic conditions we used the mean value (MCBFV) of both CBFVs for analysis. By stepwise regression analysis between MCBVF (mean +/- S.D., 80 +/- 26 cm/s) and the variables PaCO2 (33 +/- 4 mmHg), MAP (86 +/- 12 mmHg), ICP (20 +/- 11 mmHg), CPP (70 +/- 14 mmHg) and CSF or plasma IL-6, IL-8 and IL-10, it turned out that MCBFV correlated significantly with PaCO2 (r = 0.478; P < 0.01) and CSF IL-8 (r = -0.361; P < 0.05). CONCLUSIONS: When CPP is adequate for brain perfusion, CBFV in large brain supplying arteries depends predominantly on PaCO2 and shows only a slight association to intrathecal IL-8 levels. For clinical interpretation of CBFV data, the inflammatory response seems to be of minor relevance.

[Sleep and breathing disorders in patients with brain stem lesions]. / Störungen von Schlaf und Atmung bei Patienten mit Hirnstammläsionen.

Most information about the structures within the brain stem that modulate respiration and sleep are gathered from animal experiments. Therefore we examined 10 patients several weeks after an infarction of the brain stem by means of polysomnography and tested the chemosensitive drives of respiration. None of these patients complained about symptoms of sleep disordered breathing. In each case polysomnographic measurements and ventilatory response curves revealed pathologic findings. The respiratory response to CO2 was diminished or completely abolished in each patient. In some cases hypoventilation or disturbances of the respiratory rhythmicity could be seen. In several cases missing REM sleep, sleep fragmentation or the reduction of slow wave sleep were observed. The study indicates that on the base of results from animal research the comparison of morphological and pathophysiological data is helpful to gain a better understanding on the coupling of the respiratory system with sleep at the brain stem level as well as on the pathomechanism of sleep related breathing disorder.

Utilidad de los agonistas de GnRH en el tratamiento preoperatorio de la miomatosis uterina complicada: caso clínico / Utility of the GnRH agonists in the presurgical treatment of complicated uterine myomatosis

Los agonistas de GnRH de uso prolongado producen un hipogonadismo hipogonadotrópicoreversible, por lo que han sido utilizados en el tratamiento preoperatorio de miomas uterinos logrando amenorrea y disminución del tamaño de ellos. Se presenta el caso de una paciente de 43 años, portadora de una miomatosis uterina asociada a metrorragia que ingresa por un cuadro de trombosis venosa profunda extensa con indicación absoluta de anticoagulación, dado el riesgo de exacerbación de la metrorragia por los anticoagulantes y considerando al alta morbilidad asociada a una hiosterectomía de urgencia en ella; se decide tratamiento médico con un agonista de GnRH de depósito (acetato de leuprolide 3,75 mg IM mensual). Se obtiene el cese de la metrorragia en 3 días y una significativa disminución del tamaño uterino permitiendo mantener tratamiento anticoagulante y proceder a una histerectomía total electiva 3 meses después. Se analizan las características de los análogos de GnRH, mecanismo de acción, efectos adversos y otras indicaciones en medicina

Enfermedad de Hansen: histopatología de sus lesiones neurológicas / Leprosy: histopathology of the neural lesions

Se reseñan las alteraciones histopatológicas neurales periféricas de la enfermedad de Hansen, es decir las modificaciones experimentadas por nervios cutáneos y gruesos troncos nerviosos periféricos. Estudiamos ciático poplíteo externo, cubital y rama auricular del plexo cervical superficial. Las lesiones nerviosas cutáneas más importantes se observan en la forma de iniciación indeterminada y en la forma polar Tuberculoide, pues, en ambas formas el estudio de la neuritis cutánea es fundamental para el diagnóstico de la enfermedad. En el Hansen Indeterminado se produce la infiltración de nervios dérmicos por un infiltrado linfomonocitario ("Neuritis indeterminado"), que por sí sola puede fundamentar el diagnóstico histopatológico. Es importante, además investigar la eventual presencia del M.Leprae en el interior de los nervios dérmicos, estén o no infiltrados, y en los infiltrados inflamatorios. En el Hansen tuberculoide se observa la destrucción parcial o total del nervio cutáneo por un granuloma tuberculoide o sarcoidal. En el nervio periférico, además de estos infiltrados granulomatosos, pueden producirse alteraciones degenerativas y/o fibróticas, que acentúan los síntomas comprensivos neurales. En la forma lepromatosa, la lesión de los nervios cutáneos y troncos periféricos es menos importante, pues es menos frecuente; más tardía y menos completa que en la forma tuberculoide. Las formas lepromatosas neuríticas puras son raras en nuestra experiencia. En la forma dimorfa, las lesiones cutáneas neurales son más frecuentes que en las lepromatosas, aún en las formas dimorfas que se acercan al polo lepromatoso. No tienen caracteres distintivos propios; su histopatología dependerá del polo al cual se aproxime el caso en estudio. En cuanto a los episodios reaccionales, cualquiera sea la variante clínica, suelen acentuar los cambios patológicos neurales

Enfermedad de Hansen: histopatología de sus lesiones neurológicas / Leprosy: histopathology of the neural lesions

Se reseñan las alteraciones histopatológicas neurales periféricas de la enfermedad de Hansen, es decir las modificaciones experimentadas por nervios cutáneos y gruesos troncos nerviosos periféricos. Estudiamos ciático poplíteo externo, cubital y rama auricular del plexo cervical superficial. Las lesiones nerviosas cutáneas más importantes se observan en la forma de iniciación indeterminada y en la forma polar Tuberculoide, pues, en ambas formas el estudio de la neuritis cutánea es fundamental para el diagnóstico de la enfermedad. En el Hansen Indeterminado se produce la infiltración de nervios dérmicos por un infiltrado linfomonocitario ("Neuritis indeterminado"), que por sí sola puede fundamentar el diagnóstico histopatológico. Es importante, además investigar la eventual presencia del M.Leprae en el interior de los nervios dérmicos, estén o no infiltrados, y en los infiltrados inflamatorios. En el Hansen tuberculoide se observa la destrucción parcial o total del nervio cutáneo por un granuloma tuberculoide o sarcoidal. En el nervio periférico, además de estos infiltrados granulomatosos, pueden producirse alteraciones degenerativas y/o fibróticas, que acentúan los síntomas comprensivos neurales. En la forma lepromatosa, la lesión de los nervios cutáneos y troncos periféricos es menos importante, pues es menos frecuente; más tardía y menos completa que en la forma tuberculoide. Las formas lepromatosas neuríticas puras son raras en nuestra experiencia. En la forma dimorfa, las lesiones cutáneas neurales son más frecuentes que en las lepromatosas, aún en las formas dimorfas que se acercan al polo lepromatoso. No tienen caracteres distintivos propios; su histopatología dependerá del polo al cual se aproxime el caso en estudio. En cuanto a los episodios reaccionales, cualquiera sea la variante clínica, suelen acentuar los cambios patológicos neurales

Ectopic geographic tongue and AIDS.

A 23-year-old man with AIDS developed a lesion with the clinical characteristics of an ectopic geographic tongue in the lower lip, near the right commissure.

[Pruritus in chronic kidney insufficiency]. / Prurito en la insuficiencia renal crónica.

Itching is the dermatologic symptom more often found in patients with chronic renal failure. We have studied 80 patients with end-stage renal disease; itching was present in 56.3% of the cases. We didn't detected in this study any correlation between itching, long term hemodialysis, high calcium, phosphorus, alkaline phosphatase or phosphocalcic product levels. We have seen: 1. Those patients with itching were older than the rest. 2. Itching was important in those patients with residual diuresis less than 500 ml/day (p greater than 0.01). 3. Those men without itching had higher hematocrit levels (p greater than 0.01). 4. Histologic findings on optic and electronic microscopy were more frequent in patients who presented this symptom.

Chronic benign familial pemphigus.

Ten patients with benign familial chronic pemphigus (BFCP) (Hailey-Hailey disease) were evaluated; semiologic and localization differences were described, and special attention was given to solitary or atypical forms. In all the cases, the diagnosis was confirmed by histopathology; some histopathologic differences and the results achieved by direct immunofluorescence of skin are discussed. Most of the patients responded to the treatment with corticosteroids and antibiotics.

[Cutaneous metastasis of a cloacogenic tumor]. / Metástasis cutánea de tumor cloacogénico.

A case of cloacogenic carcinoma with cutaneous metastases in a 74 year old man is reported. The patient presented with a six months history of two polyps of the lowest portion of the anal canal. Physical examination of the inguino-scrotal area revealed a 5 X 7 cm. hard infiltrative plaque with three ulcero-vegetative scars. Histologic examination of both polyps revealed two of the four cytologic patterns described in this neoplasm. One polyp showed undifferentiated cells, type IV and second one, type II differentiated. The biopsy of the cutaneous metastases showed dermal infiltrative clusters of the cytologic type II differentiated epidermal cells. Treatment with radiotherapy and chemotherapy was ineffective. Cloacogenic carcinoma of the canal anal is a transitional cells neoplasm believed to arise from vestigial remnants of cloacal origin. Metastases occurred in 19% of cases but cutaneous colonization develops exceptionally.

[Chronic benign familial pemphigus. Clinical, histological and immunological study of 7 cases]. / Pénfigo familiar benigno crónico. Estudio clínico, histológico e inmunológico de siete casos.

A clinical, histopathological and immunological study was carried on a series of seven patients of Familial Benign Chronic Pemphigus (FBCP). This condition is characterized by recurrent small blisters, mainly, on intertriginous areas and on the sides of the neck, that become wet and crusted rapidly. They are generally sharply marginated and Nikolsky's sign is often positive. The lesions appear spontaneously and may be precipitated by warm, humid environment, mechanical trauma, radiations, bacterial or mycotic infection. Healing occurs with residual non scarring hyperpigmentation. Histopathologically, the epidermal alteration respond to a primary acantholytic mechanism. Ultramicroscopic studies have suggested an alteration on the desmosome-tonofilament complex. Comparatively with Pemphigus, another acantholytic disease in which immunological pathogenesis is strongly suspected, only few reports are referred to immunological studies in FBCP. In the present paper, a direct immunofluorescent study on spontaneous and provoked blisters was made in order to investigate deposits of immunoglobulins and complement. Indirect IF was performed with sera of teh patients for detection of circulating antibodies. Two cases were also sensitized with erythrocytic antigen. The immunological response to this substance was evaluated. The clinical and histopathological findings of the present series, are similar with previous descriptions. The immunofluorescent studies do not provide evidence of antibodies to epidermal intercellular space, like Pemphigus.(ABSTRACT TRUNCATED AT 250 WORDS)

Forma inusual de presentacion de un penfigo. / Unusual presentation form of pemphigus

Se presenta el caso de una paciente de 69 anos de edad con una dermatosis clinicamente similar a la enfermedad de Duhring-Brocq, histologia caracterizada por el hallazgo de espongiosis neutroeosinofilica y focos minimos de acantolisis e inmunofluorescencia directa compatible con penfigo vulgar en epidermis y vasculitis en dermis. El control de la misma requiro dosis bajas de corticosteroides. Se encuadro esta entidad dentro del llamado penfigo herpetiforme, realizandose una puesta al dia sobre esta patologia

Forma inusual de presentacion de un penfigo. / Unusual presentation form of pemphigus

Se presenta el caso de una paciente de 69 anos de edad con una dermatosis clinicamente similar a la enfermedad de Duhring-Brocq, histologia caracterizada por el hallazgo de espongiosis neutroeosinofilica y focos minimos de acantolisis e inmunofluorescencia directa compatible con penfigo vulgar en epidermis y vasculitis en dermis. El control de la misma requiro dosis bajas de corticosteroides. Se encuadro esta entidad dentro del llamado penfigo herpetiforme, realizandose una puesta al dia sobre esta patologia