[Arthritis psoriatica]. / Arthritis psoriatica.

The symptoms ofpsoriatic arthritis vary from arthralgia and enthesitis to chronic erosive and mutilating arthritis, and are seen in 6-39% of all psoriasis patients. Because of increasing awareness of the clinical signs of psoriatic arthritis among both dermatologists and rheumatologists, the diagnosis ofpsoriatic arthritis is made more often; this is important since earlier diagnosis and treatment can avoid irreversible joint destruction. The overlap between the immunological mechanisms in the pathogenesis ofpsoriasis and psoriatic arthritis has led to the identification of common therapeutic targets, of which tumour-necrosis factor (TNF) is the most important. The successful treatment of psoriasis patients with TNF-a-blocking agents has not only brought about a marked improvement in the quality of life of many patients but has also improved the insight into the pathogenesis, for example by demonstrating that the role of acquired immunity is much more important than was previously thought. The Dutch Society of Dermatology and Venereology and the Dutch Society of Rheumatology have drawn up guidelines for the treatment of patients with psoriasis and psoriatic arthritis using these so-called biologics.

Early effects of tumour necrosis factor alpha blockade on skin and synovial tissue in patients with active psoriasis and psoriatic arthritis.

BACKGROUND: Tumour necrosis factor alpha (TNFalpha) blockade using infliximab, a chimeric anti-TNFalpha antibody, is an effective treatment for both psoriasis and psoriatic arthritis (PsA). OBJECTIVE: To analyse the early effects of infliximab treatment on serial skin and synovial tissue biopsy samples. METHODS: Twelve patients with both active psoriasis and PsA received a single infusion of either infliximab (3 mg/kg) (n = 6) or placebo (n = 6) intravenously. Synovial tissue and lesional skin biopsy specimens were obtained at baseline and 48 hours after treatment. Immunohistochemical analysis was performed to analyse the inflammatory infiltrate. In situ detection of apoptotic cells was performed by TUNEL assay and by immunohistochemical staining with anti-caspase-3 antibodies. Stained tissue sections were evaluated by digital image analysis. RESULTS: A significant reduction in mean (SEM) T cell numbers was found in both lesional epidermis (baseline 37 (11) cells/mm, 48 hours 26 (11), p = 0.028) and synovial tissue (67 (56) cells/mm(2)v 32 (30), p = 0.043) after infliximab treatment, but not after placebo treatment (epidermis 18 (8) v 43 (20), NS; synovium 110 (62) v 46 (21), NS). Similarly, the number of macrophages in the synovial sublining was significantly reduced after anti-TNFalpha treatment (100 (73) v 10 (8), p = 0.043). The changes in cell numbers could not be explained by induction of apoptosis at the site of inflammation. CONCLUSIONS: The effects of anti-TNFalpha therapy in psoriasis and psoriatic arthritis may be explained by decreased cell infiltration in lesional skin and inflamed synovial tissue early after initiation of treatment.

The 'mirrored' Bennett fracture of the base of the fifth metacarpal.

Fractures of the base of the metacarpals are usually treated conservatively. The intra-articular fracture of the base of the first metacarpal ('Bennett fracture') is an exception to this rule because inadequate repositioning and fixation of the dislocated radial fragment lead to permanent deformity of the joint and subsequent degenerative joint disease. The dislocated intra-articular fracture of the base of the fifth metacarpal is similar to a Bennett fracture in many aspects. Repositioning of this 'mirrored' Bennett fracture cannot be guaranteed by a plaster cast. Inadequate repositioning will lead to pain, reduced strength and early degenerative joint disease. We present six patients with dislocated intra-articular fractures of the base of the fifth metacarpal to illustrate the necessity of surgical reduction and fixation.

Secondary corrections of the vulva in male-to-female transsexuals.

From December of 1980 to May of 1998, 390 male-to-female transsexuals underwent vaginoplasty by inversion of the penile skin and a triangular perineoscrotal flap. Although minor modifications were made throughout the years, the basic surgical technique remained the same over this 17.5-year period. In 86 of the 390 patients (22 percent), secondary corrections of the vulva were deemed necessary. A total of 130 corrections were performed in these 86 patients. In the same 17.5-year period, the authors performed 26 secondary corrective procedures in 19 patients in whom the initial vaginoplasty had been done elsewhere. Bilateral Z-plasties were performed 69 times to center the labia in instances when the ventral part of the labia majora remained too far apart. This is not advisable, primarily because it will reduce the vascular supply of the penile skin flap. Introital widening by five-flap advancement was performed in 40 cases in which a dorsal skin fold obstructed the introitis. The use of the triangular perineoscrotal flap favors the vaginal and introital width, but its base should be close to the anal ring to prevent such a skin fold. Secondary construction of the labia minora was performed 27 times, and a skin reduction of the labia majora was performed 20 times. So far, the authors have been unable to develop a satisfactory method for primary construction of the labia minora. Because the appearance of the vulva may charge gradually during the first postoperative year, secondary vulvar corrections should not be performed in that period.