The Roman Catholic community was the first to observe and describe what later became known as Gardner-Diamond syndrome (GDS), otherwise known as psychogenic purpura. They attributed the dermatological manifestations of GDS to the 'Holy Stigmata' or the 'Five Holy Wounds,' physical and sensory signs linked to Jesus Christ's crucifixion. Between 1927-1989, medical curiosity resulted in the discovery of a link between these stigmata and a recognizable hematologic condition, which later became known as GDS. GDS is an autoimmune hematological disease associated with emotional and physical stress that involves painful ecchymosis. This stress is often related to psychiatric conditions such as depression, anxiety, and obsessive-compulsive disorder. GDS, the medical condition, must not be confused with mimicking presentations, such as variants of fictional disorder in which so-called ' fraudulent stigmatists' self-inflict similarly-presenting wounds. As such, clinicians must be able to distinguish patients with true GDS from religious individuals who have self-mutilated to mimic the ' Five Holy Wounds'. Reaching this diagnosis of true GDS might require a multidisciplinary approach between psychiatry, hematology and dermatology.

To the Editor: We make an observation about the use of the word granuloma after a recent publication in this journal on noninfectious granulomas by Shoimer et al, which says, in part, “The lesions have variable morphology and may represent as papules, plaques, or nodules that often become crusted, atrophic, or ulcerated.” Another publication solely on the topic of granulomas appeared in the Dermatological Clinics entitled “Granulomatous Disorders of Adult Skin,” where there are excellent articles on the various histologic features of granulomas. After an extensive review of the literature, we found that most manuscripts comment on the histologic findings of a granuloma but strangely do not tell us much about the corresponding clinical description of each type of granuloma. In fact, literature describing the correlation between clinical and histologic findings in any granulomatous disease is very limited. How has the meaning of the word granuloma and the pathological entities it represents changed over time? Granuloma originates from the Latin word granule, which means “a grain,” and oma, which refers to tumor or cancer. The word is used in the histologic descriptions of the various processes that involve packed cellular elements into “grain-like” conglomerations in the dermis. Classically, granuloma, as a gross living pathological term, was used to describe the following entities: lupus vulgaris, tuberculosis, tertiary syphilis, leprosy, deep mycotic infections, granuloma annulare, and sarcoidosis. In current literature, the term is used to describe a wide spectrum of unrelated disorders, including infections, vasculitides, immunologic disorders, hypersensitivity pneumonias, chemical reactions, drug reactions, and neoplasia. These conditions have varied clinical presentations. For instance, granuloma annulare presents as an annular erythematous papular eruption. Necrobiosis lipoidica has sclerosing papules and plaques that are variable in color, typically located on the lower extremities with telangiectasia and possible ulceration. Granuloma has even been used in such old misnomers as granuloma fungoides and, in present-day language, pyogenic granuloma. So what does a granuloma look like? There is no welldefined description. Most textbooks only describe the different histologic types of granulomatous disorders. The chapters in a textbook of dermatology by Bolognia et al describe a wide variety of granulomatous disorders, but there is no description of what a granuloma looks like with the naked eye that enables one to say, “Ah, it shows the living gross pathology of a granuloma.” Clearly, the meaning of granuloma has come to include multiple entities that clearly do not have similar gross morphologic features. Interestingly, Rapini strongly suggests that a ruptured comedone is the most common granuloma in the skin!

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Background: There is much information on the life and accomplishments of John Hinchman Stokes (1885–1961), the dermatologist and syphilologist. There is little detailed information on his 1944 classic text on syphilis, Modern Clinical Syphilology. Objective: To review and critique this book. Methods: A careful review of the book, his life, and the accomplishments that were undertaken in relation to the age in which he lived. Results: The book is indeed a goldmine of information of all aspects of syphilis from pre–World War I (1905) until the late (1944) World War II era. Conclusion: The factors that make it a classic are as follows: (1) the disease had a specific cause; (2) Stokes's 25-year obsession with the disease; (3) there was no effective simple cure for most of the time he was studying it; (4) Stokes was an obsessive, intelligent, well-trained physician; (5) he lived in a well-developed, reasonably stable country; and (6) he was able to see how the disease could be adequately treated with penicillin and compare these events with those in the prepenicillin era.

The nevoid basal cell carcinoma syndrome is an autosomal dominant condition that consists of multiple basal cell carcinomas of the skin, odontogenic keratocysts, pits of the hands and feet (especially the palms and soles), various ectopic calcifications, notably lamellar calcification of the falx cerebri and skeletal anomalies. As well as these major findings, there are many other associated abnormalities. This paper is a 15-year follow-up study on twelve cases from the Ottawa Valley with details on nine new cases discovered during that time. Sixteen were males; 5, females. The number of basal cell cancers requiring removal varied greatly from patient to patient. There was one patient with a horror lesion; none had metastatic disease.

Background: In all types of dementia, cognitive abilities are affected, behaviour is altered and functional capacity is progressively lost. This cognitive deterioration manifests in the decrease of abilities required to perform the activities of daily living (ADL). The objective of this pilot study was to assess the effect of an Occupational Therapy programme based on the training of ADL through cognitive stimulation on the independence of ADL of persons with dementia. Methods: Institutionalized older adults with major neurocognitive disorder or dementia (N = 58) were randomly allocated to receive either the Occupational Therapy ADL cognitive stimulation programme or conventional Occupational Therapy. The cognitive level and the independence level performing ADL were measured at baseline (week 0), after 5 weeks of treatment (week 5) and after 6 weeks of follow up (week 12). A value of p < 0.05 and α = 0.0025 (Bonferroni correction) was considered as statistically significant. Results: The results obtained showed improvements in the level of independence performing ADLs in the intervention group compared to the control group (p = 0.006). The improvements were seen in relation to feeding (p = 0.001), dressing (p = 0.005) and bladder and bowel incontinence (p = 0.003), the changes observed in feeding are statistically significant. However, those improvements were not maintained after the follow up period. There were no significant changes in relation to the cognitive level (p = 0.741). Conclusions: Occupational Therapy based on ADL cognitive stimulation can have a positive effect, increasing the independence of subjects with major neurocognitive disorder or dementia who are institutionalised.

Phagedena is an old term for serious deep, necrotic and gangrenous skin ulcers. In the past these have been regarded as severe infections. A review of 31 cases revealed that except in cases of Streptococcus pyogenes or Clostridium welchii infection a bacterial of fungal infection was only one of several factors that led to the development of phagedenic ulcers. Initiating factors may be a bacterial infection, a debilitated state as a result of immunosuppressive therapy or of such conditions as alcoholism, severe diabetes, inflammatory bowel disease or severe arteriosclerosis, and various types of injury or trauma. Continuing factors include enzymatic mechanisms, the release of toxins from large areas of dead tissue and vascular disorders. In general, antibiotics are of limited value. systemic corticosteroid therapy may be useful in the subacute or chronic case. In acute, spreading, gangrenous phagedena with surrounding erythema, fever and systemic toxic effects, immediate excision of dead tissue may be lifesaving.