Lipschütz Ulcer: An Unusual Diagnosis that Should Not be Neglected

Abstract The diagnosis of genital ulcers remains a challenge in clinical practice. Lipschütz ulcer is a non-sexually transmitted rare and, probably, underdiagnosed condition, characterized by the sudden onset of vulvar edema along with painful necrotic ulcerations. Despite its unknown incidence, this seems to be an uncommon entity, with sparse cases reported in the literature. We report the case of an 11-year-old girl who presented at the emergency department with vulvar ulcers. She denied any sexual intercourse. The investigation excluded sexually transmitted infections, so, knowledge of different etiologies of non-venereal ulcers became essential. The differential diagnoses are extensive and include inflammatory processes, drug reactions, trauma, and malignant tumors. Lipschütz ulcer is a diagnosis of exclusion. With the presentation of this case report, the authors aim to describe the etiology, clinical course, and outcomes of this rare disease, to allow differential diagnosis of genital ulceration.

The Effect of Trigger Point Injections on Pain in Patients with Advanced Cancer / 가정의학회지

BACKGROUND: It has been reported that in 62.5% of cases of incurable cancer pain, the complaint is due to myofascial pain syndrome. Trigger point injections using dibucaine hydrochloride help patients with such cancer pain. This study evaluated the efficacy of trigger point injections for alleviating pain in patients with advanced cancer. METHODS: Twenty patients with advanced cancer who had a life expectancy of 6 months or less and had been diagnosed with myofascial pain syndrome were treated with trigger point injections. Prior to treatment, a Visual Analog Scale (VAS) was used to measure the resting pain level and discomfort upon application of pressure on the site of pain. These values were compared with last treatment measurements. RESULTS: The mean pre-treatment VAS scores for pain at rest and upon application of pressure on the pain site were 7.3 and 9.0, respectively. These scores decreased significantly to 1.95 and 3.2, respectively, after the treatment (P<0.05). CONCLUSION: Trigger point injection is an alternative and effective pain control modality for advanced cancer patients with myofascial pain syndrome.

Postoperative topical analgesia of hemorrhoidectomy with policresulen and cinchocaine: a prospective and controlled study / Analgesia tópica com policresuleno e cinchocaína no pós-operatório de hemorroidectomias: um estudo prospectivo e controlado

OBJECTIVE: To evaluate the effects of topical policresulen and cinchocaine in the postoperative pain behavior of open hemorrhoidectomy. METHODS: We conducted a prospective, double-blinded, controlled study. The control group received the usual guidelines with oral medications. The topical treatment group received, in addition, the application of the ointment and was comprised of two subgroups (policresulen + cinchocaine, and placebo). Pain intensity was recorded with the visual analogue scale. RESULTS: 43 patients were operated on: control group - n = 13, one excluded; placebo - n = 15; and policresulen + cinchocaine - n = 15. The mean age was 45.98 years and 37.2% were men. The average pain intensity was 4.09 (immediate postoperative), 3.22 (hospital discharge), 5.73 (day 1) , 5.77 (day 2), 5.74 (day 3), 5.65 (day 7), 5.11 (day 10), 2.75 (day 15) and 7.70 (first bowel movement), with no difference between groups in all periods. CONCLUSION: This study showed no reduction in pain after hemorrhoidectomy with the use of topical policresulen and cinchocaine. .

OBJETIVO: avaliar a ação do policresuleno e cinchocaína tópicos no comportamento da dor no pós-operatório de hemorroidectomias abertas. MÉTODOS: estudo prospectivo, duplo cego e controlado. O grupo controle recebeu as orientações usuais com medicações de uso oral. O grupo de tratamento tópico recebeu, adicionalmente, a aplicação de pomada e foi composto de dois subgrupos (policresuleno + cinchocaína; e placebo). A intensidade da dor foi registrada a partir da escala visual analógica. RESULTADOS: foram operados 43 pacientes: grupo controle (n=13; um excluído), placebo (n=15) e policresuleno + cinchocaína (n=15). A média de idade foi 45,98 anos e 37,2% foram homens. A média da intensidade da dor foi 4,09 (PO imediato), 3,22 (alta hospitalar), 5,73 (dia 1), 5,77 (dia 2), 5,74 (dia 3), 5,65 (dia 7), 5,11 (dia 10), 2,75 (dia 15) e 7,70 (primeira evacuação), sem diferença entre os grupos em todos os períodos estudados. CONCLUSÃO: este estudo não demonstrou redução da dor após hemorroidectomias como o uso do tratamento tópico. .

Study of reactive oxygen species on the regulation of platelet apoptosis / 中华血液学杂志

<p><b>OBJECTIVE</b>To study the effect of reactive oxygen species (ROS) on the regulation of platelet apoptosis.</p><p><b>METHODS</b>Washed healthy human platelets were pre-incubated with N-caetyl-Lcysteine (NAC), and then stimulated with dibucaine or thrombin. The production of ROS and depolarization of mitochondrial membrane potential (∆ ψm) were detected by flow cytometry. The activation of caspase-3 and expression of Bcl-xL were analyzed by Western blot.</p><p><b>RESULTS</b>(1)The average ROS fluorescence value of NAC+dibucaine group was lower than that of dibucaine group(0.66 ± 0.11 vs 1.06 ± 0.08, P<0.01), while that of NAC+thrombin group was also lower than that of thrombin group(0.45 ± 0.05 vs 0.71 ± 0.11, P=0.001). (2)The percentage of platelets with normal ∆ψm in NAC+Dibucaine group was higher than that of dibucaine group[(86.30 ± 9.37)% vs (13.52 ± 3.01)%, P=0.000], while that of NAC+thrombin group was also higher than that of thrombin group[(93.00 ± 3.03)% vs (76.58 ± 5.28)%, P=0.000]. (3)Fragmentation generated by caspase-3 activation in dibucaine group was much more than that in DMSO control group, while the fragmentation in NAC+dibucaine group was significantly decreased. (4)The expression of anti-apoptosis protein Bcl-xL of NAC+dibucaine group was significantly higher than that of the dibucaine group, while that of NAC+thrombin group was also higher than that of thrombin group.</p><p><b>CONCLUSION</b>Through the regulation of ROS, NAC could inhibit the platelet apoptosis induced by dibucaine or thrombin.</p>

Allergic Contact Dermatitis due to a Topical Antipruritic Containing Dibucaine / 대한피부과학회지

Dibucaine hydrochloride is an amide-type local anesthetic and it is well known to be a contact allergen. Although there are some reports of allergic contact dermatitis due to over-the-counter medications containing dibucaine in the foreign literature, there is only one report of it in the Korean literature. We report here on a case of allergic contact dermatitis due to an over-the-counter drug containing dibucaine in a 41-year-old-woman. The patch test with the preparation that she had used and the TRUE(R) test revealed positive reactions to the dibucaine mix and Moscool(R).

Selective analytical determination of cinchocaine hydrochloride in presence of its degradation products or in its binary mixture with hydrocortisone

Cinchocaine HCI was degraded by refluxing with 2N HCI for 4 hr. The degradation products were isolated and their structures were confirmed by IR and mass spectrophotometry. Cinchocaine HCI was then determined in presence of its degradation products by spectrophotometric and spectro-densitometric techniques. For the spectrophotometric methods, cinchocai ne HCI was determined by first derivative spectrophotometry [Dl] at 333.6 nm or by first derivative ratio spectrophotometry [DDI] at 301.6 or 332 nm in concentration ranges 5-80 microg/ml. For the spectro-densitometric method, silica gel plates were used together with benzene: acetone: methanol: 25% NH3 [5:3:0.5:0.1, v/v] as developing solvent and the Rf values were 0.55, 0.12 and zero for cinchocaine HCI and its degradation products, respectively. Cinchocainc HCI and hydrocortisone binary mixture can be determined by the aforementioned densitometric method in concentration ranges 2-20 microg/spot and 2-16 microg/spot for cinchocaine HCI and hydrocortisone, respectively. Alternatively, cinchocaine HCI can be determined spectrophotometrically at 327.8 nm without any interference from hydrocortisone, while hydrocortisone was determined by third derivative spectrophotometry [D3] at 254 and 275.8 nm in concentration ranges 10-100 microg/ml and 5-35 microg/ml for cinchocaine HCI and hydrocortisone, respectively. The proposed methods were successfully applied for the analysis of laboratory prepared mixtures containing cinchocaine HCI and different percentages of its degradation products or cinchocaine HCI and hydrocortisone. These methods were also applied for the analysis of pharmaceutical dosage forms and the results obtained were assessed by the standard addition technique. Local anesthetics produce anesthesia by blocking sodium channels in the axonal membrane, reducing sodium conductance; this in turn reduces the rate and degree of depolarization of the nerve cell and prevents propagation of the action potential.[1] The local anesthetics should be soluble in water and should be effective when injected into tissue or when applied topically to mucous membranesi[2]. Local anesthetics are available as gel, ointments, creams and spray to provide reversible block of conduction along cutaneous nerves[3]. Cinchocaine HCI is a local anesthetic that was formerly used as nerve block and spinal anesthesia, but now, it is available only in topical form[4]. Hydrocortisone is a famous anti-inflammatory agent and it is incorporated with cinchocaine HCI in pharmaceutical preparation for treatment of haemorrhoid[3] Several methods have been described for the determination of cinchocaine HCI. These include spectrophotometric methods [5-15], fluorimetric methods [16-18] HPLC [19-22], TLC [23-27], GC [28-29] NMR [30-31] polarographic methods [32-33] and titrimetric methods [34-37] This work describes spectro-densitometric and spectrophotometric methods for the selective determination of cinchocaine HCI in presence of its two acid degradation products or in combination with hydrocortisone

Prescription pattern for treatment of hemorrhoids under the universal coverage policy of Thailand.

The Universal Coverage Policy (UCP) or "30 Baht Scheme" was launched in Thailand in 2001. The policy caused a cutback in the budgets of all public hospitals and health service centers. Traditional medicine was then viewed as an alternative to save costs. This study examines whether this had any influence on hemorrhoid treatment prescription patterns, ratio of traditional/modern medicine, or the cost of hemorrhoid treatment after the UCP was implemented at a community hospital. The traditional medicine prescribed was Petch Sang Kart and the modern alternative was Proctosedyl. All hemorrhoid prescriptions at a community hospital from October 2000 to January 2003 were surveyed. Segmented Regression Analysis was applied to evaluate prescription trends, the ratios between the types of medicine, and the hemorrhoid treatment cost. A total of 256 prescriptions were analyzed. The average number of traditional medicine prescriptions per month were more than modern medicine (41 versus 16). During the study period, the trend of modern medicine use and the treatment cost was decreased (p < 0.01). The ratio of traditional/modern medicine increased 0.2 times (p = 0.02).

Anti-Leishmania effect of intralesional procaine and dibucaine in hamsters

Se compara el efecto terapéutico de los anestésicos locales "caínicos" Procaína y Dibucaína administrados intralesionalmente (IL), con el del tratamiento intramuscular (IM) convencional con Glucantime®, para lograr la cura clínica y parasitológica sobre lesiones dérmicas en la base de la cola de hámsters machos heterocigotos experimentalemente infectados con 4 x 10³ amastigotes de Leishmania (Viannia) braziliensis. Los resultados revelaron que todas las drogas ensayadas reducen significativamente (P<0,01) los tamaños promedio de las lesiones granulomatosas, cuando se comparan con los aninales controles sin tratamiento. El tratamiento local con la Dibucaína fue tan eficaz clínicamente como el Glucantime® administrado sistémicamente, y tuvo mejor eficacia para la resolución clínica de las lesiones que la Procaína IL. Se detectó la presencia de amastigotes viables en nódulos granulomatosos o cicatrices en su totalidad de los hámsters evaluados, después de 75-165 días de haberse finalizado los tratamientos, mediantes los métodos de frotis directo, histopatología convencional, medios de cultivo (NNN) y la técnica de la inmunoperoxidasa, lo que sugiere que la medición de las lesiones cutáneas por sí solo no es un método totalmente confiable y válido para evaluar la eficacia quimioterapéutica en la LC experimental. La eficiencia clínica de los anestésicos locales parece estar relacionada con sus tiempos de vida media y lipofilia relativa. De una manera preliminar, estos resultados parecieran apoyar la inclusión de los anestésicos locales "caínicos" como parte del armamentarium alternativo para el tratamiento de las LC animal y humana

Randomized, double-blind trial comparing topical nitroglycerine with xylocaine and Proctosedyl in idiopathic chronic anal fissure.

OBJECTIVE: To compare symptomatic relief, healing, and changes in maximal anal resting pressure with the use of topical formulations in patients with chronic anal fissure. METHODS: Sixty-four consecutive patients with chronic anal fissure were randomized into 4 groups that received, in a double-blind manner, a topical ointment that contained 0.2% nitroglycerine (GTN), 5% xylocaine, Proctosedyl (hydrocortisone acetate, heparin, framycetin sulfate, esculoside, ethoform, butoform) or petroleum jelly (Vaseline), to be applied twice daily. Patients were reviewed at 2-week intervals for 6 weeks. Anal manometry was done before, and 20 minutes after, the first application of the ointment. RESULTS: There was significant (p < 0.0001) reduction in mean anal resting pressure after application of GTN, but not any other ointment. Of 16 patients receiving GTN, complete pain relief occurred in 6 and 15 patients after 2 and 4 weeks of treatment, respectively; this was more frequent than in the other 3 groups. At 6 weeks also, complete pain relief occurred more often with GTN than with Vaseline or xylocaine. After 4 weeks of treatment, 3 patients on GTN had complete healing of fissure as compared to one each in the xylocaine and Proctosedyl groups and none in the Vaseline group. At 6 weeks, healing of fissure had occurred in 15 of 16 patients receiving GTN as compared to 4 receiving Vaseline, 11 receiving xylocaine, and 12 on Proctosedyl. CONCLUSIONS: Topical nitroglycerine produces 'chemical sphincterotomy' with reduction in mean anal resting pressure. Pain relief and healing of fissure occurred earlier with GTN than with other treatments. GTN should be considered as the treatment of choice for the non-surgical management of patients with chronic anal fissure.

Revisión analítica de estudios multicéntricos con policresuleno en patología hemorroidal / Analytical review of multicenter studies with polycresulene for hemorrhoidal pathologies

Seven centers investigated the therapeutic efficacy and tolerability of policresulene associated to cinchocaine administered locally as ointment, suppositories or both formulations in 2287 patients with hemorrhoid pathology. The studies were conducted with a standardised protocol and case report forms and with the same score criteria for rating efficacy and tolerability according to the physicians and the patients. Highly satisfactory results were achieved in 1904 patients (83.2 per cent) according to the investigators criteria. Patients rated the outcome most satisfactory for 1881 cases (82.2 per cent). The following were found to be the principal indications: external and internal hemorrhoids associated with bleeding, acute anal fissures, rhagades and perforated or incised perianal thrombosis, anal eczema and anal pruritus, proctitis and wound treatment after proctologic surgery. None of the investigators found any serious adverse event. Mild to moderate adverse reactions in 10 per cent of the patients were local discomfort, pruritus, burning or irritation. Such symptoms occurred at the beginning of treatment. The favourable effects of pol icresulene are attributed to its unique mechanism of action. The highly acid characteristic of the substance causes a selective coagulation of the necrotic tissues leaving healthy tissues unaffected. The desquamation and remotion of the necrotic tissues induces rapid wound cleansing, and a reactive hyperemia of the treated area enhancing epithelization. Its highly acid pH produces a marked bactericidal action on the most common pathogens and C. albicans as well. Policresulene has hemostyptic properties producing vasoconstriction of the myofibrils of the blood vessels arresting profuse bleeding from large areas. The local anesthetic cinchocaine contributes to the initial pain relief. None of the formulations contains corticosteroids which makes this preparations also suitable for long term treatment periods.

Role of phospholipase A2 in hypoxia-induced renal cell injury

The present study was designed to assess the roles of PLA2 activation and arachidonic acid (AA) metabolites in hypoxia-induced renal cell injury. Hypoxia increased LDH release in a dose-dependent manner in rabbit renal cortical slices, and this increase was significant after 20-min hypoxia. The hypoxia-induced LDH release was prevented by amino acids, glycine and alanine, and extracellular acidosis (pH 6.0). Buffering intracellular Ca2+ by a chelator, but not omission of Ca2+ in the medium produced a significant reduction in hypoxia-induced LDH release. The effect of hypoxia was blocked by PLA2 inhibitors, mepacrine, butacaine, and dibucaine. A similar effect was observed by a 85-kD cPLA2 inhibitor AACOCF3. AA increased hypoxia-induced LDH release, and albumin, a fatty acid absorbent, prevented the LDH release, suggesting that free fatty acids are involved in hypoxia-induced cell injury. These results suggest that PLA2 activation and its metabolic products play important roles in pathogenesis of hypoxia-induced cell injury in rabbit renal cortical slices.

Saddle block; with pethidine and cinchocaine

Twenty five patients each undergoing perineal operations were given saddle block intradural with Pethidine Hydrochloride 0.5 mg/kg and Cinchocaine 0.5%. The site of injection was given between L3/L4 and L4/L5. The motor blockade caused by Pethidine was adequate and post operative analgesia was much longer than that of Cinchocaine

Roles of Na+-Ca2+ exchange in the negative force-frequency relationship

Frequency-force relationships (FFR) were studied in electrically field stimulated rat left atria (LA) by reducing the stimulation frequency from resting 3 Hz to test frequencies (0.1-1 Hz) for 5 minutes. The twitch amplitudes of LA elicited the typical negative staircases with 3-phased changes: the initial rapid increase, the second decrease and the following plateau at test frequencies. Verapamil (3 X 10-5 M) pretreatment elicited frequency-dependent suppression of the twitch amplitudes, exaggerating the negative staircase. Monensin pretreatment enhanced not the peak but the plateau amplitudes in a concentration-dependent manner. When the Na+-Ca2+ exchange was blocked by Na+ and Ca2+ depletion in the Krebs Hensleit buffer (0 Na+-0 Ca2+ KHB), the twitch amplitudes increased in a frequency-dependent manner, changing the negtive staircase into the positve one. Meanwhile, the 0 Na+-0 Ca2+ KHB applicationinduced enhancement was strongly suppressed by caffeine (5 mM) pretreatment. Only dibucaine among the local anesthetics increased the basal tone during frequency reduciton. There were no differences in 45Ca uptakes between 0.3 Hz and 3 Hz stimulation except at 1 min when it was significantly low at 0.3 Hz than 3 Hz, illustrating net Ca2+ losses. Monensin pretreatment enhanced the rate of this Ca2+ loss. Taken together, it is concluded that Na+-Ca2+ exchange extrudes more SR released Ca2+ out of the cell in proportion to the frequency, resulting in the negative rate staircase in the rat LA.

Relationship between succinylcholine-induced apnea and dibucaine number in patients with genetic deficiency of plasma cholinesterase

In this study, a commercially available kit in which propionylthiocholine is used as a substrate and a dibucaine solution to determine the variants of the enzyme were utilized. Plasma cholinesterase activity of 151 patients who underwent different operations was measured during a period of six months. The mean +/- SD of the enzyme activity in 150 patients was 4.39 +/- 1.17 kU/L. Seventeen patients [11.2%] were found to have a serum cholinesterase activity of less than normal [<3 kU/L], but the period of apnea and the dibucaine number [DN] were found to be normal. Eight patients [5.3%] displayed an increased sensitivity to succinylcholine. Six of these patients [4%] were heterozygous for atypical enzyme with a mean period of apnea of 18.6 min [range 12-35 minutes] and had a dibucaine number of less than normal [<80%]. The DN of the other two patients [1.3%] who were homozygotes and had an exceedingly low atypical enzyme allele was 10% and 24%. The mean +/- SD DN value, in the 149 out of 151 patients was 84.41 +/- 2.91%, and the DN ranged from 10-90% in these patients. The mean +/- SD apnea period in the 149 patients was 6.37 +/- 4.28 min

Saddle block with pethidine and cinchocaine for perineal operations in Sir Ganga Ram Hospital, Lahore

Two groups of twenty five patients each undergoing perineal operations in intradural saddle block with Pethidine Hydrochloride 0.5mg/kg and Cinchocaine 0.5%. The site of injection was space between L[4] / L[5]. The motor blockade caused by pethidine was adequate and post operative analgesia was much longer than that of cinchocaine

Comparison of Pseudocholinesterase Activity between Nonpregnant and Term-pregnant Women with the Genotypically Normal Enzyme / 대한마취과학회지

BACKGROUND: Many reports on the change of pseudocholinesterase activity in pregnant women showed that it declines during pregnancy and in the immediate postpartum period. In Korea, there are two papers that show dissident results. However, they didn't prove that the subjects in their studies had genotypically normal enzyme. So, we compared the pseudocholinesterase activities between nonpregnant and term-pregnant women who have the genotypically normal enzyme. METHODS: We measured the dibucaine, fluoride, chloride number as well as the pseudocholinesterase astivity using butyrylthiocholine as substrate by automatic analyser, urea and scoline numbers using benzoylcholine as substrate by manual technique in nonpregnant(n=15) and term-pregnant(n=15) women aging 20 to 40 years old before induction of anesthesia. RESULTS: The dibucaine, fluoride, chloride, urea and scoline numbers(mean+/-SD,%) in female subjects were 86+/-1.2, 50+/-5.2, 5+/-2.4, 47+/-2.8 and 92+/-2.0, respectively. There were two subjects showing low pseudocholinesterase activity(<4.8 U/ml) and the one(3.9 U/ml) was in nonpregnant group, the other(4.5 U/ml) in term-pregnant group. We found that they had genotypically normal enzymes because their inhibition numbers were within normal ranges. Pseudocholinesterase activity(mean+/-SD) in term-pregnant group(7.04+/-1.30) was significantly decreased compared with that in nonpregnant group(9.15+/-2.01)(P<0.01). CONCLUSIONS: We conclude that in subjects with the genotypically normal enzyme, term-pregnant women had significantly lower pseudocholinesterase activity than nonpregnant ones did.

Inhibition Numbers of Pseudocholinesterase in Korean Adults / 대한마취과학회지

Pseudocholinesterase is an essential enzyme for hydrolysis of succinylcholine and some people has low activity. The pseudocholinesterase from a normal individual has a greater apparent affinity for the cholinester substrate than the enzyme from succinylcholine-sensitive individuals, who has genetic variants. The ideal situation would be one in which a single, simple test would detect and identify all the variant forms of enzyme, but no such test currently exsits. The inhibitors frequently used to identify variants are dibucaine, fluoride, chloride, urea or succinylcholine as inhibition numbers. The authors found that dibucaine, fluoride and chloride numbers in Korean adults (mean+/-SD, %) are 85.8+/-1.83, 46.5+/-2,05 and 3.53+/-1.64, respectively (substrate is butyrylthiocholine).

Existence of a silent gene for pseudocholinesterase in a Trinidad population

Although the values reported were higher than those reported for Caucasians, differences in dibucaine number for pseudocholinesterase values among the three ethnic groups in Trinidad and Tobago, were not significant. Eight individuals had intermediate dibucaine numbers values between 40 and 70; one of them was African, 3 were East Indians, and 4 Mixed. Two of the mixed group were of Portuguese lineage and had significantly lower dibucaine numbers and enzyme concentration. Two sisters of East Indian origin had an inestimable dibucaine number and their pseudocholinesterase values were just detectable, suggesting the presence of a 'silent gene' for pseudocholinesterase. These studies, which are being extended, suggest that the dibucaine number should be estimated prior to succinylcholine administration in patients in Trinidad and Tobago who are at risk of apnoea

Prolonged Neuromuscular Blockade Following Succinycholine Administration in a Patient with Plasma Cholinestrase Variant / 대한마취과학회지

The authors experienced a case of plasma cholinesterase variant who received succinylcholine, atracurium and reversal with pyridostigmine, and showed prolonged neuromuscular blockade postoperatively, and was ventilated artificia1ly until complete recovery. The patient and her two children later gave samples of blood. The patients blood revealed very low plasma cholinesterase activity of 0.11 IU/L(normal range; 5-12 IU/L) and dibucaine number of 33. In consideration of her childrens plasma cholinesterase activities and dibucaine numbers, we suggest that she has genetically abnormal plasma cholinesterase and probably her genotype is E E or E E.