New insights into pathways of the accessory nerve and transverse cervical artery for distal selective accessory nerve blockade.

BACKGROUND: The aim of this study was to clarify the topographical relationship between the accessory nerve (AN) and transverse cervical artery (TCA) to provide safe and convenient injection points for AN blockade. METHODS: This study included 21 and 30 shoulders of 14 embalmed Korean adult cadavers and 15 patients, respectively, for dissection and ultrasound (US) examination. RESULTS: The courses of the TCA and AN in the scapular region were classified into four types based on their positional relationships. Type A indicated the nerve that was medial to the artery and ran parallel without changing its location (38%). In type B (38%), the nerve was lateral to the artery and ran parallel without changing its location. In type C (19%), the nerve or artery traversed each other only once during the whole course. In type D (5%), the nerve or artery traversed each other more than twice forming a twist. At the levels of lines I-IV, the nerve was relatively close to the artery (approximately 10 mm). TCAs were observed in all specimens around the superior angle of the scapula at the level of line II, whereas they were not found below line VI. In US images of the patients, the TCA was commonly observed at the level of line II (93.3%) where all ANs and TCAs were observed in cadaveric dissection. CONCLUSIONS: The results expand the current knowledge of the relation between the AN and TCA, and provide helpful information for selective diagnostic nerve blocks in the scapular region.

The Association of Perioperative Serum Lactate Levels with Postoperative Delirium in Elderly Trauma Patients.

BACKGROUND: Several studies have shown the utility of lactate level as a predictor of early outcomes in trauma patients. We conducted this study to evaluate the association of perioperative serum lactate levels with postoperative delirium (POD) in elderly trauma patients. MATERIALS AND METHODS: This study included 466 elderly trauma patients with measurements of serum lactate levels on admission and 1 h after surgery. The associations of POD with serum lactate levels (on admission and 1 h after surgery) and lactate clearance were analyzed using Kendall's correlation. Perioperative serum lactate levels and lactate clearance as predictors of POD were evaluated using univariate and multivariable analyses. RESULTS: The incidence of POD in the present study was 38.1%. Serum lactate levels on admission and at 1 h after surgery were significantly higher in major trauma than in minor trauma. In univariate analysis of perioperative serum lactate levels and lactate clearance as predictors of POD, the odds ratio (OR) for serum lactate level on admission was 4.19 (P < 0.01, 2.91 < 95% confidence interval (CI) < 6.02) and that 1 h after surgery was 3.83 (P < 0.01, 2.79 < 95% CI < 5.25); however, the OR for serum change of lactate level was 0.99 ((P < 0.09, 0.99 < 95% CI < 1.00). In multivariable analysis for predictors of POD, the OR for serum lactate level on admission was 2.40 (P < 0.09, 0.87 < 95% CI < 6.7), that for serum lactate 1 h after surgery was 2.83 (P=0.01, 1.28 < 95% CI < 6.24), that for ICU admission was 3.01 (P=0.01, 2.09 < 95% CI < 6.03), and that for ISS was 1.47 (P < 0.01, 1.27 < 95% CI < 3.70). CONCLUSIONS: Taking together the results of univariate and multivariable analyses, serum lactate level 1 h after surgery may be used as a prediction model of POD development in elderly trauma patients.

New insights into pathways of the dorsal scapular nerve and artery for selective dorsal scapular nerve blockade.

BACKGROUND: The aim of this study was to clarify the topographical relationships between the dorsal scapular nerve (DSN) and the dorsal scapular artery (DSA) in the interscapular region to identify safe and convenient injection points related to DSN blockade. METHODS: Thirty shoulders of embalmed Korean cadavers and 50 live subjects were used for dissection and ultrasound (US) analysis. RESULTS: The running patterns of the DSA and DSN in the interscapular region were classified into 3 types. Type I was defined as nerves that were medial to the artery and parallel without changing location (80.0% of specimens). In type II (13.3%), the nerve and artery traversed one another only one time over their entire length. In type III (6.7%), the nerve and artery traversed one another, resembling a twist. Above the level of the scapular spine, the nerve was always medial to the artery. Below the scapular spine, the number of arteries was obviously decreased. Most of the arteries were lateral to the medial border of the scapula, except at the level of the superior angle of the scapula artery (SA). The positional tendency of the DSN toward the medial or lateral sides from the medial border of the scapula was similar. In US imaging of live subjects, the DSA was most observed at the level of the SA (94.0%). CONCLUSIONS: Results of this study enhance the current knowledge regarding the pathway of the DSN and DSA and provide helpful information for selective diagnostic nerve blocks in the interscapular region.

Misato underlies visceral myopathy in Drosophila.

Genetic mechanisms for the pathogenesis of visceral myopathy (VM) have been rarely demonstrated. Here we report the visceral role of misato (mst) in Drosophila and its implications for the pathogenesis of VM. Depletion of mst using three independent RNAi lines expressed by a pan-muscular driver elicited characteristic symptoms of VM, such as abnormal dilation of intestinal tracts, reduced gut motility, feeding defects, and decreased life span. By contrast, exaggerated expression of mst reduced intestine diameters, but increased intestinal motilities along with thickened muscle fibers, demonstrating a critical role of mst in the visceral muscle. Mst expression was detected in the adult intestine with its prominent localization to actin filaments and was required for maintenance of intestinal tubulin and actomyosin structures. Consistent with the subcellular localization of Mst, the intestinal defects induced by mst depletion were dramatically rescued by exogenous expression of an actin member. Upon ageing the intestinal defects were deteriorative with marked increase of apoptotic responses in the visceral muscle. Taken together, we propose the impairment of actomyosin structures induced by mst depletion in the visceral muscle as a pathogenic mechanism for VM.

Effectiveness of Specific Sublingual Immunotherapy in Korean Patients with Atopic Dermatitis.

BACKGROUND: Sublingual immunotherapy (SLIT) with house dust mites (HDM) preparation has recently been proven to be beneficial for treating allergic rhinitis and asthma. However, there has been no report regarding the efficacy and safety of SLIT in Korean patients with atopic dermatitis (AD). OBJECTIVE: We intended to investigate the efficacy and safety of SLIT in Korean patients with AD. METHODS: A total of 34 patients with AD and immunoglobulin E (IgE)-proven HDM sensitization (Class ≥3) were recruited. Eczema area and severity index (EASI) score, total serum IgE level, specific IgE assays to Dermatophagoides pteronyssinus, D. farinae, and adverse effects were recorded during follow-up. "Responder" was defined as a patient with ≥30% improvement in EASI score after SLIT. RESULTS: Twenty-three patients continued SLIT for 12 months or more, whereas 3 patients (8.8%) dropped out because of exacerbation of dermatitis, and 8 patients (23.5%) were lost to follow-up. The average duration of SLIT treatment was 22.4 months (range, 12~32 months). EASI scores reduced significantly after 6 months of treatment (p<0.05) compared with those at baseline. A total of 18 patients were determined to be responders to SLIT after 6 months. Total and specific IgE serum levels did not significantly reduce after SLIT. No patients experienced serious adverse events, with the exception of two patients who developed transient lip and tongue swelling. CONCLUSION: Our study demonstrated that SLIT with HDM extracts is effective and tolerable in Korean patients with AD. Further controlled long-term trials are required to reinforce the current results.

Evidence-based guidelines for fall prevention in Korea.

Falls and fall-related injuries are common in older populations and have negative effects on quality of life and independence. Falling is also associated with increased morbidity, mortality, nursing home admission, and medical costs. Korea has experienced an extreme demographic shift with its population aging at the fastest pace among developed countries, so it is important to assess fall risks and develop interventions for high-risk populations. Guidelines for the prevention of falls were first developed by the Korean Association of Internal Medicine and the Korean Geriatrics Society. These guidelines were developed through an adaptation process as an evidence-based method; four guidelines were retrieved via systematic review and the Appraisal of Guidelines for Research and Evaluation II process, and seven recommendations were developed based on the Grades of Recommendation, Assessment, Development, and Evaluation framework. Because falls are the result of various factors, the guidelines include a multidimensional assessment and multimodal strategy. The guidelines were developed for primary physicians as well as patients and the general population. They provide detailed recommendations and concrete measures to assess risk and prevent falls among older people.

Efficacy and Safety of Calcipotriol/Betamethasone Dipropionate Ointment for the Treatment of Trachyonychia: An Open-Label Study.

BACKGROUND: Despite efforts to treat trachyonychia, there is no promising treatment modality. OBJECTIVE: This study evaluated the efficacy and safety of calcipotriol plus betamethasone dipropionate ointment on trachyonychia. METHODS: A total of 39 patients with 432 nails affected by trachyonychia were enrolled. All patients applied calcipotriol/betamethasone ointment once daily without occlusion for 6 months. Outcome measures were assessed by physician's global assessment (degree of roughness: 0, clear; 1, mild; 2, moderate; 3, marked; 4, severe) at all time points. RESULTS: After 6 months of therapy, 98.6% (426/432) of nails showed significant clinical improvement; 4.2% were completely free from nail lesions. The mean physician global assessment score decreased significantly from 3.5 to 1.7 points (p< 0.05). No serious side effects were reported, except mild pruritus and erythema in 2 patients. CONCLUSION: This is the first study to prospectively evaluate the efficacy and safety of calcipotriol/betamethasone ointment for the treatment of trachyonychia. The results indicate topical calcipotriol/betamethasone is an effective and safe treatment for symptom improvement of trachyonychia.

Erythrodermic Psoriasis Treated with Golimumab: A Case Report.

Erythrodermic psoriasis (EP) is a very severe variant of psoriasis whose management poses a challenge to physicians, as currently available therapies often provide unsatisfactory results. Many biologics have been used to treat chronic plaque psoriasis, the most common form of psoriasis; however, their effectiveness for EP is poorly understood. A recently developed biologic, golimumab, has been extensively studied for the treatment of moderate-to-severe active rheumatoid arthritis, psoriatic arthritis, active ankylosing spondylitis, and chronic plaque psoriasis. However, no clinical trials have been performed for EP. Here, we report the case of a 32-year-old man who presented with severe psoriasis that previously failed to respond satisfactorily to methotrexate, cyclosporine, retinoid, narrow-band ultraviolet B phototherapy, and topical agents (i.e., steroids and calcipotriol). Skin lesions worsened progressively and developed into erythroderma. Psoriatic arthritis was also detected. Conventional therapies lacked efficacy. Therefore, we administered golimumab 50 mg. The skin lesions improved significantly according to the Psoriasis Area and Severity Index score after the first administration; lesions improved further throughout the treatment course. Although additional studies are required to fully evaluate the efficacy and safety of golimumab, this agent may be an alternative treatment strategy for some patients with recalcitrant EP.

Screening for Psoriatic Arthritis in Korean Psoriasis Patients Using the Psoriatic Arthritis Screening Evaluation Questionnaire.

BACKGROUND: Psoriatic arthritis (PsA) is chronic seronegative inflammatory arthritis that causes irreversible joint damage. Early recognition of PsA in patients with psoriasis is important for preventing physical disability and deformity. However, diagnosing PsA in a busy dermatology outpatient clinic can be difficult. OBJECTIVE: This study aimed to validate the Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire for the detection of PsA in Korean patients with psoriasis. METHODS: The PASE questionnaire was prospectively given to 148 patients diagnosed with psoriasis but without a previous diagnosis of PsA. All patients underwent radiologic and laboratory examinations, and a subsequent clinical evaluation by a rheumatologist. RESULTS: Eighteen psoriasis patients (12.2%) were diagnosed with PsA according to the Classification Criteria for Psoriatic Arthritis. The PASE questionnaire scores of differed significantly between PsA and non-PsA patients. Receiver operator characteristic analysis showed an area under the curve of 0.82 (95% confidence interval: 0.72, 0.92) for PASE score. A PASE score cut-off of 37 points had a sensitivity of 77.8% and specificity of 82.3% for the diagnosis of PsA. CONCLUSION: The PASE questionnaire is a simple and convenient screening tool for detecting PsA in Korean dermatology clinics. A PASE questionnaire score of 37 points appears to be an appropriate cut-off for screening Korean psoriasis patients.

Clinical features and course of generalized pustular psoriasis in Korea.

The clinical course of generalized pustular psoriasis (GPP) is variable and unpredictable. Sufficient data on the clinical course of the disease has not been reported due to its rarity. To investigate the clinical features and course of GPP according to its subtypes, medical records of patients diagnosed with GPP from 2002 to 2012 at two tertiary hospitals were reviewed. The data included patient demographics, associated symptoms, aggravating factors, patterns of relapse and prognosis. Thirty-three patients with GPP were included in our study, with a mean age of 45.6 years and a male : female ratio of 1:1.2. Patients were categorized based on the following subtypes: acute GPP, 21 (63.6%); GPP of pregnancy, two (6.1%); juvenile GPP, three (9.1%); and annular GPP, seven (21.2%). In the acute GPP population, skin lesions cleared within 2 months in 11 (73.3%) patients, and six (40.0%) of these had no relapse. Severe complications, abortion or death, were observed in two patients (100.0%) with GPP of pregnancy. Nineteen (76.0%) of the GPP patients experienced persistence or relapse of skin lesions. The patterns of skin lesions upon relapse included plaques in six patients (31.6%), pustules in eight patients (42.1%), and plaques and pustules in five patients (26.3%). Among acute GPP patients, 16.7% of patients with no relapse had a history of plaque psoriasis. However, 77.8% of patients with persistence and relapse in their clinical course had a history of plaque psoriasis. In conclusion, our study presents the detailed clinical course of GPP by subtype in Korean patients.

Diagnosing Psoriatic Arthritis from the Dermatologist's View.

Psoriatic arthritis is a chronic inflammatory arthropathy associated with skin psoriasis. It is considered a unique arthropathy with distinct clinical and radiologic features. Up to 40% of patients with psoriasis may develop psoriatic arthritis. Psoriasis usually precedes psoriatic arthritis, so dermatologists are in a critical position for screening patients of psoriatic arthritis early in the disease course. Psoriatic arthritis may be challenging to diagnose, especially for dermatologists, because it has an insidious disease course, non-specific symptoms, and no specific biomarkers. Psoriatic arthritis is a polygenic autoimmune disorder of unknown etiology, but immunologic roles have recently been validated. In recent years, treatment modalities have rapidly advanced in the fields of psoriasis and psoriatic arthritis. Biologic agents, including TNF-α inhibitors and anti-IL12/23 agents, have shown dramatic improvement.

Narrowband UVB treatment of progressive macular hypomelanosis.

BACKGROUND: Little information is available on effective treatments for progressive macular hypomelanosis (PMH). To our knowledge, only one case of narrowband ultraviolet B (NB-UVB) therapy as an efficient treatment for patients with PMH has been reported in the recent literature. OBJECTIVE: We aimed to investigate the clinical features of PMH in Koreans and to determine the therapeutic efficacy of NB-UVB therapy in the management of PMH. METHODS: We performed an uncontrolled prospective study designed to evaluate the usefulness of NB-UVB therapy in PMH. A total of 23 patients with PMH were enrolled in the study. Of these, 17 patients underwent treatment with NB-UVB therapy once or twice weekly and were eligible for analysis. The remaining 6 patients were lost to follow-up before completion of the treatment. Repigmentation was evaluated by two dermatologists using photographic documentation. RESULTS: In our trial, NB-UVB therapy was used successfully in 9 of 16 patients (56.2%), who showed more than 90% repigmentation. We found that 13 of 16 patients (81.3%) experienced at least 50% repigmentation. The repigmented sites showed an excellent color match. No signs of recurrence have been detected in 11 of these 16 patients (68.7%) up to the present time (13.2 ± 8.2 months of follow-up). LIMITATIONS: Our study includes a small number of subjects examined, and it was an uncontrolled and non-double-blind study. CONCLUSIONS: The findings of this study suggest that NB-UVB therapy is an effective and safe method for use in the treatment of PMH.

Recurrent basal cell carcinoma following ablative laser procedures.

BACKGROUND: In Korea, many patients diagnosed with basal cell carcinoma (BCC) have a history of laser ablations of undiagnosed lesions. OBJECTIVE: To evaluate the clinical/pathological and surgical features of BCC developing from undiagnosed lesions following laser ablations (not full-face cosmetic ablations) and to compare them with primary BCCs. METHODS: This study enrolled 359 patients with 373 biopsy-proven BCC lesions. All of the patients were treated by Mohs micrographic surgery (MMS) at the Department of Dermatology, Pusan National University Hospital from 1998 to 2008. BCC was classified by previous treatment history of lesion ablative laser: post-laser BCC vs primary BCC. We conducted a retrospective study through clinical photographs, pathology slides, and MMS sheets. RESULTS: Among 373 BCCs, 58 lesions (15.5%) were post-laser BCCs. The post-laser BCC group was younger (59.9 vs 65.4 years, P = .001), but had a longer disease interval until pathologic diagnosis (7.18 vs 3.33 years, P < .0001) than the primary BCC group. The post-laser BCC group had a greater frequency of the micronodular pattern (22.4% vs 10.8%, P = .01), required more stages of excision (2.69 ± 1.63 vs 2.15 ± 1.05, P < .001), and had fewer cases with one Mohs stage excision (10.3% vs 27%, P = .006) than the primary BCC group. LIMITATIONS: We could not identify the type of laser used in all 58 cases; instead, we supposed that most of the patients were likely treated with the carbon dioxide laser. CONCLUSIONS: The results demonstrated that the post-laser BCC group had a longer disease interval to diagnosis, a more aggressive histologic pattern, and required more stages of excision in MMS than the primary BCC group.

Oral hairy leukoplakia which occurred as a presenting sign of acute myeloid leukemia in a child.

Oral hairy leukoplakia (OHL) is caused by the reactivation of a previous Epstein-Barr virus (EBV) infection in the epithelium of the tongue. Most lesions are characterized by corrugated whitish patches on the lateral border of the tongue. It is frequently associated with AIDS, but cases in patients with other immunosuppressed states have also been reported. In leukemia patients, OHL is rarely encountered, and appears only after chemotherapy. We report a case of OHL which occurred as a presenting sign of acute myeloid leukemia (AML) in a previously healthy 15-year-old child. A 15-year-old boy presented with a whitish patch on the left lateral border of the tongue. The biopsy specimen revealed papillomatosis, hyperkeratosis, acanthosis and ballooning degeneration in the stratum spinosum. The patient was EBV seropositive, and PCR analysis of EBV DNA in the lesional tissue was positive. After the diagnosis of OHL in dermatologic department, the patient was referred to pediatrics due to the abnormal peripheral blood smear, and was diagnosed with AML.

Two cases of pyodermatitis-pyostomatitis vegetans.

Pyodermatitis-pyostomatitis vegetans (PPV) is a rare chronic pustular and vegetating mucocutaneous dermatosis. The oral lesions present as multiple, friable and yellowish pustules, which form "snail tracts" and rupture easily. The cutaneous lesions begin as crusted erythematous papulopustules that coalesce to form large vegetating plaques, usually in the axillae, genital area and scalp. Cutaneous lesions usually develop at the same time as the oral lesions or thereafter. PPV is usually considered as a specific marker for inflammatory bowel disease since the concurrence of PPV and inflammatory bowel disease has been reported in approximately 70% of cases. We report two patients who showed typical clinical and histopathological features of PPV, but were not accompanied by inflammatory bowel disease.