Different associations of periventricular and deep white matter lesions with cognition, neuropsychiatric symptoms, and daily activities in dementia.

We investigated the associations of periventricular white matter hyperintensities (PWMHs) and deep white matter hyperintensities (DWMHs) with cognition, activities of daily living (ADLs), and neuropsychiatric symptoms in dementia. This was a hospital-based MRI300 study. We recruited patients newly diagnosed with mild-to-moderate dementia caused either by Alzheimer's disease or subcortical ischemic vascular dementia from 13 dementia clinics at university or general hospitals in South Korea. We enrolled 289 patients aged over 50 from August 2007 to March 2008. We compared cognition, ADLs, and neuropsychiatric symptoms among 3 groups according to the severities of PWMHs and DWMHs, respectively, by adjusting for age, vascular risk factors, and level of other WMHs. A higher severity of PWMHs was related to lower cognitive function and severer neuropsychiatric symptoms, whereas basic ADLs were associated with DWMH. Both PWMHs and DWMHs exhibited different associations with cognition, neuropsychiatric symptoms, and daily activities.

Open-label study comparing the efficacy and tolerability of aripiprazole and haloperidol in the treatment of pediatric tic disorders.

Due to its unique pharmacodynamic properties of dopamine partial agonist activity, and its association with few and mild side effects, aripiprazole is a candidate atypical antipsychotic for patients with tic disorders. This open-label study compared the efficacy and tolerability of aripiprazole with haloperidol, a typical antipsychotic widely used to treat patients with tic disorders. Forty-eight children and adolescents with tic disorders were recruited from the outpatient clinic at South Korea and treated with aripiprazole (initial dose, 5.0 mg/d; maximum dose 20 mg/d) or haloperidol (initial dose, 0.75 mg/d; maximum dose, 4.5 mg/d) for 8 weeks. Treatment efficacy was measured using the yale global tic severity scale (YGTSS), and tolerability was measured using the extrapyramidal symptom rating scale (ESRS) and an adverse effects checklist. Total tic scores as measured by the YGTSS decreased over time in both groups (p < 0.001) without any significant differences between groups. ESRS scores were significantly higher in the haloperidol group during the 4 weeks after commencement of medication (p < 0.05). These results indicate that aripiprazole may be a promising drug in the treatment of children and adolescents with tic disorders. Further controlled studies are needed to determine the efficacy and tolerability of aripiprazole in these patients.

A case report of palmar xanthoma with xanthomatous neuropathy.

Xanthomas are plaques or nodules consisting of an accumulation of excess lipids, resulting in the formation of foam cells in the skin or tendons. Typically, xanthomas are not accompanied by other symptoms. Here, we report a patient with a presentation of painful palmar xanthomas and subsequent diagnosis of metabolic and cardiovascular morbidities. A 44-year-old man presented with multiple yellowish, firm, and painful nodules on his right palm and fingers. Lipid panel and medical examination revealed a diagnosis of type III hyperlipoproteinemia and diabetes mellitus type II. Histopathological examination of the lesions revealed numerous lipid-laden foamy cells surrounding the nerve bundles through the dermis. This unique presentation of painful xanthomas prior to the manifestation of more significant underlying conditions suggested that xanthomas might be used as early diagnostic indicators. Based on this case, we propose more thorough examinations of palmar xanthomas in patients for earlier detection of potentially lethal diseases.

A case report of primary cutaneous marginal zone B-cell lymphoma with mastocytosis.

A 53-year-old man presented with asymptomatic, dusky reddish nodules on his trunk, which had persisted for 7 years. Histological findings showed nodular to diffuse dermal infiltration of lymphocytes with irregular nuclei, eosinophils, plasma cells, and mast cells. CD20 revealed patch positivity. Periphery of lymphoid follicles showed BCL-2 positivity and BCL-6 positivity focally at the center. CD30 and toluidine blue staining showed positivity, and several mast cells were confirmed. The immunoglobulin heavy chain gene rearrangement result showed B-cell monoclonality. The patient's condition was diagnosed as cutaneous marginal zone B-cell lymphoma, plasmacytoid type with mastocytosis. Primary cutaneous marginal zone B-cell lymphoma is an indolent lymphoma with a tendency for local recurrence. In the specimen obtained from our patient, multiple mast cells were observed. Primary cutaneous marginal zone B-cell lymphoma with prominent mastocytosis is rare and there are a few reported cases. Therefore, this case is worth reporting for its rarity and for the purpose of reminding mastocytosis in primary cutaneous marginal zone B-cell lymphoma.

Histopathological features of acquired dermal melanocytosis.

Acquired dermal melanocytosis (ADM) is the term used for pigmentary disorders characterized by blue brown macules, most frequently seen on the face (acquired bilateral nevus of Ota-like macules, ABNOM), and rarely found on the trunk or extremities. Although extrafacial ADM and ABNOM are not usually considered separate entities because of similar features, there has been debate as to whether extrafacial ADM and ABNOM might be part of the same disease spectrum, with or without the same pathogenesis. In order to investigate the relationship between these two entities, the histopathological features of extrafacial ADM and ABNOM were evaluated. We examined nine cases of extrafacial ADM and ten cases of ABNOM. Biopsies were performed on both normal and lesional skin, or on lesional skin only. The sections were stained using hematoxylin-eosin, Fontana-Masson, and NKI/beteb. There was no difference in the degree of melanin pigmentation and the number of melanocytes per unit area in the lesional skin of the epidermis and dermis in the comparisons between extrafacial ADM and ABNOM. The mean depth of the dermal melanocytes was significantly increased in extrafacial ADM (0.88 +/- 0.19 mm) compared to ABNOM (0.58 +/- 0.19 mm); however, in both extrafacial ADM and ABNOM, dermal melanocytes were distributed from the upper to the mid dermis. In conclusion, there was no significant difference in the histopathological features, including relative depth of melanocytes, between extrafacial ADM and ABNOM. To the best of our knowledge, this is the first study to demonstrate by histopathology that extrafacial ADM is the same as ABNOM.

Late Onset Foreign Body Reaction due to Poly-L-Lactic Acid Facial Injections for Cosmetic Purpose.

The safety and efficacy of Poly-L-lactic acid (PLLA) as an injectable facial volumizer for the treatment of lipoatrophy and facial rejuvenation has been widely proven. We experienced a remarkable case of deep-seated nodules on both the cheeks of 57-year-old female 18-months after administration of PLLA filler injection for cosmetic purpose and performed a skin biopsy. With hematoxylin and eosin stain, the nodule showed non-caseating granulomas consisting of histiocytes with central foreign bodies in the dermis. This case report represents the late-onset foreign body reaction due to PLLA facial injections.

Patient Consent Management by a Purpose-Based Consent Model for Electronic Health Record Based on Blockchain Technology.

OBJECTIVES: Currently, patients' consent is essential to use their medical records for various purposes; however, most people give their consent using paper forms and have no control over it. Healthcare organizations also have difficulties in dealing with patient consent. The objective of this research is to develop a system for patients to manage their consent flexibly and for healthcare organizations to obtain patient consent efficiently for a variety of purposes. METHODS: We introduce a new e-consent model, which uses a purpose-based access control scheme; it is implemented by a blockchain system using Hyperledger Fabric. All metadata of patient records, consents, and data access are written immutably on the blockchain and shared among participant organizations. We also created a blockchain chaincode that performs business logic managing patient consent. RESULTS: We developed a prototype and checked business logics with the chaincode by validating doctors' data access with purpose-based consent of patients stored in the blockchain. The results demonstrate that our system provides a fine-grained way of handling medical staff 's access requests with diverse intended purposes for accessing data. In addition, patients can create, update, and withdraw their consents in the blockchain. CONCLUSIONS: Our consent model is a solution for consent management both for patients and healthcare organizations. Our system, as a blockchain-based solution that provides high reliability and availability with transparency and traceability, is expected to be used not only for patient data sharing in hospitals, but also for data donation for biobank research purposes.

Application of Blockchain to Maintaining Patient Records in Electronic Health Record for Enhanced Privacy, Scalability, and Availability.

OBJECTIVES: Electronic Health Record (EHR) systems are increasingly used as an effective method to share patients' records among different hospitals. However, it is still a challenge to access scattered patient data through multiple EHRs. Our goal is to build a system to access patient records easily among EHRs without relying on a centralized supervisory system. METHODS: We apply consortium blockchain to compose a distributed system using Hyperledger Fabric incorporating existent EHRs. Peer nodes hold the same ledger on which the address of a patient record in an EHR is written. Individual patients are identified by unique certificates issued by a local certificate authorities that collaborate with each other in a channel of the network. To protect a patient's privacy, we use a proxy re-encryption scheme when the data are transferred. We designed and implemented various chaincodes to handle business logic agreed by member organizations of the network. RESULTS: We developed a prototype system to implement our concept and tested its performance including chaincode logic. The results demonstrated that our system can be used by doctors to find patient's records and verify patient's consent on access to the data. Patients also can seamlessly receive their past records from other hospitals. The access log is stored transparently and immutably in the ledger that is used for auditing purpose. CONCLUSIONS: Our system is feasible and flexible with scalability and availability in adapting to existing EHRs for strengthening security and privacy in managing patient records. Our research is expected to provide an effective method to integrate dispersed patient records among medical institutions.

The KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children: Part 2. Management of H1-Antihistamine-Refractory Chronic Urticaria.

Quite a few patients with chronic spontaneous urticaria (CSU) are refractory to H1-antihistamines, even though the dose of H1-antihistamines is increased up to 4-fold. CSU that is not controlled with H1-antihistamines results in increased disease burden. Several immunomodulators have been used to manage these patients. The guidelines reported herein are connected to Part 1 of the KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children, and aimed to provide evidence-based recommendations for the management of H1-antihistamine-refractory CSU. Part 2 focuses on the more commonly used additional treatment options for refractory CSU, including omalizumab, cyclosporine, leukotriene receptor antagonist, dapsone, methotrexate, and phototherapy. The evidence to support their efficacy, dosing, safety, and selection of these agents is systematically reviewed. To date, for patients with refractory CSU, the methodologically sound data to evaluate the use of omalizumab has been growing; however, the evidence of other immunomodulators and phototherapy is still insufficient. Therefore, an individualized stepwise approach with a goal of achieving complete symptom control and minimizing side effects can be recommended. Larger controlled studies are needed to elevate the level of evidence to select a rational therapeutic agent for patients with refractory CSU.

The KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children: Part 1. Definition, Methodology and First-line Management.

Chronic spontaneous urticaria (CSU) is defined as the occurrence of spontaneous wheals, angioedema, or both for >6 weeks in the absence of specific causes. It is a common condition associated with substantial disease burden both for affected individuals and societies in many countries, including Korea. CSU frequently persists for several years and requires high-intensity treatment; therefore, patients experience deteriorations in quality of life and medication-associated complications. During the last decade, there have been major advances in the pharmacological treatment of CSU and there is an outstanding need for evidence-based guidelines that reflect clinical practice in Korea. The guidelines reported here represent a joint initiative of the Korean Academy of Asthma, Allergy and Clinical Immunology and the Korean Dermatological Association, and aim to provide evidence-based guidance for the management of CSU in Korean adults and children. In Part 1, disease definition, guideline scope and development methodology as well as evidence-based recommendations on the use of antihistamines and corticosteroids are summarized.

Effect of methylphenidate on the quality of life in children with epilepsy and attention deficit hyperactivity disorder: and open-label study using an osmotic-controlled release oral delivery system.

This open study explored whether methylphenidate could be tolerated and effective in improving the quality of life (QOL) and attention deficit hyperactivity disorder (ADHD) symptoms of children with epilepsy and ADHD. Twenty-five subjects (aged 10.1 +/- 3.0 years) with ADHD and epilepsy were recruited at an outpatient clinic in Seoul, Korea. We used the Quality of Life in Childhood Epilepsy Questionnaire (QOLCE), ADHD rating scale (ARS) and clinical global impression (CGI) in this study. Osmotic-controlled release oral delivery system (OROS) methylphenidate, 1.0 +/- 0.4 mg/kg/day, was administered for 55.2 +/- 7.5 days. The QOL subscales including physical restriction (p = 0.005), self-esteem (p = 0.002), memory (p < 0.001), language (p = 0.005), other cognition (p < 0.001), social interaction (p = 0.002), behaviour (p < 0.001), general health (p = 0.002) and QOL (p < 0.001) were significantly increased and the ARS (p < 0.001) and CGI-Severity of illness scores (p < 0.001) were significantly reduced after medication. Although 60% of subjects had experienced adverse effects, most were tolerable and only two subjects withdrew from the study owing to unbearable adverse effects (anorexia and insomnia). Two subjects had seizure attacks during the study period without having to discontinue the trial drug. Despite limitations related to the small sample size and the open design of the present pilot study, our results suggest that OROS methylphenidate may be well tolerated and effective in reducing ADHD symptoms and improving QOL in this patient population.

Histopathological features in both the eschar and erythematous lesions of Tsutsugamushi Disease: identification of CD30+ cell infiltration in Tsutsugamushi disease.

Tsutsugamushi disease is an acute febrile infectious disease caused by Rickettsia tsutsugamushi. An infection is heralded by the presence of an eschar at the site of the inoculating chigger bite and followed by the development of a disseminated erythematous macular rash. CD30 expression is found in anaplastic large cell lymphoma; however, expression in nonneoplastic cutaneous disorders, such as atopic dermatitis, drug reactions, scabies, and various infectious diseases, has also been reported. Study of the cutaneous histopathology of tsutsugamushi disease has been limited. In this study, we performed biopsies of both the eschar and erythematous lesions of 15 cases of tsutsugamushi disease to assess the histopathological changes including the CD3, CD4, CD20, CD30, and CD68 reactivity. Twelve women and 3 men were included with an age range from 21 to 73 years. The most common location of the eschar was the trunk (53.3%). The histological features showed increased leukocytoclastic vasculitis in the eschar (93.3%) compared with the erythematous lesions (33.3%); basal vacuolar changes were more common in the erythematous (100%) than in the eschar lesions (20%). The inflammatory infiltrate had a majority of CD3- and CD68-positive cells. Seven erythematous lesions and 7 eschar lesions showed atypical cells that were CD30-positive cells. Here, we report on the cutaneous histopathology and pattern of inflammatory infiltrates of tsutsugamushi disease. Leukocytoclastic vasculitis and basal vacuolar changes were the characteristic features of the eschar and the erythematous lesions, respectively. In addition, CD30-positive cell infiltration was identified for the first time in this disease.

Macular Pigmentation Following Low Fluence Nd:YAG Laser Procedure at Sites of Gold Thread Implantation.

Use of gold thread rejuvenation and Q-switched low fluence neodymium-doped yttrium aluminum garnet (Nd:YAG) laser treatments have become a recent fashion trend in the skin care industry, and are frequently used for skin care management. Although the efficacy and side effects of the individual procedures have been well documented, the combined effects of the two treatments have not been reported. We describe a unique case of macular pigmentation on the face, resulting from the low fluence (3 J/cm2) Nd:YAG laser procedure solely at the sites of gold thread implantation. A skin biopsy revealed rod-shaped foreign material and tiny golden colored granules surrounded by minor inflammatory infiltrates. Therefore, the use of a Nd:YAG laser at a specific wavelength (potentially 1064 nm) may trigger macular pigmentation when in contact with pre-implanted gold threads by as yet unknown mechanism.

Privacy Enhanced Healthcare Information Sharing System for Home-Based Care Environments.

OBJECTIVES: Home-based nursing care services have increased over the past decade. However, accountability and privacy issues as well as security concerns become more challenging during care provider visits. Because of the heterogeneous combination of mobile and stationary assistive medical care devices, conventional systems lack architectural consistency, which leads to inherent time delays and inaccuracies in sharing information. The goal of our study is to develop an architecture that meets the competing goals of accountability and privacy and enhances security in distributed home-based care systems. METHODS: We realized this by using a context-aware approach to manage access to remote data. Our architecture uses a public certification service for individuals, the Japanese Public Key Infrastructure and Health Informatics-PKI to identify and validate the attributes of medical personnel. Both PKI mechanisms are provided by using separate smart cards issued by the government. RESULTS: Context-awareness enables users to have appropriate data access in home-based nursing environments. Our architecture ensures that healthcare providers perform the needed home care services by accessing patient data online and recording transactions. CONCLUSIONS: The proposed method aims to enhance healthcare data access and secure information delivery to preserve user's privacy. We implemented a prototype system and confirmed its feasibility by experimental evaluation. Our research can contribute to reducing patient neglect and wrongful treatment, and thus reduce health insurance costs by ensuring correct insurance claims. Our study can provide a baseline towards building distinctive intelligent treatment options to clinicians and serve as a model for home-based nursing care.

Clinical and radiological results after modified distal metatarsal osteotomy for hallux valgus.

BACKGROUND: The chevron osteotomy is an acceptable method for correction of mild and moderate hallux valgus, but can result in instability at the osteotomy site. The purpose of this study was to present clinical and radiological results with our modified technique of osteotomy. MATERIALS AND METHODS: We performed a modified technique of distal osteotomy of the first metatarsal on 77 feet of 46 patients with symptomatic hallux valgus; followed up for an average of 52 months. RESULTS: All of the patients experienced satisfactory pain relief and acceptable cosmesis. The mean postoperative reduction in the intermetatarsal angle was 6.5 degrees and of the metatarsophalangeal angle was 23.0 degrees. There was no loss of correction and there was no discrepancy in preoperative and postoperative lengths of the first metatarsal during the followup period. CONCLUSION: We found our modified distal metatarsal osteotomy to be an effective method of correcting hallux valgus.

Clinical and Histopathologic Study of Confluent and Reticulated Papillomatosis by Anatomic Site and Age.

BACKGROUND: Confluent and reticulated papillomatosis (CRP) is an uncommon dermatosis characterized by hyperpigmented scaly macules or papillomatous papules coalescing into confluent patches or plaques centrally with a reticular pattern peripherally. Few studies regarding this have been reported in the literature. OBJECTIVE: The purpose of this study was to investigate the clinical and histologic characteristics of CRP in Korean patients according to anatomic site and age. METHODS: We retrospectively reviewed the medical records, clinical photographs, and 40 histopathologic slides of 29 patients diagnosed with CRP. RESULTS: Sixteen adults and 13 adolescents were included. The predominantly involved anatomic sites were the trunk (89.7%) and axillae (27.6%); flexural area involvement was mainly found in the adolescent group. The mean disease duration was 2.3 times longer in the adult group than in the adolescent group. The histopathologic features included hyperkeratosis (95.0%), acanthosis (87.5%), and papillomatosis (77.5%) in the epidermis. In the adult group, only 10 specimens (52.6%) showed mild to moderate papillomatosis. There was no relationship between the histologic findings and disease duration; however, the former was associated with the anatomic site. CONCLUSION: The present study is the first to present the clinical and histologic features of CRP according to age and anatomic site in Korean patients. The patients in this study more frequently had fungal infections (31%) than patients in a previous study (12.8%). Histologic changes were more prominent in the adolescent group than in the adult group and in the flexural area than in the non-flexural area.

Peroxisome proliferator-activated receptors-gamma activator, ciglitazone, inhibits human melanocyte growth through induction of apoptosis.

Peroxisome proliferator-activated receptors (PPARs) are members of the nuclear hormone receptor superfamily. All three PPAR subtypes, PPAR-alpha, PPAR-beta/delta and PPAR-gamma are expressed in human melanocytes. In this study, we investigated the effects of PPAR-gamma activator on melanocyte growth, and apoptosis. The PPAR-gamma activators ciglitazone, troglitazone, and 15-deoxy-prostaglandin J2 inhibited melanocyte growth in a dose-dependent manner. This inhibitory effect of ciglitazone seemed to occur through induction of apoptosis. Apoptosis was increased after ciglitazone treatment, which was observed by the TUNEL method and flow cytometry. We noted a decrease in extracellular signal regulated kinase protein expression under ciglitazone treatment. Western blot analysis revealed an apparent time-dependent reduction in Bcl-2 protein levels in ciglitazone-treated melanocytes. In terms of Bax expression, a difference was not found. The expression of caspase-3 proteins was increased time-dependently with ciglitazone treatment. These results indicate that melanocyte growth and apoptosis may be modulated through PPAR-gamma and that ciglitazone, a PPAR-gamma activator, inhibits growth of human melanocytes by inducing apoptosis.