The effect of atropine on the bispectral index response to endotracheal intubation during propofol and remifentanil anesthesia.

Atropine has been reported to increase the propofol requirements for the induction of anesthesia during continuous infusion of propofol. We investigated the influence of atropine on the bispectral index (BIS) response to endotracheal intubation during anesthetic induction with propofol and remifentanil target controlled infusion (TCI). Fifty-six patients aged 18-50 years undergoing general anesthesia, were enrolled. For induction of anesthesia, propofol TCI was set at a target effect-site concentration of 4.0 µg/ml. Two minutes later, remifentanil was started at an effect-site concentration of 4.0 ng/ml. Four minutes after the start of propofol TCI, patients received either atropine (10 µg/kg) or an equal volume of normal saline. Tracheal intubation was performed 10 min after anesthetic induction. Mean arterial pressure, HR, SpO2, and BIS were recorded during the 15 min-anesthesia induction. From 2 to 5 min after tracheal intubation, BIS was significantly higher in the atropine group than in the control group (p = 0.043, 0.033, 0.049, and 0.001, respectively). When compared with baseline values (immediately before intubation), BIS showed a significant increase at 1 min after intubation in both groups, without intergroup differences, whereas it decreased significantly from 4 to 5 min after intubation only in the control group. This study demonstrated that atropine maintained BIS increases in response to endotracheal intubation during anesthetic induction with propofol and remifentanil TCI, although the maximal response did not differ between the groups.

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.

Trichloroacetic acid matricectomy in the treatment of ingrowing toenails.

BACKGROUND: Ingrowing toenails can be treated with conservative therapy or surgery, but frequent relapse can be a problem in conservative therapy and surgical therapy without matricectomy. Thus, permanent nail ablation by partial matricectomy is now accepted as the treatment of choice. OBJECTIVE: To evaluate the efficacy and safety of trichloroacetic acid (TCA) matricectomy in the treatment of ingrowing nail. MATERIALS AND METHODS: Forty ingrowing toenail edges in 25 patients were enrolled. TCA matricectomy with 100% trichloroacetic acid after partial nail avulsion was performed. For a few weeks after surgery, postoperative complications such as pain, discharge, and infection were assessed. After a mean follow-up period of 22.9 months, recurrence rate and cosmetic outcomes were investigated to evaluate the effects of the surgery. RESULTS: The wounds almost always healed within 2 weeks without prolonged exudative discharge. Pain was mild and transient. A case of secondary infection occurred. Recurrence was found in only two nails of one patient, and the success rate was 95%, with good cosmetic results. CONCLUSION: TCA matricectomy showed a low recurrence rate with minimal side effects and was easy to perform in outpatient clinic. Therefore, it may be a good alternative treatment of ingrowing toenails.

Sphingosylphosphorylcholine stimulates expression of fibronectin through TGF-beta1-Smad-dependent mechanism in human mesenchymal stem cells.

Sphingosylphosphorylcholine (SPC) has been reported to stimulate the expression of fibronectin (FN), which plays a key role in cell recruitment and adhesion during wound healing. In a previous study, we reported that SPC induces differentiation of human adipose tissue-derived mesenchymal stem cells (hATSCs) to smooth muscle-like cell types through ERK-dependent autocrine secretion of TGF-beta1 and delayed activation of the TGF-beta1-Smad pathway. In the present study, we demonstrated that SPC dose- and time-dependently increased the expression of FN in hATSCs. Pretreatment of the cells with U0126, an MEK inhibitor, markedly attenuated the SPC-induced expression of FN and delayed phosphorylation of Smad2, suggesting that ERK is involved in the SPC induction of FN expression through activation of Smad2. In addition, the SPC-induced expression of FN and delayed activation of Smad2 were abrogated by SB-431542, a TGF-beta type I receptor kinase inhibitor, or anti-TGF-beta1 neutralizing antibody. Furthermore, the SPC-induced expression of FN was abrogated by adenoviral expression of Smad7, an inhibitory Smad, or short interference RNA (siRNA)-mediated depletion of endogenous Smad2 expression, suggesting that SPC induces the expression of FN through ERK-dependent activation of the TGF-beta1-Smad2 crosstalk pathway. Adhesion of U937 monocytic cells to hATSCs was enhanced by pretreatment of hATSCs with SPC or TGF-beta1 for 4 days, and the peptide GRGDSP (an antagonist of fibronectin receptors) blocked the adhesion of U937 cells to the hATSCs. These results led us to suggest that SPC-induced FN expression plays a pivotal role in the wound healing by stimulating adhesion and recruitment of leukocytes.

Baumann Skin Type in the Korean Female Population.

BACKGROUND: To meet the need for a subspecialized skin type system, the Baumann skin type (BST) system was proposed. OBJECTIVE: To evaluate the distribution of BST types and influencing factors among Korean women. METHODS: BST questionnaires were administered to 1,000 Korean women. The possible responses were as follows: oily (O) or dry (D), sensitive (S) or resistant (R), pigmented (P) or non-pigmented (N), and wrinkled (W) or tight (T). The correlations of the BST with the subjects' age, location, ultraviolet (UV) ray exposure, drinking and smoking habits, and blood type were assessed. RESULTS: The OSNT, DSNT, DRNT, and OSNW skin types were the most common skin types (55.3%). The O, S, P, and W types accounted for 46.6%, 68.8%, 23.2%, and 31.9%, respectively. The proportion of the O and S type was the highest in Gyeongsangbuk-do (55.0%) and Seoul (77.2%). The proportion of the P and W type was the highest in Gyeongsangbuk-do (33.0%) and Chungcheong-do (39.0%). The O type decreased in the higher age group, whereas the P and W type showed a reversed tendency. In smokers, the proportion of W type was significantly higher than in the non-smokers (66.3% vs. 24.1%, p<0.05). CONCLUSION: The 4 most common BST types were OSNT, DSNT, DRNT, and OSNW. In the comparison across the 4 BST parameters according to the age, region, smoking and drinking habits, occupation, blood type, and UV exposure, significant differences were observed. Individualized and customized skin care is required according to the personal skin type.

Insulin-like growth factor-II regulates the expression of vascular endothelial growth factor by the human keratinocyte cell line HaCaT.

Psoriasis is a chronic, relapsing skin disease characterized by enhanced angiogenesis. The pathogenetic process resulting in hypervascularity remains to be further investigated. It has been reported that a potent angiogenic factor, vascular endothelial growth factor (VEGF) is overexpressed in psoriatic epidermis and that the level of insulin-like growth factor II (IGF-II) is significantly elevated in the tissue fluid and serum of the psoriatic lesion. We considered the possibility that IGF-II might function as a paracrine inducer of VEGF. Here, we demonstrated that exposure of HaCaT keratinocytes to IGF-II induced both mRNA and protein expression of VEGF through the MAP kinase (extracellular signal-regulated kinase (ERK2) pathway. Particularly, we determined that phosphorylation of ERK2 but not p38 and JNK1/2 was activated by IGF-II in a time-dependent manner. Additionally, we found that IGF-II treatment induced the expression of MDM2 through the MAP kinase pathway. Moreover, the increase of MDM2 resulted in decreased levels of p53 followed by increased expression of HIF-1alpha and VEGF. Taken together, these results suggest that IGF-II enhances the expression of VEGF in HaCaT cells by increasing HIF-1alpha levels.

Intralesional interferon alfa-2b treatment of keratoacanthomas.

BACKGROUND: Complete excision is not always easy when a keratoacanthoma is large or located in certain anatomic areas. An effective nonsurgical treatment would be desirable in such cases. OBJECTIVE: This was a pilot study of the effects of intralesional interferon alfa-2b in the treatment of rapidly growing keratoacanthomas. METHODS: A total of 4 large, rapidly growing keratoacanthomas, which were located on the lower lip, neck, and cheeks of the 4 different patients, were treated with intralesional interferon alfa-2b injection weekly. Serial photographs were taken to observe the course of responses. RESULTS: All lesions resolved completely in 5 to 7 weeks with acceptable cosmetic results. CONCLUSION: Intralesional interferon alfa-2b can be a treatment modality of these difficult lesions.

Expression of basic fibroblast growth factor, vascular endothelial growth factor, and thrombospondin-1 related to microvessel density in nonaggressive and aggressive basal cell carcinomas.

The aggressive forms of basal cell carcinoma (BCC) are biologically different in a number of features from their nonaggressive counterparts. The expression of basic Fibroblast Growth Factor (bFGF), Vascular Endothelial Growth Factor (VEGF), and Thrombospondin-1 (TSP-1) was examined in primary culture samples of nonaggressive and aggressive BCCs. We studied the relationship between neoangiogenesis by counting microvessels, tumor aggressiveness, and the expression of three different angiogenic factors. bFGF mRNA was detectable in all BCC samples, but there was no significant difference in the levels of expression between the two types. VEGF mRNA was also detectable in all BCC samples. VEGF expression in the aggressive type was approximately 3.5-fold higher than in the nonaggressive type. TSP-1 expression was variable and not related to the type of BCC. The mean value of microvessel density (MVD) was significantly higher for the aggressive type than for the nonaggressive type. There was a significant correlation between VEGF levels and MVD. No significant relationships were found between bFGF, TSP-1 mRNA expression, and MVD. In conclusion, the results of present study suggest that VEGF expression and angiogenesis might play important roles in the progression to aggressive BCC.

Multiple basal cell carcinomas arising in a port-wine stain with a remote history of therapeutic irradiation.

The coexistence of a basal cell carcinoma and a port-wine stain is a very rare condition that may be associated with previous treatments. We present a case of multiple basal cell carcinomas developing within the boundaries of a port-wine stain, which had been treated with a tholium X and argon laser. Our case suggests that port-wine stains which were previously treated with irradiation or argon laser should be examined carefully and regularly by both physician and patient, because they may hide basal cell carcinomas.

Widespread and invasive Trichophyton rubrum infection mimicking Kaposi's sarcoma in a patient with AIDS.

Opportunistic fungal infections are commonly encountered in AIDS patients. Candidiasis, tinea pedis, onychomycosis, and deep mycotic infections have been the fungal infections most frequently reported in these patients. Dermatophyte infections can appear to be atypical and aggressive in these patients and may lead to a misdiagnosis. We report a Trichophyton rubrum infection in a 44-year-old man with AIDS that presented as a widespread and multiple tumor-like appearance. After the patient was treated with terbinafine for 21 weeks, the lesions cleared completely. We think that this type of dermatophyte infection is very unusual in patients with AIDS and could lead to inappropriate diagnostic processes and treatments.

Effect of tracheal lidocaine on intubating conditions during propofol-remifentanil target-controlled infusion without neuromuscular blockade in day-case anesthesia.

BACKGROUND: Lidocaine is a useful intravenous and topical adjunct to facilitate tracheal intubation. We evaluated the effect of tracheal lidocaine on tracheal intubating conditions without neuromuscular blocking agent and hemodynamics during anesthesia induction with propofol and remifentanil target-controlled infusion (TCI). METHODS: Fifty patients, aged 18-60 years, scheduled for closed reduction of fractured nasal bone were randomly assigned to the control group (n = 25) or lidocaine group (n = 25). Anesthesia was induced with propofol-remifentanil TCI with the effect-site concentration of 5 µg/ml and 5 ng/ml. Four minutes after the start of propofol-remifentanil TCI, 4% lidocaine or saline 3 ml was instilled to larynx and trachea, and intubation was performed 1 min later. Acceptable intubation was defined as excellent or good intubating conditions. Hemodynamic data, induction and recovery profiles were recorded. RESULTS: Intubating condition was clinically acceptable in 13 out of 25 (52%) patients in the control group and in 22 out of 25 (88%) in the lidocaine group, and there was a significant difference between the two groups in regard to acceptable intubating conditions (P = 0.005). Mean arterial pressure change over time was significantly different between the two groups. There were no significant differences in the heart rate between the two groups. CONCLUSIONS: This study demonstrated that laryngotracheal administration of 4% lidocaine could increase the percentage of acceptable conditions for tracheal intubation during propofol and remifentanil anesthesia without neuromuscular blockade.

Spinal arteriovenous malformation masquerating zoster sine herpete.

Zoster sine herpete (ZSH) is difficult to diagnosis during an acute period due to the absence of the characteristic zosteriform dermatomal rash; therefore, progression to postherpetic neuralgia is more common than typical zoster. In addition, misdiagnosis of other neuropathic pain as ZSH is common in clinical situations. Here, we report a case of spinal arteriovenous malformation that mimics ZSH. This is a rare condition; therefore, high clinical suspicion for a correct diagnosis and proper examination are not easy. However, early diagnosis and definitive treatment are essential to prevent neurologic deficit and mortality.

Antibiotic susceptibility of Propionibacterium acnes isolated from acne vulgaris in Korea.

Propionibacterium acnes plays an important role in the development of acne, and inflammatory lesions are improved by antibiotics. Long-term use of antibiotics may result in development of resistant strains and treatment failure. The aim of the present study was to investigate the isolation rate of P. acnes and to evaluate its antibiotic susceptibility to widely used antibiotics in acne in Korea. Among 46 patients, 31 P. acnes strains were cultured. Isolated P. acnes was measured for minimum inhibitory concentration (MIC) of tetracycline, doxycycline, minocycline, erythromycin and clindamycin using an Epsilometer test. Age, disease duration and previous history of antibiotic therapy for acne were compared in relation to the MIC. The mean MIC of tetracycline, minocyclines, doxycycline, clindamycin and erythromycin were all below the breakpoint of antibiotic resistance. The patients with acne vulgaris with disease duration of more than 2 years documented higher MIC values in doxycycline, erythromycin, and clindamycin than those of less than 2 years. The patients who were previously treated with topical or systemic antibiotics showed higher MIC in doxycycline. Antibiotic resistance of P. acnes is still low in Korea, but at this point, there is an increasing trend of MIC. Caution and acknowledgement of increased risk of antibiotic resistant P. acnes should be advised in acne antibiotic treatment to minimize and avoid the emergence of the resistant strain.

The significance of incomplete skull fracture in the birth injury.

Vaginal delivery is accomplished by the force of the labor overcoming the resistance forces of birth canal. During this process, the fetal head passes through the birth canal and the skull receives pressure on the lateral aspect, resulting in molding, the convex shaping of the cranium. Also, the infant's skull is compressed by the mother's pelvic bony structures. These forces may lead to skull fractures and brain injuries. The hypothesis by the authors is that many skull fractures of the newborn present as incomplete fractures. The bony skull of the newborn is histologically primary bone tissue and which is incomplete in its ossification process. During birth the pressure forces upon the newborn's skull is gradual in one direction, rather than a sudden impact, and therefore it is thought that the skull fracture would be an incomplete fracture. However, it is very hard to ascertain the presence of incomplete fractures especially in incompletely ossified skulls with plain X-ray studies, and therefore it is possible that the real incidence of skull fractures in the newborn are higher than reported in the current and past literature. It is also probable that the external forces upon the skull that are sufficient to cause skull fractures, would also lead to significant brain injury more frequently than actually observed, and subsequently contribute to development of many brain disease later in children. The authors of this study propose that very close examination should be conducted to find incomplete fracture, and increased efforts should be made to establish the presence of possible accompanied brain injuries in babies with incomplete skull fracture. The definitive diagnosis and treatment, as well as close follow up of patients with brain injury will assist the clinician in determining the causes of neurological diseases especially in those with previously unknown etiologies, which may be due to birth injuries. Assistance may be also afforded in the early treatment and prevention of such conditions.

The Effect of Detergents on the Morphology and Immunomodulatory Activity of Malassezia furfur.

BACKGROUND: Several workers have found that Malassezia are capable of suppressing cytokine release and downregulating the phagocytic function of monocytes. But lipid-depleted Malassezia furfur (M. furfur) extracts have also been shown to induce increased production of TNF-alpha, IL-6 and IL-1beta in monocytes. We thought that the detergents in shampoos or soaps could change the composition of the lipid in the M. furfur cell wall. OBJECTIVE: We studied whether detergents affect the morphology of M. furfur and if the inflammatory cytokine profiles change in the monocytes treated with detergent-treated M. furfur. METHODS: Commonly used detergents such as sodium lauryl sulfate, ammonium lauryl sulfate and tween-80 were respectively added to the modified Leeming-Notman's media. M. furfur was cultivated in each media (detergent-added or untreated). Thereafter, the surface morphology of the yeast was evaluated by scanning and transmission electron microscopy. The cytokine profiles of monocytes, which were treated by M. furfur with or without detergents, were also evaluated. RESULTS: The detergent-treated M. furfur were similar to the lipid-extracted form of M. furfur on the electron microscopic study, with a recessed, withered surface and with thinner and rather electron transparent cell walls than the detergent-untreated M. furfur. The levels of TNF-alpha were higher in monocytes treated with detergent-treated Malassezia than that in the monocytes treated with the detergent-untreated Malassezia (p<0.05). CONCLUSION: According to the findings in this study, it could be inferred that the detergents in shampoos or soaps affect the lipid layers of the Malassezia cell wall and these lipid-extracted Malassezia induce or aggravate some inflammatory conditions. But to correlate the relationship between detergents and Malassezia-associated diseases, in vivo experiments that will focus on short-term contact with detergents in real life conditions should be done.

Primary venous aneurysms of the superficial venous system.

Venous aneurysm can be classified into superficial or deep and secondary or primary. The aim of this study was to introduce primary venous aneurysm of the superficial venous system and to report the experiences treating it with sclerotherapy. A retrospective study with 120 cases of venous dilatation detects 4 patients. The clinical features, histopathology, and radiological findings were investigated. In 2 patients, sclerotherapy was performed. The patients had an asymptomatic, soft subcutaneous mass on the extremities or neck for 5.2 years on an average. Color duplex scanning showed a well-defined anechoic cystic structure with no arterial flow. Histopathologically, normal vein wall with varying degrees of thinning was observed. The patients who underwent sclerotherapy were treated successfully with no recurrence. Primary venous aneurysm of the superficial venous system should be included in the differential diagnosis of subcutaneous mass. In addition, it may be simply and effectively treated with sclerotherapy.