Acantholytic Anaplastic Extramammary Paget's Disease: A Case Report and Review of the Literature

Extramammary Paget's disease (EMPD) is an uncommon intraepithelial neoplasm that most commonly arises on the vulva and perianal region. Very few cases of EMPD revealing a histological Bowenoid appearance have been reported. This study describes scrotal EMPD presenting with histological features of Bowen's disease in a 79-year-old man. He presented with a 5-year history of a pruritic erythematous plaque and a verrucous papule on the scrotum. The verrucous papule histopathologically showed Bowenoid features, and the erythematous plaque demonstrated acantholytic EMPD. Immunohistochemical findings revealed strong expression for carcinoembryonic antigen, Cam 5.2, epithelial membrane antigen, cytokeratin (CK) 7, and pancytokeratin (AE1/AE3) in both areas, but negative CK20 staining, supporting the overall diagnosis of primary acantholytic anaplastic EMPD. This is the first reported case of acantholytic anaplastic EMPD in the Korean literature

Ceramides and Cell Signaling Molecules in Psoriatic Epidermis: Reduced Levels of Ceramides, PKC-α, and JNK

Ceramides are the main lipids in the stratum corneum and are generated during cellular stress and apoptosis by de novo synthesis or by the action of sphingomyelinase. In addition, they are lipid second messengers produced by sphingolipid metabolism and trigger important cell responses, including protein kinase C-alpha (PKC-α) activation and the stimulation of signal transduction pathways with apoptosis and stress-activated protein kinases (SAPK), such as c-jun N-terminal kinase (JNK). Thus, ceramides have anti-proliferative and apoptotic effects. This study measured the changes in the levels of epidermal ceramides and ceramide-related apoptotic signaling molecules in psoriasis patients. Samples from lesional and non-lesional epidermis were obtained from psoriasis patients. Total ceramides were fractionated using thin-layer chromatography, and the levels of PKC-α and JNK expression were measured using Western blot analysis with specific antibodies. The ceramide level was reduced significantly, and this was associated with the downregulation of apoptotic signaling molecules, such as PKC-α and JNK, in the lesional epidermis of psoriasis patients. These results suggest that the decreased level of ceramides downregulates the apoptotic pathway, leading to epidermal proliferation in psoriasis

Transforaminal Epidural Steroid Injection for Lumbosacral Radiculopathy: Preganglionic versus Conventional Approach

OBJECTIVE: The present study was undertaken to evaluate the effectiveness of transforaminal epidural steroid injection (TFESI) with using a preganglionic approach for treating lumbar radiculopathy when the nerve root compression was located at the level of the supra-adjacent intervertebral disc. MATERIALS AND METHODS: The medical records of the patients who received conventional TFESI at our department from June 2003 to May 2004 were retrospectively reviewed. TFESI was performed in a total of 13 cases at the level of the exiting nerve root, in which the nerve root compression was at the level of the supra-adjacent intervertebral disc (the conventional TFESI group). Since June 2004, we have performed TFESI with using a preganglionic approach at the level of the supra-adjacent intervertebral disc (for example, at the neural foramen of L4-5 for the L5 nerve root) if the nerve root compression was at the level of the supra-adjacent intervertebral disc. Using the inclusion criteria described above, 20 of these patients were also consecutively enrolled in our study (the preganglionic TFESI group). The treatment outcome was assessed using a 5-point patient satisfaction scale and by using a VAS (visual assessment scale). A successful outcome required a patient satisfaction scale score of 3 (very good) or 4 (excellent), and a reduction on the VAS score of > 50% two weeks after performing TFESI. Logistic regression analysis was also performed. RESULTS: Of the 13 patients in the conventional TFESI group, nine showed satisfactory improvement two weeks after TFESI (69.2%). However, in the preganglionic TFESI group, 18 of the 20 patients (90%) showed satisfactory improvement. The difference between the two approaches in terms of TFESI effectiveness was of borderline significance (p = 0.056; odds ratio: 10.483). CONCLUSION: We conclude that preganglionic TFESI has the better therapeutic effect on radiculopathy caused by nerve root compression at the level of the supra-adjacent disc than does conventional TFESI, and the difference between the two treatments had borderline statistical significance

Mycobacterium kansasii Pulmonary Diseases in Korea

Mycobacterium kansasii is one of the most common cause of pulmonary diseases due to nontuberculous mycobacteria. We investigated the changing in the number of isolation of M. kansasii and the clinical characteristics of M. kansasii pulmonary disease in Korea. Through searching the database of the Korean Institute of Tuberculosis, we identified the cases of isolated M. kansasii from 1992 to 2002. The number of M. kansasii isolation had increased from once in 1992 to 62 in 2002. Fifteen patients with M. kansasii pulmonary disease were identified during the period January 1997 to December 2002. Twelve patients (80%) were male and fourteen (93%) were from highly industrialized areas. The most common symptom was a cough. Seven patients (47%) had a cavitary lesion and right upper lobe was most commonly involved. Patients responded well to isoniazid and rifampicin based regimens both bacteriologically and radiographically. In conclusion, M. kansasii isolation has increased, especially in highly industrialized areas, as well as other nontuberculous mycobacteria in Korea

New genetic loci link adipose and insulin biology to body fat distribution.

Body fat distribution is a heritable trait and a well-established predictor of adverse metabolic outcomes, independent of overall adiposity. To increase our understanding of the genetic basis of body fat distribution and its molecular links to cardiometabolic traits, here we conduct genome-wide association meta-analyses of traits related to waist and hip circumferences in up to 224,459 individuals. We identify 49 loci (33 new) associated with waist-to-hip ratio adjusted for body mass index (BMI), and an additional 19 loci newly associated with related waist and hip circumference measures (P < 5 × 10(-8)). In total, 20 of the 49 waist-to-hip ratio adjusted for BMI loci show significant sexual dimorphism, 19 of which display a stronger effect in women. The identified loci were enriched for genes expressed in adipose tissue and for putative regulatory elements in adipocytes. Pathway analyses implicated adipogenesis, angiogenesis, transcriptional regulation and insulin resistance as processes affecting fat distribution, providing insight into potential pathophysiological mechanisms

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Three Cases of Primary Inoculation Tuberculosis as a Result of Illegal Acupuncture

Primary inoculation tuberculosis results from the direct inoculation of Mycobacterium tuberculosis into the skin of a person who has no natural or artificially acquired immunity to the organism. The pathogenesis requires a break in the skin from an abrasion or injury that allows entry of the tubercle bacilli. We report 3 cases of primary inoculation tuberculosis resulting from illegal acupuncture. Three patients over 70 years old presented with erythematous, ulcerative, indurated plaques on the back. Skin lesions had developed at the acupuncture sites 1 or 2 weeks after a session of acupuncture, which was intended to relieve back pain. An unlicensed, non-medically trained person conducted each session. The patients' past medical and family histories were unremarkable. Granulomatous inflammatory infiltration and acid-fast bacilli were observed histologically. M. tuberculosis was identified by mycobacterial culture and polymerase chain reaction. Nine months after the initiation of antituberculosis medication, skin lesions improved, and no evidence of recurrence or other organ involvement was observed at the 1-year follow-up visit