Systemic lupus erythematosus presenting as Stevens-Johnson syndrome and toxic epidermal necrolysis: a report of three cases

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening dermatological conditions that are characterized by mucositis, epidermal detachment and erosions. The underlying etiology in SJS and TEN is almost invariably secondary to drugs. Rarely, other causes such as systemic lupus erythematosus (SLE), infections and vaccinations have been implicated. This report describes three patients with SLE who presented with manifestations of SJS/TEN without a clear drug causality. All three patients presented with photodistributed macular exanthema, which evolved to target lesions, bullae, erosions or sheet-like detachment. This was associated with oral mucositis and conjunctivitis. The onset of the rash was insidious with a protracted clinical course. Ultraviolet exposure and steroid tapering appear to be precipitating factors. In two of the patients, SJS and TEN were the initial presentation of lupus. Although SJS and TEN are almost invariably due to medications, they may, rarely, be an initial presentation of lupus, particularly when associated with an initial photodistribution, absence of genital involvement and a prolonged clinical course.

Vitamin C protects against ethanol and PTZ-induced apoptotic neurodegeneration in prenatal rat hippocampal neurons

Exposure to alcohol during brain development may cause a neurological syndrome called fetal alcohol syndrome, characterized by pre- and postnatal growth deficiencies, craniofacial anomalies, and evidence of CNS dysfunction. The objective of this study was to evaluate pentylenetetrazol (PTZ) and ethanol effects on Bax, Bcl-2 expression, which further induced activation of caspase-3, release of cytochrome-c from mitochondria, and to observe the protective effects of vitamin C (vit-C) against PTZ and ethanol-induced apoptotic neurodegeneration in primary-cultured neuronal cells at gestational day 17.5. Apoptotic neurodegeneration and neuroprotective effect of vit-C were measured by using 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide assay, Western blot analysis, which further conformed by the measurement of mitochondrial membrane potential using JC-1 detection kit and immunofluorescence analysis. The results showed that PTZ and ethanol produced extensive Bax-dependent caspase-9 and caspase-3 activation and caused neuronal apoptosis. Furthermore, the cotreatment of vit-C along with ethanol and PTZ showed significantly decreased expression of Bax, caspase-9, caspase-3, cytochrome-c, and significantly increased expression of antiapoptotic Bcl-2 protein when compared with control group. Our findings indicate that PTZ and ethanol activate an intrinsic apoptotic death program in neurons that is likely to contribute to the neuropathologic effects in fetal alcohol exposure, and vit-C can prevent some of the deleterious effects of PTZ and ethanol on the developing brain. The available experimental evidence and the safety of vit-C in pregnancy suggest the experimental use of ascorbic acid as a new and effective protective agent ethanol and PTZ-induced apoptotic neurodegeneration.

Brain-derived neurotrophic factor gene polymorphisms and mirtazapine responses in Koreans with major depression

Brain-derived neurotrophic factor (BDNF) is a candidate molecule for influencing the clinical response to antidepressant treatment. The aims of this study were to determine the relationship between the Val66Met polymorphism in the BDNF gene and the response to mirtazapine in 243 Korean subjects with major depressive disorder (MDD). The reduction in the Hamilton Depression score over the 8-week treatment period was not influenced by BDNF V66M genotypes. A marginal effect of genotype on somatic anxiety score was observed at baseline (P = 0.047 in the dominant model). However, genotype-time interaction had no effect on somatic anxiety score after the 8-week a treatment period. Plasma BDNF levels tended to increase during mirtazapine treatment, although without statistical significance (P = 0.055). After 8 weeks of mirtazapine treatment, plasma BDNF levels were higher in Met allele homozygotes (1499.7 ± 370.6 ng/mL) than in Val allele carriers (649.7 ± 158.5 ng/mL, P = 0.049). Our results do not support the hypothesis that the Val66Met promoter polymorphism in the BDNF gene influences the therapeutic response to mirtazapine in Korean MDD patients. However, our data indicate that this polymorphism results in increased plasma BDNF after mirtazapine treatment.

Lysophosphatidic acid augments human hepatocellular carcinoma cell invasion through LPA1 receptor and MMP-9 expression

Lysophosphatidic acid (LPA), produced extracellularly by autotaxin (ATX), has diverse biological activities implicated in tumor initiation and progression, including increasing cell survival, angiogenesis, invasion and metastasis. ATX, LPA and the matrix metalloproteinase (MMP)-9 have all been implicated in hepatocellular carcinoma (HCC) invasion and metastasis. We, thus sought to determine whether ATX with subsequent LPA production and action, including induction of MMP-9 could provide a unifying mechanism. ATX transcripts and LPA receptor type 1 (LPA1) protein are elevated in HCC compared with normal tissues. Silencing or pharmacological inhibition of LPA1 significantly attenuated LPA-induced MMP-9 expression and HCC cell invasion. Further, reducing MMP-9 activity or expression significantly inhibits LPA-induced HCC cell invasion, demonstrating that MMP-9 is downstream of LPA1. Inhibition of phosphoinositide-3 kinase (PI3K) signaling or dominant-negative mutants of protein kinase Cδ and p38 mitogen-activated protein kinase (MAPK) abrogated LPA-induced MMP-9 expression and subsequent invasion. We thus demonstrate a mechanistic cascade of ATX-producing LPA with LPA activating LPA1 and inducing MMP-9 through coordinate activation of the PI3K and the p38 MPAK signaling cascades, providing novel biomarkers and potential therapeutic targets for HCC.

Intracranial stenting in patients with atherosclerotic stenosis associated with various aneurysms in the same diseased arterial segment

BACKGROUND AND PURPOSE

Aneurysms are rarely associated with symptomatic intracranial stenosis. We report the results of recanalization by stent placement in patients with symptomatic severe intracranial stenosis associated with adjacent aneurysms.

MATERIALS AND METHODS

Of 139 patients who underwent intracranial stent placement during a 5-year period, 10 (7%) had symptomatic severe intracranial stenosis associated with adjacent aneurysms. Five were in the VA, 3 in the BA, and 2 in M1. The types of aneurysm were atherosclerotic fusiform (n = 5), ulcerative (n = 4), and saccular (n = 1). We analyzed angiographic findings based on biplane and 3D angiograms and assessed patient outcomes and complications after stent placement. The results were compared with those of a control group without aneurysms who underwent stent placement during the same study period.

RESULTS

Aneurysm locations were post- (n = 6), in- (n = 2), and pre-stenotic (n = 2). After angioplasty with stent placement and/or aneurysm embolization, there were no lesion-related strokes or deaths during a median follow-up period of 25 months (range, 11-43 months). One patient had asymptomatic restenosis. The final mRS score was good (≤2) in all patients. There were no statistically significant differences in event or restenosis rates compared with the control group.

CONCLUSIONS

Adjacent aneurysms were rarely associated with severe intracranial stenosis but were more common in the posterior circulation. Intracranial stent placement may be performed without additional stroke risk, regardless of the type and location of the aneurysm.

Quality of life comparison between open and retroperitoneal video-assisted minilaparotomy surgery for kidney donors

This study compared open and video-assisted minilaparotomy surgery in live kidney donors for quality of life (QoL), pain, cosmesis, and recovery. Between January 2003 and March 2006, we reviewed data from 205 patients who underwent live-donor nephrectomy: 116 by video-assisted minilaparotomy and 89 by open surgery. Pain and satisfaction were evaluated using scales from 1 to 10, and QoL, with the 36-item Short Form questionnaire. Hospital stay was significantly shorter among the video-assisted (5.1 +/- 1.6 days) than the open group (6.9 +/- 1.3 days; P < .01). Time to resumption of walking without difficulty and normal activity was significantly shorter among the video-assisted than the open group (P<.01). The video-assisted group showed better QoL scores in 6 of 8 QoL categories, including physical role (P < .01), bodily pain (P < .01), general health (P < .01), vitality (P < .01), emotional health (P < .01), and mental health (P < .01). Patients in the video-assisted group (score, 7.3 +/- 2.4) were more satisfied with the cosmetic outcome than those in the open group (score, 5.1 +/- 3.0; P < .01). In conclusion, donors who underwent nephrectomy via video-assisted minilaparotomy showed better outcomes regarding pain, convalescence, cosmesis, and QoL than those who underwent open surgery.

Cutaneous adverse drug reactions in hospitalised patients

INTRODUCTION

Serious adverse drug reactions are common in hospitalised patients. There have been few studies examining the clinical presentation, implicated drugs and outcomes in Singapore.

METHODS

The clinical and laboratory data of all inpatient dermatology consultations with a diagnosis of cutaneous adverse drug reaction were retrospectively analysed over a one-year period.

RESULTS

A total of 97 patients were diagnosed with cutaneous adverse drug reactions. Eight different clinical reaction patterns were noted, namely drug exanthems (46.4 percent), drug rash with eosinophilia and systemic symptoms (18.6 percent), Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum (14.4 percent), urticaria/angioedema (11.3 percent), acute generalised exanthematous pustulosis (3.1 percent), fixed drug eruptions (3.1 percent), generalised exfoliative dermatitis (2.1 percent) and drug-induced vasculitis (1.0 percent). The putative medications included antibiotics (50.5 percent), anticonvulsants (11.3 percent), allopurinol (8.2 percent), chemotherapeutic agents (7.2 percent), nonsteroidal anti-inflammatory agents (7.2 percent), intravenous contrasts (3.2 percent), complementary medications (2.1 percent) and various other medications (10.3 percent). 30 patients were admitted primarily for their adverse drug reaction, with an average length of hospital stay of nine days, while the remaining 67 patients developed these reactions as a complication of their inpatient stay. A total of five deaths were recorded.

CONCLUSION

The presentation of cutaneous adverse drug reactions in hospitalised patients is diverse, ranging from self-limiting and benign reaction patterns to those that are life-threatening. Early recognition, accurate diagnosis, withdrawal of putative medications and specific treatments when indicated may improve outcome.

Application of beam emission spectroscopy to NBI plasmas of Heliotron J

This paper describes the application of the beam emission spectroscopy (BES) to Heliotron J, having the nonsymmetrical helical-magnetic-axis configuration. The spectral and spatial profile of the beam emission has been estimated by the numerical calculation taking the collisional excitation processes between plasmas (electrons/ions) and beam atoms. Two sets of the sightlines with good spatial resolution are presented. One is the optimized viewing chords which have 20 sightlines and observe the whole plasma region with the spatial resolution Δρ less than ±0.055 using the newly designed viewing port. The other is 15 sightlines from the present viewing port of Heliotron J for the preliminary measurement to discuss the feasibility of the density fluctuation measurement by BES. The beam emission has been measured by a monochromator with a CCD camera. A good consistency has been obtained between the spectral profiles of the beam emission measured by the monochromator and the beam emission spectrum deduced by the model calculation. An avalanche photodiode with an interference filter system was also used to evaluate the signal-to-noise (S/N) ratio of the beam emission in the present experimental setup. The modification of the optical system is being planned to improve the S/N ratio, which will enable us to estimate the density fluctuation in Heliotron J.

¹⁵C(d,p)¹⁶C reaction and exotic behavior in ¹⁶C

We have studied the ¹⁵C(d,p)¹⁶C reaction in inverse kinematics using the Helical Orbit Spectrometer at Argonne National Laboratory. Prior studies of electromagnetic-transition rates in ¹⁶C suggested an exotic decoupling of the valence neutrons from the core in that nucleus. Neutron-adding spectroscopic factors give a different probe of the wave functions of the relevant states in ¹⁶C. Shell-model calculations reproduce both the present transfer data and the previously measured transition rates, suggesting that ¹⁶C may be described without invoking very exotic phenomena.

Decompression and interspinous dynamic stabilization using the locker for lumbar canal stenosis associated with low-grade degenerative spondylolisthesis

BACKGROUND

Decompression and spinal fusion have been generally recommended for spinal stenosis associated with low-grade degenerative spondylolisthesis (DS), although this is still controversial. The purpose of the present study is to analyze the clinical and radiological outcomes of interspinous dynamic stabilization using the Locker (WINNOVA co, Seoul, Korea) for lumbar canal stenosis with grade I DS.

METHODS

The authors performed a retrospective review of 23 consecutive patients who underwent single level decompression and the Locker application for lumbar canal stenosis with grade I DS and were followed up for at least 2 years. Excluded were those with DS grade II or higher and DS combined with foraminal disc herniation/stenosis. The mean age of patients at the time of surgery was 62.1 years (range: 45-81 years).

RESULTS

There were no complications in the perioperative period. At a mean follow-up duration of 28.3 months (range: 24-32 months), visual analogue scale scores for back pain, leg pain, and Oswestry disability index had decreased significantly; from 4.6, 7.2, and 38.5% to 2.4, 2.6, and 15.3%, respectively. Clinical success was achieved in 87% of the patients. The mean percentage of slippage did not change significantly. The mean sagittal rotation angle significantly decreased from 9.7 to 6.5 degrees (p=0.01). One patient (4.3%) underwent secondary fusion surgery due to persistent pain.

CONCLUSIONS

Decompression and interspinous dynamic stabilization using the Locker yielded favorable clinical and radiological outcomes for lumbar canal stenosis with grade I DS and could be an alternative for spinal fusion. However, further long-term follow-up studies are necessary.

Dermatology referrals in an East Asian tertiary hospital: a need for inpatient medical dermatology

BACKGROUND

Within hospitals, there is a need for dermatological expertise, as hospitalized patients have a wider spectrum of severe and serious dermatological conditions, associated with significant morbidity.

AIM

To characterize the patient profile and referral pattern of inpatient dermatology consultations, and to evaluate the diagnostic accuracy of non-dermatologists.

METHODS

This was a retrospective study reviewing all inpatient referrals for dermatology consultations during a 1-year period from July 2005 to June 2006 (inclusive), at the largest multi-disciplinary tertiary hospital in Singapore.

RESULTS

Of the 731 referrals made for dermatology consultations, 26.9% of patients had ≥ 3 important underlying comorbidities. Eczema/dermatitis (33.1%; n = 242) and cutaneous infections (23.4%; n = 171) accounted for over half of the dermatological consultations, followed by cutaneous adverse drug reactions (12.3%; n = 90). The provisional diagnoses of the referring doctors agreed with the final diagnoses confirmed by dermatologists in only 30.2% of all referrals; incorrect diagnoses were made in 35.2% of cases, and no provisional diagnoses were made in the remaining 34.6% of cases. Most misdiagnosed skin diseases were in fact common dermatoses (such as eczemas, cutaneous infections, drug rash) that required only standard treatment.

CONCLUSION

Our study reiterates the importance of inpatient medical dermatology in terms of both service and education. There should be continual efforts to ensure that dermatologists have the highest level of training and experience in medical dermatology, to provide collaborative optimum care for hospitalized patients with dermatological diseases.

Combined pharmacogenetic effect of ADCY9 and ADRB2 gene polymorphisms on the bronchodilator response to inhaled combination therapy

WHAT IS KNOWN AND OBJECTIVE

Inhaled combination therapy composing of long-acting β2-agonist and corticosteroid has been widely applied in the management of asthma, but observed treatment responses vary. The aim of this study was to evaluate the pharmacogenetic effect of the adenylyl cyclase type 9 (ADCY9) gene polymorphism on combination therapy.

MATERIALS AND METHODS

Eighty-six mild to moderate Korean asthmatics were enrolled in this clinical trial. After the 2-week 'run-in' period, patients received budesonide (an inhaled corticosteroid) and formoterol (long-acting β2-agonist) during the following 12-week active treatment period. Forced expiratory volume in 1 s (FEV(1) ) and maximum mid-expiratory flow (MMEF) levels were measured at all visits as primary outcome. ADCY9 (Ile772Met, 150127 C/T, 150130 C/T, 150397 C/T, 150479 C/T, TTTA (5/4) ) and β2-adrenergic receptor (ADRB2, Arg16Gly) gene polymorphisms were genotyped.

RESULTS

Significant associations were observed between the ADCY9 single nucleotide polymorphisms and percent changes in FEV(1) (Ile772Met T/C, P = 0·030) and MMEF (150397 C/T, P = 0·016) after 8 weeks of combination therapy. Haplotype associations were also observed with respect to percent changes in FEV(1) after 8 weeks of therapy (Ht3[TTCC], P = 0·017). Additive therapeutic effect was observed in those with the ADCY9 Ile772Met and ADRB2 Arg16Gly gene polymorphisms in terms of percent change in FEV(1) after 8 and 12 weeks of therapy (P = 0·002 and P = 0·027 respectively).

WHAT IS NEW AND CONCLUSION

Our results suggest that ADCY9 gene polymorphisms may alone, and in combination with ADRB2 gene polymorphisms, contribute to individual response to combination therapy in mild to moderate asthmatics.

Neuroprotective effect of vitamin C against the ethanol and nicotine modulation of GABA(B) receptor and PKA-alpha expression in prenatal rat brain

Prenatal ethanol exposure has various deleterious effects on neuronal development and can induce various defects in developing brain, resulting in fetal alcohol syndrome (FAS). gamma-Aminobutyric acid (GABA(B)) receptor (R) is known to play an important role during the development of the central nervous system (CNS). Our study was designed to investigate the effect of ethanol (100 mM), nicotine (50 microM) (for 30 min and 1 h), vitamin C (vitC, 0.5 mM), ethanol plus vitC, and nicotine plus vitC on expression level of GABA(B1), GABA(B2)R, and protein kinase A-alpha (PKA) in prenatal rat cortical and hippocampal neurons at gestational days (GD) 17.5. The results showed that, upon ethanol and nicotine exposure, GABA(B1) and GABA(B2)R protein expression increased significantly in the cortex and hippocampus for a short (30 min) and long term (1 h), whereas only GABA(B2)R subunit was decreased upon nicotine exposure for a long term in the cortex. Furthermore, PKA expression in cortex and hippocampus increased with ethanol exposure during short term, whereas long-term exposure results increased in cortex and decreased in hippocampus. Moreover, the cotreatment of vitC with ethanol and nicotine showed significantly decreased expression of GABA(B1), GABA(B2)R, and PKA in cortex and hippocampus for a long-term exposure. Mitochondrial membrane potential, Fluoro-jade-B, and propidium iodide staining were used to elucidate possible neurodegeneration. Our results suggest the involvement of GABA(B)R and PKA in nicotine and ethanol-mediated neurodevelopmental defects and the potential use of vitC as a effective protective agent for FAS-related deficits.

Succinylcholine-Induced Masseter Muscle Rigidity in an Emergency Department: A Case Report

Succinylcholine is the most popular muscle relaxant employed in local accident and emergency departments because of its effectiveness and short-acting half life. Significant adverse reaction is rare and it increases the success rate of intubation. We describe a case of masseter muscle rigidity after administration of succinylcholine alone in the emergency room. The patient subsequently required nasotracheal intubation for ventilation.

High sensitive NO2 gas sensor with low power consumption using selectively grown ZnO nanorods

The noble gas sensor using multiple ZnO nanorods was fabricated with CMOS compatible process and sol-gel growth method on selective area and gas response characteristics to NO2 gas of the sensor device were investigated. We confirmed the sensors had high sensitive response denoted by the sensitivity of several tens for NO2 gas sensing and also showed pretty low power consumption close to 20 mW even though the recovery of resistance come up to almost the initial value.

Low power consumption and high sensitivity carbon monoxide gas sensor using indium oxide nanowire

In this paper, micro gas sensor was fabricated using indium oxide nanowire for effective gas detection and monitoring system. Indium oxide nanowire was grown using thermal CVD, and their structural properties were examined by the SEM, XRD and TEM. The electric properties for microdropped indium oxide nanowire device were measured, and gas response characteristics were examined for CO gas. Sensors showed high sensitivity and stability for CO gas. And with below 20 mw power consumption, 5 ppm CO could be detected.

Percutaneous endoscopic thoracic discectomy; transforaminal approach

INTRODUCTION

Because of the increasing use of magnetic resonance imaging (MRI), thoracic soft disc herniations are being easily detected in the early stages. To avoid a high morbidity rate and other complications that are associated with the conventional approach, the authors have applied a percutaneous endoscopic technique.

METHODS

From May 2001 to July 2007, fourteen patients with soft lateral or central thoracic disc herniation (TDH) underwent percutaneous endoscopic thoracic discectomy. Under local anesthesia with intravenous sedation, the authors removed the herniated disc through the thoracic intervertebral foramen after performing a foraminoplasty, which is the enlargement of the foramen by cutting the lateral and inferior part of the superior facet with a round cutter. The clinical outcome was evaluated using the visual analogue scale (VAS) and Oswestry disability index (ODI). RESULTS Six patients were male and eight were female, aged 21-75 years (mean: 48.1 years). Mean follow-up period was 60.2 months (15-89 months), mean operative time was 61 min. The mean VAS improved from 6.5 to 3.0 for back pain and 5.8 to 2.5 for leg pain at the final follow-up. The mean ODI scores also improved from 58.1 before surgery to 24.5 at the final follow-up. Conversion to an open procedure was not required for any of the patients.

DISCUSSION

As it has been proven to lessen the morbidity rate, this percutaneous endoscopic thoracic discectomy (PETD) technique for symptomatic soft TDH is a safe and effective method that provides a direct route to the lesion under local anesthesia.

First experiment with HELIOS: the structure of 13B

A first experiment is reported that makes use of a new kind of spectrometer uniquely suited to the study of reactions with radioactive beams in inverse kinematics, the helical orbit spectrometer, HELIOS. The properties of some low-lying states in the neutron-rich N=8 nucleus 13B were studied with good resolution. From the measured angular distributions of the (d,p) reaction and the relative spectroscopic factors, spin and configuration assignments of the first- and third-excited states of this nucleus can be constrained.

Predictive Factors for the Existence of Foreign Body following Fish Bone Ingestion: A Prospective Study

Objectives

To look at the factors that will affect the likelihood of a fish bone (FB) in throat and help to improve the use of oesophagogastroduodenoscopy (OGD).

Methods

It was a prospective cohort study of patients who attended the Accident and Emergency Department of Queen Elizabeth Hospital because of having foreign body sensation after eating fish in the period of 15th May 2008 to 15th February 2009. A pro forma was designed for the collection of information on various clinical parameters to be studied. Direct laryngoscopic examination (DL) and OGD findings were recorded. Tracing through the computerised Clinical Management System or telephone enquiry for the clinical outcome was employed for patients who refused or defaulted OGD. The primary outcome measured was the predictive power of the sharp pricking sensation symptom, radiographic finding and full visualisation by DL on the presence of FB. The data were analysed by logistic regression.

Results

The findings of 259 patients were analysed: 94 FBs were found; 83 (88.3%) FBs were lodged at a level above the hyoid bone; 73 FBs (77.7%) were removed by DL and 21 (22.3%) by OGD. Sharp pricking sensation was the only significant predictive factor for the presence of FB (OR=8.27; 95% CI=2.66, 25.76; p<0.01) in the group of patients requiring OGD whereas positive radiological finding (p=0.07) and full visualisation by DL (p=0.36) were not. Full visualisation by DL alone could not reliably rule out the presence of fish bone. Two FBs were missed.

Conclusion

The presence of definite sharp pricking sensation is a significant independent predictor for the presence of fish bone whilst full visualisation by DL and positive X-ray findings are not significant predictors.

Ethanol and PTZ effects on siRNA-mediated GABAB1 receptor: down regulation of intracellular signaling pathway in prenatal rat cortical and hippocampal neurons

GABA(B) receptors (R) are widely expressed and distributed in the nervous system, and have been implicated in variety of neurodegenerative and pathophysiological disorders. However, the exact molecular mechanism regarding responsibility of GABA(B1)R in downstream signaling pathway is not well understood. The present study was undertaken to explore the downstream signaling and role of GABA(B1)R upon acute ethanol and pentylenetetrazol (PTZ) exposure for (20 min) in cortical and hippocampal neuronal cell cultures by using GABA(B1)R RNA interference (i) (30 nM, 48 h) at gestational days 17.5. The results showed that GABA(B1)R and protein kinase A-alpha (PKA) showed decreased expression upon ethanol and PTZ exposure in cortical and hippocampal neurons during transfected and nontransfected conditions, whereas these effects could lead to significant changes in phosphorylation of cAMP-response element binding protein (p-CREB) expression where GABA(B1)R was knocked down. Furthermore, intracellular Ca(+2) concentrations were also reduced in some groups after transfection with GABA(B1)R RNAi. These results showed a critical role of GABA(B1)R upon ethanol and PTZ exposure by modulating downstream signaling pathway. Finally, these findings suggested that inhibition of GABA(B1)R results in the modulation of PKA, p-CREB pathway may play a role in long-term changes in the nervous system, and may be an underlying cause of ethanol's effects.