Faucial Pillar Perforation by Glidescope Intubation with Incorrectly Placed Stylet

Glidescope GVL® is frequently used in intubation of difficult airway. We report a case of right side of faucial pillar perforation during intubation with Glidescope®. A rigid stylet can facilitate placing of endotracheal tube quickly but it may also penetrate the soft tissue to cause injuries.

Unilateral Xanthelasma Forming a Kissing-Like Lesion

Xanthelasma is a common cutaneous xanthomatosis which occurs usually on the medial canthus in the upper or inferior palpebra. We describe a rare case of kissing xanthelasma which was unilateral at early onset.

Endothelin-1 enhances the proliferation of normal human melanocytes in a paradoxical manner from the TNF-α-inhibited condition, but tacrolimus promotes exclusively the cellular migration without proliferation: a proposed action mechanism for combination therapy of phototherapy and topical tacrolimus in vitiligo treatment

BACKGROUND

Vitiligo is an acquired pigmentary disorder caused by the destruction of melanocytes. Two of the major theories regarding the pathogenesis of vitiligo are the autoimmune theory and autocytotoxicity theory, but, the precise pathogenetic mechanism is still not clarified.

OBJECTIVES

We investigated the effects of ET-1, tacrolimus and tumour necrosis factor-α (TNF-α) on proliferation and migration of cultured normal human melanocytes (NHMs). We also sought to clarify the theoretical rationale underlying the topical tacrolimus monotherapy or tacrolimus-UV combination therapy as tools for vitiligo treatment.

METHODS

The effects of ET-1, tacrolimus and TNF-α on proliferation/migration of cultured NHMs were investigated by MTT assay/Boyden chamber transwell migration assay. We also examined roles of CXC-chemokine receptor II (CXCR II) and matrix metalloproteinases (MMPs) in such conditions.

RESULTS

ET-1 exerted a stimulatory effect on melanocyte proliferation and migration, but, tacrolimus exerted a stimulatory effect only on melanocyte migration higher than ET-1. TNF-α inhibited melanocyte proliferation in a dose-dependent manner. Paradoxically, TNF-α-pretreated NHMs exhibited an enhanced proliferative efficiency after being switched to ET-1. We found CXCRII was highly expressed in TNF-α-incubated melanocytes than the agents-free control, and ET-1 treatment after TNF-α preincubation showed the higher levels of CXCRII expression than the condition incubated with TNF-α alone. Moreover, the greater activities of MMP-2 and MMP-9 induced by tacrolimus than ET-1, reflected tacrolimus would enhance migration stimulatory effect in cultured NHMs.

CONCLUSIONS

Topical tacrolimus can be used an effective agent for vitiligo treatment as monotherapy, maybe due to its migration stimulatory action or TNF-α inhibitory property, and also as a component in combination therapy with UV treatment, considering the more upregulated MMPs activities are induced and the more effective migrations are feasible by itself than ET-1.

A herpes simplex virus infection secondary to acupuncture and cupping

Acupuncture and cupping have a public reputation as being safe even though these practices can lead to complications such as trauma or infection. We report here on a case of herpes simplex virus (HSV) infection secondary to acupuncture and cupping in a 56-year-old woman. The patient, who had a history of acupuncture and cupping on her left forearm for treating her myalgia, developed painful papules. Histologically, the biopsy specimen showed characteristic ballooning degeneration and inclusion bodies in the epidermis and mid-dermis. These clinical and histological findings were consistent with the diagnosis of HSV infection.

Epidemiology of complex regional pain syndrome: a retrospective chart review of 150 Korean patients

Complex regional pain syndrome (CRPS) is a chronically painful and disabling disorder. However, no data are available even on the epidemiology of CRPS in Korea. This study was undertaken to retrospectively assess the epidemiologic characteristics of CRPS in 150 consecutive patients at a tertiary chronic pain center from March 2002 to February 2006. Information was obtained regarding patients' demographics, nature of injury, and treatment modalities. Seventy-one percent of patients had CRPS type I. The mean 11-point verbal numerical rating scale score at initial examinations and at the time of study were 8.0 and 5.7, respectively. Thirty-two percent of patients showed no change or increase in pain intensity during follow-up at our pain center. The mean duration of CRPS symptoms prior to our pain center evaluation and prior to the time of study were 27 months and 50 months, respectively. These patients had seen on average 5 different physicians before being referred to our center. This study shows that the majority of CRPS patients were referred to our center after more than 2 yr of symptoms. The clinical implication of such delayed transfer and strategies to avoid this problem are discussed.

Alternative method for predicting optimal insertion depth of the laryngeal tube in children

BACKGROUND

Little information is available about the accuracy of the teeth mark on the laryngeal tube (LT) as a guide to correct placement in children. The aim of this crossover study was to evaluate three methods for optimal insertion depth of the size (#) 2 tube in children weighing 12-25 kg.

METHOD

In 24 children, the LT #2 was consecutively inserted by three different methods: (A) until the thick teeth mark on the tube was aligned with the upper incisors, (B) until resistance was felt, and (C) by inserting to a depth, previously measured, of the curved distance between the cricoid cartilage and the upper incisor. In each case, the depth of insertion, the degree of effective ventilation, the presence of leakage, and the fibreoptic view were assessed.

RESULTS

Insertion based on the teeth mark led to a shorter insertion depth and a greater incidence of inadequate ventilation compared with the other two methods. There was no difference in the adequacy of ventilation between methods B and C. The vocal cords were more easily identified with methods B (62.5%) and C (75%) than with method A (12.5%).

CONCLUSIONS

Insertion of the LT #2 aligned with the teeth mark can result in a shallow insertion depth and inadequate ventilation. The measured distance from the cricoid cartilage to the upper incisor offers alternative guidance for correct LT insertion.

A new classification of pattern hair loss that is universal for men and women: Basic and specific (BASP) classification

BACKGROUND

Pattern hair loss (PHL) can be classified into several patterns. Currently, the Hamilton-Norwood classification system for men and the Ludwig grade system for women are commonly used to describe patterns of hair loss. However, these pre-existing classifications have some limitations.

OBJECTIVE

To establish an acceptable, universal, and accurate standard of both male and female pattern hair loss and to report its use in determining the incidence of PHL.

METHODS

We developed a new classification system (BASP classification) and then applied this system to classify the types of PHL. The BASP classification was based on observed patterns of hair loss. The basic (BA) types represent the shape of the anterior hairline, and the specific types (SP) represent the density of hair on distinct areas (frontal and vertex). There are four basic types (L, M, C, and U) and two specific types (F and V). The final type is decided by the combination of the assigned basic and specific types. Between November 2004 and June 2005, 2213 Korean subjects, comprised of 1768 males and 445 females, were classified according to the BASP classification at 13 university dermatologic centers nationwide throughout South Korea, as a multicenter study of the Korean Hair Research Society.

RESULTS

For both sexes, the majority of patients enrolled in the study were in the third and fourth decade of life (65.1% of males and 56.68% of females). In males, the older group as well as the younger group in the study were more likely to have little recession of the frontal hairline (classified as type M1 approximately 2) and diffuse thinning over the top of scalp (type F1 approximately 2). The women in the study developed typical female PHL.

LIMITATIONS

The subjects of our study were mostly outpatients and some inpatients who complained about hair loss, not the general population of Korea.

CONCLUSION

The BASP classification is a new stepwise, systematic, and universal classification system for PHL, regardless of sex.

Integral lipid in human hair follicle

On the hair surface, cells are covered with a thin lipid layer (LL) covalently bonded to hair proteins. This integral hair lipid is different from sebaceus lipid. We conducted this study to examine the lipid distribution in human hair follicle. Transmission electron microscopy was performed to observe the ultrastructure of the LL. Hair follicles were cut and observed longitudinally along the hair axis. For transmission electron microscopy, new fixative (Lee's fixative: composed of OsO4 and RuO4) was designed as the conventional fixatives such as OsO4 or RuO4 alone were not appropriate for staining for hair follicle lipid. In addition, we measured the chemical composition of integral hair lipid by high-performance thin-layer chromatography. From the above experimental procedure, it was discovered that the lipid in the hair follicle was mainly distributed in hair cuticle and keratinized inner root sheath. A multitude of lamellar granule is observed in the vicinity of the above LL. The chemical composition of integral hair lipid was different from those of epidermal or sebaceous lipids. It is assumed that the LL in the hair follicle is similar to the epidermal LL playing an important role as a skin barrier in the stratum corneum. We proposed here the new terminology "hair barrier" from this point of view.

Synthetic phytoceramides induce apoptosis with higher potency than ceramides

Ceramides are naturally occurring compounds recognized to mediate apoptosis. N-acylsphingosines, containing a double bond at carbons 4 and 5 of their sphingoid backbone, are thought to be the active form, because N-acylsphinganines with completely saturated sphingoid are inactive. In the present study, we synthesized a series of N-acyl-4D-ribo-phytosphingosines (phytoceramides) that contain a hydroxyl group at carbon 4 and investigated structure-cytotoxicity relationship of the presumed functional groups in ceramides. N-Acetylphytoceramide (PCer2) and N-hexanoylphytoceramide (PCer6) were found to be more cytotoxic than ceramides as determined by released lactate dehydrogenase activity and morphological criteria. This was not caused by intracellular conversion of phytoceramides to ceramides, because no N-hexanoylsphingosine was formed after incubation of cell lysate with PCer6. Among phytoceramides having acyl chains two to eight carbons long, the cytotoxicity was highest with five or six carbons. The carbonyl group of the amide bond did not seem to be critical, because substitution of the oxygen with sulfur did not influence the cytotoxicity. The phytoceramide-induced cell death was observed to be apoptotic in nature with the use of terminal deoxynucleotidyl transferase dUTP nick-end labeling and propidium iodide staining. Because phytoceramides can be readily synthesized from yeast sources, they may present a potential and economical alternative to ceramide in future studies and therapies.

Nitric oxide mediates platelet activating factor-induced microvascular leakage in rat airways

Platelet activating factor (PAF), a highly potent chemical mediator in inflammation and allergic reactions, induces microvascular leakage in several tissues. In rat airways, PAF-induced microvascular leakage is probably mediated by an endothelial cell receptor in the microvessels. Nitric oxide (NO), first identified as endothelium-derived relaxing factor, has been suggested to be a mediator of airway microvascular leakage. However, the role of NO in PAF-induced microvascular leakage in the airways has not yet been established. The aim of this study was to investigate the role of NO in PAF-induced microvascular leakage in rat nasal mucosa and trachea. We injected PAF (1 microg/kg) intravenously, and the amount of PAF-induced microvascular leakage was measured with extravasation of Evans blue dye (30 mg/kg, injected intravenously 5 minutes before the injection of PAF) by means of spectrophotometry and fluorescence microscopy. Five Sprague-Dawley rats were pretreated with NG-nitro-L-arginine methyl ester (L-NAME; 10 mg/kg, intravenously injected 1 hour before the injection of PAF) to inhibit NO synthase, and control rats (n = 4) were pretreated with normal saline solution. The average amount of extravasated Evans blue dye was significantly lower in the L-NAME-pretreated rats than in the control rats (t-test, p < .01). Tissue sections of the L-NAME-pretreated rats clearly showed a decreased extravasation of Evans blue dye on fluorescence microscopy. In conclusion, pretreatment with L-NAME clearly inhibited PAF-induced microvascular leakage in the nasal mucosa and trachea of rats. This finding implies that PAF may activate the constitutive endothelial NO synthase in the microvessels, and that activated endogenous NO may mediate PAF-induced microvascular leakage in rat airways.

Effects of beta-toxin of Staphylococcus aureus on ciliary activity of nasal epithelial cells

OBJECTIVES

To investigate the in vitro effects of staphylococcal beta-toxin on ciliary activity and the in vivo effects on sinusitis induction.

STUDY DESIGN

The in vitro effects of staphylococcal beta-toxin on ciliary activity were investigated at different concentrations and exposure times. Experimental sinusitis was induced in rabbits with application of beta-toxin and confirmed 7 days later.

METHODS

Ciliated epithelial cells were taken from the maxillary sinus mucosa of 10 rabbits. Five culture dishes from each rabbit were used for the experimental group, and one culture dish from each rabbit was used for the control group. In the experimental group, ciliary beat frequency (CBF) was measured at concentrations of 0.1, 1, 2, 5 and 10 U/mL of beta-toxin using a video-computerized analysis technique, while in the control group, culture medium containing no toxin was used. CBF was measured 1, 2, 4, 6, 8, 12, 24, and 48 hours after administration of beta-toxin. To induce experimental sinusitis, 2 U/mL of beta-toxin was percutaneously applied to the maxillary sinus of 10 rabbits without occlusion of the natural ostium, while normal saline was percutaneously applied to the right-side maxillary sinus of 4 rabbits in the control group. At 7 days, mucosal membranes were taken from the inferomedial wall of the maxillary sinus for light microscopic study.

RESULTS

CBF dropped significantly after an 8-hour incubation at 2, 5, and 10 U/mL of beta-toxin. No ciliary activity was observed after a 24-hour incubation at 2 and 5 U/mL and a 12-hour incubation at 10 U/mL of beta-toxin. Mucoid, purulent discharge was observed in the maxillary sinuses of the beta-toxin-applied group. Prominent epithelial disruption and infiltration of inflammatory cells into the epithelium and lamina propria were observed in the beta-toxin-applied group.

CONCLUSIONS

Staphylococcal beta-toxin may reduce ciliary activity and induce sinusitis without occlusion of the natural ostium of the maxillary sinus in rabbits This study provides another animal model of sinusitis for understanding the pathogenesis of sinusitis induced by bacterial exotoxins.

Ultrastructural changes in platelet activating factor-induced epithelial damage in rabbit maxillary sinus mucosa

Platelet activating factor (PAF), a potent chemical mediator in inflammation and allergic reaction, has been thought to induce mucociliary inhibition and epithelial damage in the airway mucosa. However, several recent papers have reported that PAF may not readily damage the airway epithelium. The aim of this study was to elucidate the pathogenesis of PAF-induced epithelial damage in terms of ultrastructural changes. Sixteen micrograms of PAF (1 mL of 16 microg/mL) was administered into the maxillary sinuses of rabbits. The rabbits were divided into 2 groups according to time intervals, and the antral mucosa was taken 1 and 3 days after administration of PAF. The tissue was processed for routine transmission electron microscopy. No epithelial degeneration was observed other than platelet aggregation, red blood cell stasis, and swelling of the endothelial cells 1 day after administration of PAF. Migration of inflammatory cells into the perivascular connective tissue, infiltration of eosinophils into the subepithelial and intraepithelial spaces, and vacuolar degeneration of the epithelial cells with focal loss of cilia were seen 3 days after administration of PAF. In conclusion, PAF induced infiltration of eosinophils into the epithelium, and resulted in epithelial degeneration that varied according to the time interval. Our findings suggest that PAF may cause epithelial damage through a series of secondary events, probably due to cytotoxicity of eosinophils infiltrating the epithelium.

Origin and distribution of NADPH diaphorase-positive nerves in rat nasal mucosa

The aim of this study was to localize the distribution of (reduced) nicotinamide-adenine dinucleotide phosphate (NADPH) diaphorase-positive nerves in the rat nasal mucosa by NADPH diaphorase histochemistry, and to determine its origin by utilizing retrograde tracing with Fluoro-Gold (FG). Fine varicosities of NADPH diaphorase-positive nerve fibers were distributed around blood vessels (arterioles in particular), submucosal glands, and the subepithelial layer of the nasal mucosa. Most of the ganglion cells and nerve fibers in the sphenopalatine ganglion, and a few ganglion cells in the trigeminal ganglion, were stained by NADPH diaphorase, but no NADPH diaphorase-positive ganglion cells were found in the superior cervical ganglion. Retrograde tracing with FG and co-localization of NADPH diaphorase demonstrated that the FG-labeled ganglion cells in the sphenopalatine ganglion were NADPH diaphorase-positive, but the FG-labeled ganglion cells in both the trigeminal and the superior cervical ganglia were NADPH diaphorase-negative. In conclusion, NADPH diaphorase-positive nerves distribute around blood vessels, around submucosal glands, and in the subepithelial layer of the rat nasal mucosa, and their origin is the sphenopalatine ganglion. These findings imply that nitric oxide may be co-localized to the cholinergic innervation and be involved in vasomotor and secretomotor control of the nasal mucosa.

Paranasal sinusitis after long-term use of topical nasal decongestants

The aim of this study was to evaluate the incidence of paranasal sinusitis and the histologic changes in the sinus mucosa after long-term administration of topical nasal decongestants, phenylephrine and oxymetazoline. Experimental animals were divided into 3 groups for topical administration for 1 week, 2 weeks, and 4 weeks. Purulent maxillary sinusitis developed in 4 of 10 two-week phenylephrine group, 6 of 10 four-week phenylephrine group, 1 of 10 two-week oxymetazoline group and 3 of 10 four-week oxymetazoline group. Administration of phenylephrine and oxymetazoline for more than 2 weeks caused histologic changes in the maxillary mucosa of the rabbits. Light microscopy showed ciliary loss, epithelial ulceration, inflammatory cell infiltration and edema. The histologic changes were more pronounced with increasing duration of administration of the decongestants. Ciliary loss was more prominent in the 4-week phenylephrine group than in the oxymetazoline group. Dilatation of mitochondria and vacuolization in cytoplasm were prominent in the 4-week groups with both phenylephrine and oxymetazoline. The results of this study suggest that the administration of decongestants may cause ciliary loss with subsequent sinusitis.

Immunohistochemical and electron microscopic studies of substance P in guinea pig nasal glands

The distribution of substance P-like immunoreactive (SP-IR) nerve endings in the nasal gland of the guinea pig was studied by using histochemical techniques to detect mucous glycoprotein and immunohistochemical techniques for SP, in combination with electron microscopy. Most nasal glands were negative for both AB and periodic acid-Schiff (PAS) staining. The SP-IR nerve fibers were found to form a network around these glands. The SP-IR nerve endings were located in the region between interdigitated cytoplasmic folds of acinar cells and along the cell surface, as well as in the intercellular spaces of proximal ducts. The acini which closely contacted with SP-IR nerve endings were serous in type. Our results suggest that substance P may contribute to the regulation of serous gland secretion in the guinea pig nasal mucosa.