Ching-Chi Chi

The success of digital replantation is highly dependent on the patency of the repaired vessels after microvascular anastomosis. Antithrombotic agents are frequently used for preventing vascular occlusion. Low molecular weight heparin (LMWH) has been reported to be as effective as unfractionated heparin (UFH) in peripheral vascular surgery, but with fewer adverse effects. Its benefit in microvascular surgery such as digital replantation is unclear. To assess whether subcutaneous LMWH treatment improves the salvage rate of the digits in patients with digital replantation after traumatic amputation. The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (October 2012), CENTRAL (2012, Issue 10) and trials databases. In addition, the authors searched PubMed, CNKI (China National Knowledge Infrastructure) and CEPS (Chinese Electronic Periodical Services), and sought additional trials from reference lists of relevant publications. We selected randomised or quasi-randomised controlled trials of LMWH in patients who received digital replantation. Two review authors independently extracted data and assessed the risk of bias of the included trials. Disagreements were resolved by discussion. Two randomised trials involving 114 patients with at least 122 replanted digits met the inclusion criteria and were included. Both trials compared the efficacy and safety of LMWH with UFH. We found no trials comparing LMWH with placebo or other anticoagulants. The data from the two included studies were insufficient for meta-analysis. The overall success rate of replantation did not differ between the LMWH and UFH groups, 92.3% versus 89.2% in one trial (risk ratio (RR) 1.03; 95% confidence interval (CI) 0.87 to 1.22) and 94.3% versus 94.15% in the other trial (RR 1.00; 95% CI 0.89 to 1.13). The incidence of both postoperative arterial and venous insufficiency were reported in one trial and did not significantly differ between the LMWH and UFH groups (RR 1.08; 95% CI 0.16 to 7.10 and RR 0.81; 95% CI 0.20 to 3.27, respectively). Direct and indirect causes of microvascular insufficiency were not reported in the trials. Different methods were used to monitor the adverse effects related to anticoagulation in the two trials. Bleeding tendency was monitored for the LMWH and UFH groups in one trial and was reported by the incidence of wound haemorrhage (11.5% versus 17.9%; RR 0.65; 95% CI 0.17 to 2.44), ecchymoses (3.8% versus 10.7%; RR 0.36; 95% CI 0.04 to 3.24), haematuria (3.8% versus 7.1%; RR 0.54; 95% CI 0.05 to 5.59), nasal bleeding (0% versus 7.1%; RR 0.21; 95% CI 0.01 to 4.28), gingival bleeding (0% versus 10.7%; RR 0.15, 95% CI 0.01 to 2.83) and faecal occult blood (0% versus 3.6%; RR 0.36; 95% CI 0.02 to 8.42). The bleeding tendency was increased in the UFH group but this was not statistically significant. This trial also monitored coagulability changes using parameters such as antithrombin activity, factor Xa activity, bleeding time, clotting time and activated partial thromboplastin time (aPTT). No comparison was made between the LMWH and UFH groups but all data consistently showed that coagulability was reduced more in the UFH group than in the LMWH group. The other trial reported a postoperative decrease in platelet count in the UFH group (preoperative 278.4 ± 18.7 x 10(9)/L, postoperative 194.3 ± 26.5 x 10(9)/L; P < 0.05) but not in the LMWH group (preoperative 260.8 ± 32.5 x 10(9)/L, postoperative 252.4 ± 29.1 x 10(9)/L; P > 0.05). Current limited evidence based on two small-scaled low-to-medium quality randomised trials found no differences in the success rate of replantation between LMWH and UFH, but a lower risk of postoperative bleeding and hypocoagulability after the use of LMWH. Further well-designed and adequately powered clinical trials are warranted.

Background. The treatment of choice for clear cell acanthoma (CCA) is excision. Resolution after cryotherapy has also been reported but requires three to four courses of treatment.Objective. To demonstrate three CCA lesions in two patients successfully treated with a carbon dioxide (CO2) laser.Methods. Under local anesthesia, these lesions were vaporized by using a CO2 laser in the Silktouch mode with a spot size of 5 mm and a fluence of 20 J/cm2. Two to six passes, as needed, were delivered until the tumor was completely removed.Results. Pain was minimal or nonexistent during and after the operation. No postoperative edema was noted. The wounds healed satisfactorily without scarring. No sign of recurrence was found following operation.Conclusion. The CO2 laser has the advantages of requiring only one course, precise tumor removal, a relatively bloodless surgical field, a short operation time, and less or no postoperative pain and edema. Postoperative wound care is convenient and easy with hydrocolloid and alginate dressings. The patient's quality of life is less adversely affected. The CO2 laser may be appropriate for multiple CCAs, giant CCA, CCA overlying or near joints, CCA refractory to cryotherapy, patients on anticoagulants, and those who cannot tolerate pain from cryotherapy, especially children and the elderly.

Background Pemphigus vegetans, a variant of pemphigus vulgaris, most commonly occurs in the flexural area.Objective To describe an unusual case of pemphigus vegetans occurring in a skin graft recipient site and to discuss the possible etiology.Methods We present a 41-year-old man who developed vegetating plaques from the graft recipient site of his left leg for 8 months.Results Based on the histopathologic findings of a skin biopsy, this case was diagnosed as pemphigus vegetans. The patient's condition was successfully treated with systemic corticosteroids and acitretin.Conclusion Our case is unique in its presentation of pemphigus vegetans shortly after a split-thickness skin graft. Physicians should be aware of this entity while differentiating cutaneous lesions arising from a skin graft.YU-HUEI HUANG, MD, SHU-HUI WANG, MD, TSENG-TONG KUO, MD, PHD, AND CHING-CHI CHI, MD, HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.

... Wang, Shu-Hui MD, MS; Chi, Ching-Chi MD, MMS. ... Ching-Chi Chi, MD, MMS, Department of Dermatology, Chang Gung Memorial Hospital-Chiayi, 6, Sec West, Chia-Pu ... of clear cell acanthoma developing on an active psoriatic plaque reported by Finch and Tan also supported ...

While arsenic trioxide (As2O3) is an infamous carcinogen, it is also an effective chemotherapeutic agent for acute promyelocytic leukemia and some solid tumors. In human epidermoid carcinoma A431 cells, we found that As2O3 induced cell death in time- and dose-dependent manners. Similarly, dependent regulation of the p21WAF1/CIP1 (p21) promoter, mRNA synthesis, and resultant protein expression was also observed. Additionally, transfection of a small interfering RNA of p21 could block the As2O3-induced cell growth arrest. The As2O3-induced p21 activation was attenuated by inhibitors of EGFR and MEK in a dose-dependent manner. Using a reporter assay, we demonstrated the involvement of the EGFR-Ras-Raf-ERK1/2 pathway in the promoter activation. In contrast, JNK inhibitor enhanced the As2O3-induced p21 activation, also in a dose-dependent fashion. Over-expression of a dominant negative JNK plasmid likewise also enhanced this activation. Furthermore, MEK inhibitor attenuated the anti-tumor effect of As2O3. In contrast, in combination with JNK inhibitor and As2O3 enhanced cellular cytotoxicity. Therefore, we conclude that in A431 cells the ERK1/2 and JNK pathways might differentially contribute to As2O3-induced p21 expression and then due to cellular cytotoxicity.

Mucinous nevus is a rare entity with only 11 cases reported previously. It may be divided into two histopathologic types: connective tissue nevus of the proteoglycan (CTNP) and combined epidermal-CTNP. We describe a boy with asymptomatic grouped brown papuloplaques on the lower back since birth. A diagnosis of mucinous nevus of the combined epidermal-CTNP type was made after a biopsy. We vaporized two lesions with carbon dioxide laser, and the wounds healed satisfactorily. We present a literature review indicating a striking preponderance of male patients (M : F = 5 : 1) for mucinous nevus. In half of the cases, mucinous nevus did not appear until childhood, adolescence or early adulthood. The predominantly affected site was the trunk. Half of the cases can be assigned to the CTNP type and the other half to the combined epidermal-CTNP type. We propose that carbon dioxide laser vaporization may be a treatment option for mucinous nevus of the combined epidermal-CTNP type with multiple lesions but not for the CTNP type.

A 5-year-old boy had a 10-month remission of acute lymphocytic leukemia (ALL) after chemotherapy. Re-induction chemotherapy was performed for relapse of ALL. Thereafter, he suffered from an episode of neutropenic fever with pneumonia. One week following control of the condition with antibiotics, a 1 × 1-cm, red, painful nodule appeared on the left thigh, which was initially suspected to be Pseudomonas infection. Parenteral ceftazidime and amikacin were administered, but persistent high fever, mild cough, and a few painful erythematous papulonodules on the face and lower extremities appeared several days later (Fig. 1). These lesions increased insidiously in diameter up to 2–5 cm with central necrosis. Hemogram showed neutropenia with a shift to the left [white blood cell (WBC) count, 2.1 × 109/L; neutrophil count, 0.21 × 109/L]. A skin biopsy showed heavy growth of hyaline branching septate hyphae in the deep dermis and subcutis, together with fat necrosis (Fig. 2). Invasion of molds into vessels and sweat glands was also seen. A culture from a lesion yielded Fusarium moniliforme, but no fungi were isolated from blood specimens. Only mild infiltrations on bilateral lower lung fields were detected by chest roentgenography. The skin lesions gradually healed and the fever subsided 2 weeks after the initiation of therapy with amphotericin B 30 mg and itraconazole 200 mg daily.Figure 1. A few painful erythematous papulonodules appeared on the face and lower extremitiesDownload figure to PowerPointFigure 1. A few painful erythematous papulonodules appeared on the face and lower extremitiesDownload figure to PowerPointFigure 2. Skin biopsy showed heavy growth of hyaline branching septate hyphae in the deep dermis and subcutis along with fat necrosis (hematoxylin and eosin, ×400)Download figure to PowerPointFigure 2. Skin biopsy showed heavy growth of hyaline branching septate hyphae in the deep dermis and subcutis along with fat necrosis (hematoxylin and eosin, ×400)Download figure to PowerPointMeanwhile, relapse of leukemia was detected by hemogram showing atypical leukocytosis (WBC count of 24,400 × 109/L, with blast cells representing 78%). A course of chemotherapy with cytarabine, mitoxantrone, and VP-16 was prescribed, subsequently resulting in neutropenia (WBC count, < 0.1 × 109/L; neutrophil count, 0/L) and spiking fever. Although the aforementioned antifungal therapy was continued, the centers of the originally healed lesions turned dusky red, swollen, necrotic, and ulcerative. There were more than 10 such ecthymiform lesions. After administration for 22 days, itraconazole was discontinued because of no appreciable effects. Granulocyte colony-stimulating factor (G-CSF) salvage was used, and the neutropenia gradually subsided 20 days later. In addition, the ecthymiform lesions gradually resolved. Amphotericin B was discontinued 1 week following neutrophil recovery. The patient died of Acinetobacter baumannii and Stenotrophomonas maltophilia sepsis 8 months later.

A 32-year-old man presented with conspicuous acneiform pitting scars on the right nasolabial fold of 3 years’ duration (Fig. 1). He stated that the scars were preceded by erythematous plaques. Physical examination also revealed perilesional erythematous infiltration and telangiectasia. Tracing back the history, there was no malar erythema, oral ulcer, or arthralgia. A skin biopsy showed irregular acanthosis, follicular plugging, vacuolar degeneration of the basal cell layer with marked melanin incontinence, and heavy periadnexal mononuclear cell infiltration (Fig. 2a,b). Direct immunofluorescence studies displayed continuous granular deposition of immunoglobulin G (IgG) and C3 along the dermo-epidermal junction. The hemogram, antinuclear antibody (ANA) test, complement, and urinalysis were within normal limits. Based on the histopathologic findings and a positive lupus band test, a diagnosis of discoid lupus erythematosus (DLE) was made.Figure 1. An atrophic plaque composed of conspicuous acneiform pitting scars with surrounding erythema and telangiectasia on the right nasolabial foldDownload figure to PowerPointFigure 1. An atrophic plaque composed of conspicuous acneiform pitting scars with surrounding erythema and telangiectasia on the right nasolabial foldDownload figure to PowerPointFigure 2. (a) Marked follicular plugging and perivascular and periadnexal mononuclear cell infiltrates (hematoxylin and eosin, ×40). (b) Vacuolar degeneration of the basal layer with melanin incontinence (hematoxylin and eosin, ×400)Download figure to PowerPointFigure 2. (a) Marked follicular plugging and perivascular and periadnexal mononuclear cell infiltrates (hematoxylin and eosin, ×40). (b) Vacuolar degeneration of the basal layer with melanin incontinence (hematoxylin and eosin, ×400)Download figure to PowerPoint

Polyvinylpyrrolidone (PVP), a polymer of the monomer N-vinylpyrrolidone with various molecular weights, was originally developed as a plasma expander. Currently, it is widely used in hair sprays, skin care products, fruit juices, and as a retarding agent in drugs such as procaine and hormones. PVP polymers with a molecular weight greater than 20,000 cannot be excreted by the kidneys and therefore are phagocytosed and permanently stored in the reticular endothelial system, leading to the so-called PVP storage disease. We report a case of localized cutaneous PVP storage disease presenting with persistent upper lip swelling and mimicking cheilitis granulomatosa, which has never been reported before.

Selecting an appropriate antimycotic targeting the pathogens are among the most important factors for successfully treating onychomycosis. The aim of this study was to investigate the pathogens of onychomycosis in southern Taiwan and analyse the association between various factors and the distribution of pathogens. A total of 375 patients with onychomycosis were enrolled. Histopathological examination and fungus culture of nail specimens were performed. The pathogens were dermatophytes in 227 patients (60.5%), Candida in 118 (31.5%) and moulds in 30 (8%). Compared to patients with toenail involvement, the odds ratio (OR) for those with fingernail involvement to have non-dermatophytic onychomycosis (NDO), i.e. onychomycosis caused by Candida and moulds, was 5.04 [95% confidence interval (CI): 2.21–11.15], and the OR for those with fingernail and toenail involvement to have NDO was 2.66 (95% CI: 1.61–4.34). The F/M OR to have NDO was 2.36 (95% CI: 1.51–3.61), and 9.80 for diabetics (95% CI: 1.01–106.85). The OR for patients with paronychia to have NDO was 10.33 (95% CI: 5.61–18.88) compared to those without paronychia. Compared to patients with a non-wet occupation, the OR for those with a wet occupation to have NDO was 4.76 (95% CI: 2.01–11.16). The distribution of pathogens significantly varies with the involved sites, patients’ gender and occupation, and presence of diabetes mellitus or paronychia. In contrast to temperate western countries, NDO is more prevalent in the tropics and subtropics including southern Taiwan.