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2.  Development and validation of the Pictorial Cognitive Screening Inventory for illiterate people with dementia 
The purpose of this study was to develop and validate a tool called the Pictorial Cognitive Screening Inventory (PCSI), which consists of pictorial memory and attention tests that are not influenced by literacy level.
Patients and methods
PCSI, Mini Mental State Examination (MMSE), and Clinical Dementia Rating (CDR) questionnaires were administered to 80 elderly participants (20 illiterate normal, 20 illiterate with dementia, 20 literate normal, and 20 literate with dementia).
PCSI scores were highly correlated with those of the MMSE (r 0.51) and the CDR (r −0.71). In addition, the PCSI scores differed significantly between the normal group and the dementia group (mean difference 1.71, standard error [SE] 0.14, P<0.001), while no such difference was observed between the illiterate group and the literate group (mean difference 0.00, SE 0.24, P=0.997). Diagnostic validity of the PCSI is excellent, with a sensitivity of 90% and a specificity of 98% for screening dementia, whereas the MMSE has a sensitivity of 85% and a specificity of 60%.
These results indicate that the PCSI is a sensitive and reliable test for screening dementia, regardless of an individual’s literacy skills. The PCSI meets the increasing needs for screening of dementia in illiterate elderly populations in developing countries.
PMCID: PMC4181741  PMID: 25285007
screening; dementia; literacy; cognition
3.  A Case of Acquired Idiopathic Pterygium Inversum Unguis 
Annals of Dermatology  2014;26(3):374-376.
Pterygium inversum unguis (PIU) is a rare nail abnormality in which the distal nail bed adheres to the ventral surface of the nail plate, with obliteration of the distal groove. Because of the rarity of this condition, its exact origin is unknown. This disorder can be either congenital or acquired, with or without a family history. The acquired forms may be idiopathic or secondary to systemic connective tissue diseases or other causes such as stroke, neurofibromatosis, leprosy, or the use of nail fortifiers. We present an unusual case of acquired idiopathic PIU of the 10 fingernails in a 22-year-old man.
PMCID: PMC4069649  PMID: 24966638
Malformed nails; Pterygium inversum unguis
4.  Clinical Characteristics of Cholinergic Urticaria in Korea 
Annals of Dermatology  2014;26(2):189-194.
Cholinergic urticaria is a type of physical urticaria characterized by heat-associated wheals. Several reports are available about cholinergic urticaria; however, the clinical manifestations and pathogenesis are incompletely understood.
The purpose of this study was to investigate the clinical characteristics of cholinergic urticaria in Korea.
We performed a retrospective study of 92 patients with cholinergic urticaria who were contacted by phone and whose diagnoses were confirmed by the exercise provocation test among those who had visited The Catholic University of Korea, Catholic Medical Center from January 2001 to November 2010.
All 92 patients were male, and their average age was 27.8 years (range, 17~51 years). Most of the patients had onset of the disease in their 20s and 30s. Non-follicular wheals were located on the trunk and upper extremities of many patients, and the symptoms were aggravated by exercise. Eight patients showed general urticaria symptoms and 15 had accompanying atopic disease. Forty-three patients complained of seasonal aggravation. Most patients were treated with first and second-generation antihistamines.
Dermatologists should consider these characteristics in patients with cholinergic urticaria. Further investigation and follow-up studies are necessary to better understand the epidemiological and clinical findings of cholinergic urticaria.
PMCID: PMC4037671  PMID: 24882973
Cholinergic; Epidemiology; Phenotype; Signs and symptoms; Urticaria
5.  Prevalence and Risk Factors of Depression in Geriatric Patients with Dermatological Diseases 
Annals of Dermatology  2013;25(3):278-284.
Although rarely life threatening, dermatological diseases may have a considerable influence on a patient's quality of life and psychological well-being. As with morbidity and mental distress from other chronic diseases, a skin disorder can be the one of the main causes of depression in the geriatric population.
To determine the prevalence of depression in elderly patients with dermatological disease in Korea and to identify factors associated with depression.
Patients over the age of 60 years with dermatologic diseases were solicited for a questionnaire survey. The Geriatric Depression Scale (GDS) was used to obtain a patient-based measurement of depression. Additionally, demographic information and medical history were collected.
The questionnaire was completed by 313 patients (39.94% men, mean age 69.04 years, mean disease duration 3.23 years). Dermatological disease overall had a significant effect on patients' depression (χ2=177.13, p<0.0001), with a mean GDS score of 12.35 (out of 30). The patients who had a GDS score greater than 10 was 62.3% which indicated increased prevalence of mild to severe depression when compared to the general population among whom only 22.22% percent have GDS score greater than 10. In the univariate analysis, physical health, education level, and the presence of concurrent diseases were risk factors for geriatric depression. However, we did not find any demographic or disease related variables that were independent predictors of depression.
Geriatric patients with dermatological disease experience an increase burden of depression. Thus, it is important for clinicians to evaluate geriatric patients with dermatologic diseases for depression.
PMCID: PMC3756190  PMID: 24003268
Depression; Geriatric population; Skin disorder
7.  Multiple Bowen's Disease: In a Veteran Who Participated in Vietnam War 
Annals of Dermatology  2012;24(4):478-480.
PMCID: PMC3505785  PMID: 23197920
8.  Type B Pigmentary Demarcation Lines of Pregnancy Involving the Anterior Thighs and Knees 
Annals of Dermatology  2012;24(3):348-350.
Pigmentary demarcation lines are abrupt transition lines between the areas of deeper pigmentation and the areas of lighter, normal pigmentation. Type B pigmentary demarcation lines involve the posterior medial portion of the lower extremities and are more commonly associated with pregnancy. We present a case of pigmentary demarcation lines of pregnancy with erythematous changes, involving both the anterior and posterior aspects of the lower extremities.
PMCID: PMC3412246  PMID: 22879721
Erythema; Knee; Pigmentation; Pregnancy; Thigh
9.  Tumor Necrosis Factor-α and Mortality in Patients Infected with Vibrio vulnificus 
Serum tumor necrosis factor-α (TNF-α) was evaluated in Vibrio vulnificus-infected patients at admission. The median TNF-α concentration in the non-survivor group was determined to be 261.0 pg/mL, in contrast to 69.5 pg/mL in the survivor group (P = 0.001). Hence, serum TNF-α concentration may potentially be an early predictor of the mortality in patients with Vibrio septicemia.
PMCID: PMC3042819  PMID: 21363981
10.  Fixed Drug Eruption Due to Allopurinol: Positive Oral Provocation 
Annals of Dermatology  2011;23(Suppl 3):S402-S403.
A fixed drug eruption (FDE) is characterized by the presence of a solitary or multiple, pruritic, well-circumscribed, erythematous plaques. These lesions have tendency to recur at same sites and heal with residual hyperpigmenation. With repeated attacks, the size and/or number of the lesions may increase. So far, more than 100 drugs have been implicated in causing FDEs, including ibuprofen, sulfonamide, naproxen, and tetracylines. FDE caused by allopurinol has been rarely reported in the literature, but there has been no confirmed case based on oral provocation test. Herein, we report a case of FDE in which the lesions recurred whenever allopurinol was administered for the treatment of gout. A 64-year-old male experienced repeated episodes of well-demarcated dusky erythematous patches on the whole body for 2 months. He took allopurinol intermittently for amelioration of his gout symptom, but denied other medication history. Pruritic erythematous edema developed on the previous lesions 12 hours after oral provocation of 200 mg of allopurinol.
PMCID: PMC3276808  PMID: 22346289
Allopurinol; Fixed drug eruption; Oral provocation test; Topical provocation test
11.  Photodynamic Therapy Combined with CO2 Laser Vaporization on Disseminated Superficial Actinic Porokeratosis: A Report of 2 Cases on the Face 
Annals of Dermatology  2011;23(Suppl 2):S211-S213.
Disseminated superficial actinic porokeratosis (DSAP) is a skin condition that usually shows a poor response to different modalities of treatment. Herein we describe 2 patients with DSAP on the face, each treated with 3 to 4 sessions of photodynamic therapy combined with laser vaporization.
PMCID: PMC3229068  PMID: 22148053
Disseminated superficial actinic porokeratosis (DSAP); Face; Laser vaporization; Photodynamic therapy (PDT)
12.  Multiple Granulocytic Sarcomas in a Patient with Longstanding Complete Remission of Acute Myelogenous Leukemia 
Annals of Dermatology  2011;23(Suppl 2):S270-S273.
Granulocytic sarcoma is an extramedullary tumor composed of granulocytic precursor cells. It usually presents as a nodular mass in the course of acute myelogenous leukemia. Rarely, the tumor develops in non-hematological conditions or in a patient with complete remission from the acute myelogenous leukemia. In such cases, aleukemic granulocytic sarcoma can be a preceding sign of systemic leukemia or a first sign of hematologic relapse of leukemia. We present an unusual case of multiple granulocytic sarcomas developed in a patient with longstanding complete remission of acute myelogenous leukemia, who has not had bone marrow and peripheral blood involvement for a long time.
PMCID: PMC3229084  PMID: 22148069
Aleukemic leukemia cutis; AML M1; Granulocytic sarcoma
13.  Non-familial Acrokeratosis Verruciformis of Hopf 
Annals of Dermatology  2011;23(Suppl 1):S61-S63.
Acrokeratosis verruciformis of Hopf is a rare genodermatosis with an autosomal dominant mode of inheritance. It is a disorder of keratinization, characterized by multiple, flat-topped, skin-colored keratotic lesions resembling plane warts typically observed on the dorsum of the hands and feet. Histopathologically, the lesion shows considerable hyperkeratosis, acanthosis, and papillomatosis, mimicking a "church spire", and a thickened granular layer. It arises in early life, often at birth or infancy. Herein, we report on a rare sporadic case of acrokeratosis verruciformis of Hopf. A 44-year-old Caucasian man presented with multiple, grouped, hyperkeratotic, whitish, flat papules on his shins and feet, which had been present for more than one year. Histopathological examination showed typical findings of acrokeratosis verruciformis of Hopf. Our case is unique in that the patient had no familial history of similar skin lesions.
PMCID: PMC3199425  PMID: 22028575
Acrokeratosis verruciformis of Hopf; Non-familial acrokeratosis verruciformis
14.  Disease Awareness and Management Behavior of Patients with Atopic Dermatitis: A Questionnaire Survey of 313 Patients 
Annals of Dermatology  2015;27(1):40-47.
Patients with atopic dermatitis (AD) should be relatively well informed about the disorder to control their condition and prevent flare-ups. Thus far, there is no accurate information about the disease awareness levels and therapeutic behavior of AD patients.
To collect data on patients' knowledge about AD and their behavior in relation to seeking information about the disease and its treatment.
We performed a questionnaire survey on the disease awareness and self-management behavior of AD patients. A total of 313 patients and parents of patients with AD who had visited the The Catholic University of Korea, Catholic Medical Center between November 2011 and October 2012 were recruited. We compared the percentage of correct answers from all collected questionnaires according to the demographic and disease characteristics of the patients.
Although dermatologists were the most frequent disease information sources and treatment providers for the AD patients, a significant proportion of participants obtained information from the Internet, which carries a huge amount of false medical information. A considerable number of participants perceived false online information as genuine, especially concerning complementary and alternative medicine treatments of AD, and the adverse effects of steroids. Some questions on AD knowledge had significantly different answers according to sex, marriage status, educational level, type of residence and living area, disease duration, disease severity, and treatment history with dermatologists.
Dermatologists should pay more attention to correcting the common misunderstandings about AD to reduce unnecessary social/economic losses and improve treatment compliance.
PMCID: PMC4323601
Awareness; Complementary therapies; Dermatitis; atopic; Disease management; Information seeking behavior
15.  A Case of Pyoderma Gangrenosum with Ulcerative Colitis Treated with Mesalazine 
Annals of Dermatology  2010;22(4):422-425.
Pyoderma gangrenosum (PG) manifests as recurrent deep ulceration of the skin and PG is associated with a variety of disorders. Approximately 30% of the cases of PG develop in patients with inflammatory bowel disease. A 34-year-old woman presented with a one-week history of recurrent ulcers on the right cheek and back. She was diagnosed with ulcerative colitis (UC) 4 years previously and with PG 1 year previously. The clinical course of the skin lesions followed the status of her UC. The patient's skin lesions and bowel symptoms were not improved with prednisolone. After she was started on mesalazine, we observed rapid resolution of skin lesions and bowel symptoms. Herein, we report a case of recurrent PG with UC, and we discuss the possible association between these two conditions, and the efficacy of mesalazine therapy for the treatment of PG combined with UC.
PMCID: PMC2991719  PMID: 21165212
Mesalazine; Pyoderma gangrenosum; Ulcerative colitis
16.  Developing a Common Health Information Exchange Platform to Implement a Nationwide Health Information Network in South Korea 
We aimed to develop a common health information exchange (HIE) platform that can provide integrated services for implementing the HIE infrastructure in addition to guidelines for participating in an HIE network in South Korea.
By exploiting the Health Level 7 (HL7) Clinical Document Architecture (CDA) and Integrating the Healthcare Enterprise (IHE) Cross-enterprise Document Sharing-b (XDS.b) profile, we defined the architectural model, exchanging data items and their standardization, messaging standards, and privacy and security guidelines, for a secure, nationwide, interoperable HIE. We then developed a service-oriented common HIE platform to minimize the effort and difficulty of fulfilling the standard requirements for participating in the HIE network. The common platform supports open application program interfaces (APIs) for implementing a document registry, a document repository, a document consumer, and a master patient index. It could also be used for testing environments for the implementation of standard requirements.
As the initial phase of implementing a nationwide HIE network in South Korea, we built a regional network for workers' compensation (WC) hospitals and their collaborating clinics to share referral and care record summaries to ensure the continuity of care for industrially injured workers, using the common HIE platform and verifying the feasibility of our technologies.
We expect to expand the HIE network on a national scale with rapid support for implementing HL7 and IHE standards in South Korea.
PMCID: PMC4330195
Health Information Exchange; Electronic Health Records; Health Level Seven; Computer System; Data Security
17.  Scrub Typhus Meningitis or Meningoencephalitis 
Orientia tsutsugamushi induces vasculitis leading to symptoms of systemic organ invasion including meningitis and meningoencephalitis. We conducted a retrospective case-control study of scrub typhus patients to investigate the clinical and laboratory features of patients with scrub typhus meningitis or meningoencephalitis, and the therapeutic outcomes, and to determine the predictor factors. Cases were 22 patients with scrub typhus meningitis or meningoencephalitis, and controls were 303 patients without meningitis or meningoencephalitis. Multivariate analysis showed that the presence of pneumonitis was associated with the occurrence of scrub typhus meningitis and meningoencephalitis (odds ratio [OR] 8.9; P < 0.001; confidence interval [CI] 2.9–27.2). Although appropriate antimicrobials such as doxycycline agents were administered at an early stage, meningitis or meningoencephalitis still occurred in some cases. Physicians should be aware that meningitis or meningoencephalitis may develop during appropriate drug therapy such as doxycycline. Close observation and great care are essential for patients with risk factors, particularly pneumonitis.
PMCID: PMC3854902  PMID: 24166036
18.  Diverse Toll-Like Receptors Mediate Cytokine Production by Fusobacterium nucleatum and Aggregatibacter actinomycetemcomitans in Macrophages 
Infection and Immunity  2014;82(5):1914-1920.
Toll-like receptors (TLRs) orchestrate a repertoire of immune responses in macrophages against various pathogens. Fusobacterium nucleatum and Aggregatibacter actinomycetemcomitans are two important periodontal pathogens. In the present study, we investigated TLR signaling regulating cytokine production of macrophages in response to F. nucleatum and A. actinomycetemcomitans. TLR2 and TLR4 are redundant in the production of cytokines (interleukin-6 [IL-6] and tumor necrosis factor alpha [TNF-α]) in F. nucleatum- and A. actinomycetemcomitans-infected macrophages. The production of cytokines by macrophages in response to F. nucleatum and A. actinomycetemcomitans infection was impaired in MyD88-deficient macrophages. Moreover, cytokine concentrations were lower in MyD88-deficient macrophages than in TLR2/TLR4 (TLR2/4) double-deficient cells. An endosomal TLR inhibitor, chloroquine, reduced cytokine production in TLR2/4-deficient macrophages in response to F. nucleatum and A. actinomycetemcomitans, and DNA from F. nucleatum or A. actinomycetemcomitans induced IL-6 production in bone marrow-derived macrophages (BMDMs), which was abolished by chloroquine. Western blot analysis revealed that TLR2/4 and MyD88 were required for optimal activation of NF-κB and mitogen-activated protein kinases (MAPKs) in macrophages in response to F. nucleatum and A. actinomycetemcomitans, with different kinetics. An inhibitor assay showed that NF-κB and all MAPKs (p38, extracellular signal-regulated kinase [ERK], and Jun N-terminal protein kinase [JNK]) mediate F. nucleatum-induced production of cytokines in macrophages, whereas NF-κB and p38, but not ERK and JNK, are involved in A. actinomycetemcomitans-mediated cytokine production. These findings suggest that multiple TLRs may participate in the cytokine production of macrophages against periodontal bacteria.
PMCID: PMC3993440  PMID: 24566622
19.  Injection-Site Reaction Following 5-Azacitidine Injection 
Annals of Dermatology  2014;26(5):669-670.
PMCID: PMC4198610  PMID: 25324675
20.  Patterns of Reduced Cortical Thickness in Late Life Depression and Relationship to Psychotherapeutic Response 
Cortical atrophy has been associated with late life depression (LLD) and recent findings suggest that reduced right hemisphere cortical thickness is associated with familial risk for major depressive disorder but cortical thickness abnormalities in LLD have not been explored. Further, cortical atrophy has been posited as a contributor to poor antidepressant treatment response in LLD but the impact of cortical thickness on psychotherapy response is unknown. This study was conducted to evaluate patterns of cortical thickness in LLD and in relation to psychotherapy treatment outcomes.
Participants included 22 individuals with LLD and 12 age matched comparison subjects. LLD participants completed 12 weeks of psychotherapy and treatment response was defined as a 50% reduction in depressive symptoms. All participants participated in Magnetic Resonance Imaging (MRI) of the brain and cortical mapping of grey matter tissue thickness was calculated.
LLD individuals demonstrated thinner cortex than controls prominently in the right frontal, parietal, and temporal brain regions. Eleven participants (50%) exhibited positive psychotherapy response after 12 weeks of treatment. Psychotherapy non-responders demonstrated thinner cortex in bilateral posterior cingulate and parahippocampal cortices, left paracentral, precuneus, cuneus, and insular cortices, and the right medial orbito-frontal and lateral occipital cortices relative to treatment responders.
Our findings suggest more distributed right hemisphere cortical abnormalities in LLD than have been previously reported. Additionally, our findings suggest that reduced bilateral cortical thickness may be an important phenotypic marker of individuals at higher risk for poor response to psychotherapy.
PMCID: PMC3732520  PMID: 23567394
22.  Facile fabrication of high-efficiency near-infrared absorption film with tungsten bronze nanoparticle dense layer 
Nanoscale Research Letters  2014;9(1):294.
An excellent transparent film with effective absorption property in near-infrared (NIR) region based on cesium-doped tungsten oxide nanoparticles was fabricated using a facile double layer coating method via the theoretical considerations. The optical performance was evaluated; the double layer-coated film exhibited 10% transmittance at 1,000 nm in the NIR region and over 80% transmittance at 550 nm in the visible region. To optimize the selectivity, the optical spectrum of this film was correlated with a theoretical model by combining the contributions of the Mie-Gans absorption-based localized surface plasmon resonance and reflections by the interfaces of the heterogeneous layers and the nanoparticles in the film. Through comparison of the composite and double layer coating method, the difference of the nanoscale distances between nanoparticles in each layer was significantly revealed. It is worth noting that the nanodistance between the nanoparticles decreased in the double layer film, which enhanced the optical properties of the film, yielding a haze value of 1% or less without any additional process. These results are very attractive for the nanocomposite coating process, which would lead to industrial fields of NIR shielding and thermo-medical applications.
78.67.Sc; 78.67.Bf; 81.15.-z
PMCID: PMC4066286  PMID: 24982605
Nanodistance; Nanoparticles; Double layer; Near-infrared absorption; Surface plasmon resonance; Tungsten bronzes
23.  Spatial memory impairments in amnestic mild cognitive impairment in a virtual radial arm maze 
This study aims to apply the virtual radial arm maze (VRAM) task to find spatial working memory and reference memory impairments in patients of amnestic mild cognitive impairment (aMCI) and Alzheimer’s disease (AD). Spatial memory functions between aMCI converters and nonconverters are also compared using VRAM results.
We assessed the spatial memory in 20 normal controls, 20 aMCI, and 20 mild AD subjects using VRAM. The Mini-Mental State Examination, Clinical Dementia Rating scale, and other neuropsychological tests were given to the subjects in conjunction with the VRAM test. Scores in working memory errors and reference memory errors were compared among the three groups using repeated measures analysis of variance. In addition, aMCI patients were followed-up after 5 years and surveyed for AD conversion rate.
In AD patients, both spatial working and reference memory were impaired. However, in aMCI subjects, only spatial reference memory was impaired. Significant spatial reference memory impairment was found in the aMCI converter group when compared to the nonconverter group.
Spatial working memory is less impaired in aMCI while reference memory is similarly damaged in AD. In aMCI patients, more severe spatial reference memory deficit is a neuropsychological marker for AD conversion. VRAM may be well utilized in humans to assess spatial memory in normal aging, in aMCI, and in AD.
PMCID: PMC4000250  PMID: 24790448
spatial behavior; Alzheimer’s disease; user computer interface; cognition
24.  Association between Ischemic Stroke and Vascular Shear Stress in the Carotid Artery 
Background and Purpose
Vascular shear stress is essential for maintaining the morphology and function of endothelial cells. We hypothesized that shear stress in the internal carotid artery (ICA) may differ between patients with ischemic stroke and healthy control subjects.
ICA shear stress was calculated in 143 controls and 122 patients with ischemic stroke who had a normal ICA or an ICA with <50% stenosis. The stroke group included patients who presented with a first-ever or recurrent ischemic stroke but excluded cardioembolic stroke and uncertain etiologies. Of the 122 patients, 107 (87.7%) and 15 (12.3%) patients were categorized as first-ever and recurrent stroke, respectively.
Carotid diameters were significantly larger, and both peak-systolic and end-diastolic velocities were significantly lower in patients with ischemic stroke than in controls (all p values <0.05). Mean values of peak-systolic and end-diastolic shear stress in both ICAs were significantly lower in patients with ischemic stroke in models that adjusted for age, sex, and vascular risk factors (p for trend <0.05). The ICA shear stress was lowest in patients with recurrent stroke or the subtype of small-vessel occlusion. Higher peak-systolic and end-diastolic shear stresses in both ICAs were independently and negatively associated with ischemic stroke after adjusting for potential confounders (all p values <0.05).
ICA shear stresses were significantly lower in patients with ischemic stroke than in control subjects. Future studies should attempt to define the causal relationship between carotid arterial shear stress and ischemic stroke.
PMCID: PMC4017016  PMID: 24829599
carotid artery; hemodynamics; ischemic stroke; shear stress
25.  Immunomodulatory Effects of Balneotherapy with Hae-Un-Dae Thermal Water on Imiquimod-Induced Psoriasis-Like Murine Model 
Annals of Dermatology  2014;26(2):221-230.
Balneotherapy, although not a well-established dermatological treatment, is thought to have therapeutic properties for psoriasis and is used as an alternative treatment modality throughout the world.
To evaluate the mechanism underlying the therapeutic immunologic effects of thermomineral water.
A murine model of imiquimod-induced psoriasis-like skin inflammation was used for evaluating the therapeutic effects of balneotherapy with Hae-Un-Dae hot spring mineral water. The clinical improvements were evaluated by a dermatologist. Lesional cytokines, including interleukin (IL)-17A, IL-23, and IL-22, were quantitatively measured by real-time reverse transcriptase polymerase chain reaction. Serum levels of interferon-γ, IL-4, IL-5, and IL-17A were measured by enzyme-linked immunosorbent assay. T cell proportions in the spleen were evaluated by flow cytometry, and histopathological evaluation of the skin was also performed.
The mineral water balneotherapy group showed faster improvement in skin erythema and scales than the distilled water bathing group. A substantial reduction was observed in the lesional mRNA levels of IL-17A and IL-23 in the mineral water group. Serum levels of IL-4 and IL-5 were significantly decreased in the mineral water group but not in the distilled water group. Normalized T cell proportions were observed after bathing.
Balneotherapy showed immunomodulatory effects in a psoriasis-like murine model. Balneotherapy suppressed lesional IL-23 and IL-17A, which are important cytokines in the pathogenesis of psoriasis. These results suggest that balneotherapy can be used as an effective and safe treatment for psoriasis.
PMCID: PMC4037676  PMID: 24882978
Bath; Immunomodulation; Mineral waters; Psoriasis

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