The Korean Journal of Medicine

Training Directions for Internal Medicine Residents

Sun, 01 Feb 2026 00:00:01 +0100

In September 2025, following the resolution of prolonged conflicts between residents and the government, internal medicine residents returned to their training hospitals. The recently implemented Resident Training Environment Innovation Project limited duty hours to a maximum of 72 per week and prohibited continuous shifts longer than 24 hours. Moreover, if the proposed Resident Training Environment Improvement and Status Enhancement Act is enacted, resident duty hours may be further reduced. While these changes represent a significant advancement in protecting residents rights as workers, concerns remain about whether adequate training and clinical experience can be ensured within such restricted schedules. This perspective article outlines the challenges faced by the Korean Society of Internal Medicine and training hospitals. The Korean Society of Internal Medicine should take the lead in restructuring residency curricula with a stronger emphasis on general internal medicine, strengthening support for faculty supervisors, and establishing competency-based evaluation systems. Training hospitals should no longer view residents as indispensable labor but as trainees, deploying them according to educational goals while balancing labor and education. Residents themselves must also engage in self-directed learning and professional development. Through these coordinated efforts, future internists in Korea can grow into true professionals equipped with both patient-centered clinical competence and academic capability.

Microbiome in Autoimmune Diseases: Present and Future

Sun, 01 Feb 2026 00:00:01 +0100

The human microbiome shapes immune development and maintains homeostasis. Cumulative evidence has linked dysbiosis to the initiation and progression of autoimmune diseases. In this review, we summarize disease-specific microbial signatures and immunologic axes of rheumatoid arthritis, axial spondylarthritis, systemic lupus erythematosus, inflammatory bowel disease, and type 1 diabetes. Despite the promise of microbiome-based therapeutics, including probiotics, next-generation probiotics, engineered live biotherapeutics, and fecal microbiota transplantation, their translation into clinical practice is limited by heterogeneity, low-biomass contamination issues, and reliance on relative abundance metrics. We highlight the requirement for standardized sampling/analytics and absolute-quantitative approaches, multicenter validation of biomarker panels, and mechanism-driven interventional trials. The integration of microbial, metabolomic, and host immune response aspects is a pivotal step in the transition from association to causation and in the development of precise and safe microbiome-based diagnostics and therapeutics for autoimmune diseases.

2025 ERS/ATS Update of the Classification of Interstitial Pneumonias: Key Changes

Sun, 01 Feb 2026 00:00:01 +0100

Interstitial pneumonia is a heterogeneous group of diffuse parenchymal lung diseases characterized by variable combinations of inflammation and fibrosis involving the interstitium, airways, and alveolar spaces. The classification of interstitial pneumonia has undergone a major update for the first time in 12 years since 2013. The 2025 European Respiratory Society/American Thoracic Society (ERS/ ATS) update introduces an integrated framework that extends beyond idiopathic entities to include secondary causes such as connective tissue disease and hypersensitivity pneumonitis. This update classifies interstitial pneumonias into interstitial patterns and alveolar filling patterns based on the predominant site of involvement, with interstitial patterns further subclassified into fibrotic and nonfibrotic. Furthermore, it newly defines and reintroduces the bronchiolocentric interstitial pneumonia pattern to replace the traditional hypersensitivity pneumonitis pattern and renames the terms acute interstitial pneumonia and desquamative interstitial pneumonia to diffuse alveolar damage and alveolar macrophage pneumonia, respectively, to more accurately reflect the underlying pathophysiology. Importantly, the update distinguishes morphologic patterns from multidisciplinary discussion diagnoses and formalizes the concept of diagnostic confidence, presenting a system of confident, provisional, or unclassifiable interstitial lung disease. Although this update is based on expert consensus, the new classification framework can provide a more comprehensive and practical approach for clinicians managing patients with complex interstitial pneumonias. This review summarizes these key changes and their clinical implications.

Recent Advances in Therapeutic Strategies for FLT3-Mutated Acute Myeloid Leukemia

Sun, 01 Feb 2026 00:00:01 +0100

FLT3 mutations occur in approximately 25% to 30% of newly diagnosed cases of acute myeloid leukemia (AML) and are typically associated with adverse prognoses characterized by a high risk of relapse. In recent years, the AML therapeutic landscape has been notably reshaped by the introduction of FLT3 inhibitors, including midostaurin, quizartinib, and gilteritinib. The European LeukemiaNet 2022 guidelines classify all FLT3-ITD-positive AML as intermediate risk, regardless of allelic ratios, thereby highlighting the importance of co-mutations and measurable residual disease (MRD). In fit patients (intensive chemotherapy eligible), the current standard therapy incorporates FLT3 inhibitor-based chemotherapy, allogeneic hematopoietic stem cell transplantation during the initial complete remission, and post-transplant maintenance. Long-term follow-up from the RATIFY trial confirmed durable survival benefits using midostaurin (10-year overall survival, 43.7%), whereas the QuANTUM-first study has provided evidence for the marked efficacy of quizartinib in patients with NPM1 and DNMT3A co-mutations. For unfit patients, although azacitidine plus venetoclax remains the standard therapy, early-phase studies evaluating FLT3 inhibitor-containing triplet regimens have revealed complete remission rates exceeding 80%. In addition, for cases of relapsed or refractory FLT3-mutated AML, gilteritinib has been established to provide a median overall survival of 9.3 months and serves as an effective bridge to transplantation, whereas venetoclax combinations can contribute to enhancing the length of remission. Recent advances in characterizing resistance mechanisms, including secondary TKD mutations and RAS/MAPK pathway activation, are contributing to the developments of next-generation covalent and multi-kinase FLT3 inhibitors, and it is anticipated that MRD-guided therapeutic adaptation and genomics-driven precision medicine will facilitate further refinement of future standards of the care.

A 53-Year-Old Woman with Worsening Diarrhea during Treatment for Ulcerative Colitis: Practical ...

Sun, 01 Feb 2026 00:00:01 +0100

Clostridioides difficile infection (CDI) poses a diagnostic challenge in patients with inflammatory bowel disease (IBD), as symptoms and endoscopic findings frequently overlap with those of disease flares, and asymptomatic colonization is relatively common. Consequently, positive microbiological test results do not always indicate active infection. We report the case of a 53-year-old woman with ulcerative colitis (UC) who presented with worsening bloody diarrhea and abdominal pain during maintenance therapy with infliximab. At initial admission, she had clinically significant diarrhea with elevated inflammatory markers. Stool testing demonstrated concordant positivity for glutamate dehydrogenase (GDH) antigen and toxin A/B enzyme immunoassay, supporting a diagnosis of active CDI concomitant with a UC flare. Treatment with oral vancomycin led to clinical improvement. Three weeks later, the patient re-presented with mild recurrent diarrhea. Repeat stool testing showed discordant results, including negative toxin A/B but positive GDH, polymerase chain reaction, and culture. Given the mild symptoms, normal inflammatory markers, and spontaneous symptom resolution without further antimicrobial therapy, these findings were interpreted as colonization or residual test positivity rather than recurrent CDI. This case illustrates key principles in CDI diagnosis: testing should be guided by the presence of clinically significant diarrhea, multistep diagnostic algorithms must be interpreted in the clinical context, and positive molecular or culture-based results in IBD patients do not necessarily reflect active infection. Symptom-based assessment is essential to avoid overdiagnosis and unnecessary antimicrobial treatment in patients with UC and suspected CDI.

Microbiome and Digestive System Diseases: A Diagnostic Approach

Sun, 01 Feb 2026 00:00:01 +0100

The gut microbiome can provide valuable insights into host pathophysiological changes associated with digestive system diseases. To date, meaningful associations have been reported in gastrointestinal disorders and hepatic and pancreatobiliary diseases. Microbiome-based analyses currently have clear limitations as standalone diagnostic tools for specific diseases owing to substantial inter-individual variability, methodological heterogeneity, and constraints in functional interpretation. Diagnostic interpretation has thus shifted from assessing changes in individual microbial taxa to identifying patterns of microbial communities with associated functional characteristics. In this context, the concepts of disease-associated core microbiome or functional core microbiome offer a useful framework for understanding shared microbial functional features related to digestive diseases. Machine learning approaches, including deep learning-based methods, enable integrative analysis of high-dimensional microbiome data and provide opportunities to explore disease-related patterns that are difficult to capture using conventional analytical techniques.

Radio-Opaque Coil Localization for Small-Bowel Resection

Sun, 01 Feb 2026 00:00:01 +0100

Prior to other diagnostic methods, capsule endoscopy is performed for patients with suspected small-bowel bleeding and stable clinical condition. In contrast, angiography is used to manage patients with persistent bleeding or hemodynamic instability. Following angiography-based confirmation of bleeding, hemostasis can be successfully achieved. However, rebleeding may frequently occur, and repeated procedures may induce complications. In such cases, surgical treatment is necessary. During surgery, the swift, precise localization of the bleeding site is of paramount important, along with accurate minimization of the extent of resection. Recently, a coil was employed for embolization to locate the bleeding site, followed by surgical resection, and this case is discussed.

Hemolytic Rebound and Recurrent Thromboembolic Event Following Ravulizumab Discontinuation in a ...

Sun, 01 Feb 2026 00:00:01 +0100

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare clonal hematopoietic stem cell disorder characterized by complement-mediated hemolysis and thrombotic complications. The introduction of complement inhibitors has markedly improved survival outcomes by reducing intravascular hemolysis and thrombotic risk. We report the case of a 73-year-old man with PNH and myelodysplastic neoplasm (MDS) who developed severe thromboembolic and hemolytic events following the discontinuation of ravulizumab. His disease had previously evolved from aplastic anemia to MDS. Despite prior resolution of PNH-related thrombosis and maintained clinical stability, the cessation of treatment precipitated rebound hemolysis and multiple thrombotic events 8 months after discontinuation. These events included ischemic enterocolitis, necrotic gingivitis, ischemic epididymo-orchitis, and portal vein thrombosis. Resumption of complement inhibition with ravulizumab successfully halted the progression of PNH-related complications. This case emphasizes the life-threatening risks associated with the withdrawal of complement blockade in patients with a prior thromboembolic history and highlights the critical importance of continuous therapy, even in the context of bone marrow failure.

Questions Emerging from Medical Education in the Aftermath of the 2024 Medical Conflict in Korea

Wed, 01 Apr 2026 00:00:01 +0100

The 2024 medical conflict in Korea, often summarized as a medical crisis, exposed not only the fragility of the healthcare delivery system, but also the vulnerable foundations of undergraduate and postgraduate medical education. The abrupt withdrawal of residents and the prolonged disruption of clinical teaching did not merely create a temporary gap in the curriculum, it left a deep fissure in the development of an entire generation of physicians and medical professionals. As a clinician-educator in internal medicine, the author came to regard this crisis less as a political dispute and more as an invitation to revisit three fundamental questions about medical education: what we have been teaching, for whom we have been teaching, and how we can teach together. This article reflects on these three questions from the perspective of the educational field after the crisis and explores the internal limitations of current medical education, which centers on knowledge transmission, examination performance, and short-term workforce needs. Based on this reflection, three directions are proposed for rebuilding medical education after the crisis: healing students trauma and restoring a psychologically safe learning environment; restructuring curricula around core professional and civic competencies; and redefining educational governance through the stable participation of all stakeholders. Drawing on these proposals, this article argues that medical education in Korea should become a central arena for recovering public trust and re-articulating the social meaning of being a physician.

A New Horizon of Cardiorenal Protection through Inhibition of Inflammation and Fibrosis in ...

Wed, 01 Apr 2026 00:00:01 +0100

Non-steroidal mineralocorticoid receptor antagonists (NS-MRAs) have emerged as a novel therapeutic class while minimizing the endocrine adverse effects associated with steroidal MRAs, such as spironolactone and eplerenone. Finerenone, the first clinically approved NS-MRA, exhibits high receptor selectivity, minimal off-target hormonal activity, and exerts potent anti-inflammatory and antifibrotic actions that complement renin-angiotensin system inhibition and sodium-glucose cotransporter-2 (SGLT2) inhibitor therapy. The pivotal FIDELIO-DKD and FIGARO-DKD trials demonstrated clinically meaningful reductions in kidney disease progression and cardiovascular composite outcomes in patients with type 2 diabetes and albuminuric chronic kidney disease (urine albumin-creatinine ratio ? 30 mg/g), the pooled FIDELITY analysis confirmed consistent cardiorenal benefits across diverse risk strata. Hyperkalaemia remains a principal safety concern and requires potassium monitoring and dose adjustments in routine practice. Emerging short-term data on albuminuria suggest the additional benefits of concomitant SGLT2 inhibitor therapy, although definitive outcome evidence for combination strategies is still evolving. Ongoing clinical programs further extend the therapeutic scope of finerenone to heart failure with preserved ejection fraction, non-diabetic chronic kidney disease, and type 1 diabetes. Collectively, NS-MRAs provide a mechanistically distinct strategy targeting inflammation and fibrosis and represent an important therapeutic advance in integrated cardiorenal-metabolic risk reduction.

Systemic Treatment for Patients with Early-Stage Breast Cancer

Wed, 01 Apr 2026 00:00:01 +0100

Breast cancer is the most common malignancy among women in Korea and its incidence is rapidly increasing. Perioperative systemic treatment plays a critical role in achieving a cure for early-stage breast cancer. With the introduction of novel systemic agents, treatment outcomes have improved and perioperative strategies have become increasingly diverse. In addition to conventional anthracycline- and taxane-based chemotherapies, targeted therapies and/or immunotherapy have expanded the options to both neoadjuvant and adjuvant settings. Increasing numbers of (neo) novel adjuvant agents and post-neoadjuvant treatments have demonstrated survival benefits, supporting more individualized perioperative treatment approaches in patients with early breast cancer.

Sarcopenia in Patients with End-Stage Kidney Disease on Dialysis

Wed, 01 Apr 2026 00:00:01 +0100

Sarcopenia is characterized by progressive loss of skeletal muscle mass accompanied by a decline in muscle strength and/or physical performance. Sarcopenia may develop in patients with end-stage kidney disease due to multiple contributing factors, including uremia, malnutrition, reduced physical activity, chronic inflammation, and dialysis-related factors. In this population, sarcopenia is strongly associated with decreased quality of life and increased mortality, underscoring the need for early diagnosis and timely intervention. This review was written to provide a comprehensive overview of sarcopenia pathophysiology, diagnostic criteria, and prevalence, and describe therapeutic strategies for sarcopenia in patients undergoing dialysis.

Perioperative Pain Management in Hospital Medicine

Wed, 01 Apr 2026 00:00:01 +0100

Effective pain management for hospitalized individuals plays a crucial role in healthcare, affecting patient outcomes, and emotional and overall health. Successful pain management necessitates understanding the essence of pain and comprehending the efficacy and potential side effects of medications tailored to specific types of pain. This article reviews strategies for assessing pain and outlines principles for managing pain using opioids, non-opioid analgesics, and supplementary analgesics with the aim of improving overall quality of patient care.

Trends in Life-Sustaining Treatment Decisions and Their Implementation: An Interrupted Time ...

Wed, 01 Apr 2026 00:00:01 +0100

Background/Aims: Since enforcement of the Life-Sustaining Treatment (LST) Decisions Act, a pilot project for medical insurance reimbursement related to LST decisions and their implementation began in February 2018. This pilot project transitioned into a full-scale project in January 2022 that continues to this day. Methods: We observed trend changes in LST decisions and their implementation by performing an interrupted time series analysis of data from the Health Insurance Review and Assessment Service from February 2018 to September 2023. We focused on two events: coronavirus disease 2019 (COVID-19) and the transition to a full-scale project. Results: Our interrupted time-series analysis used the onset of COVID-19 (January 2020) as its reference point. The slopes of most codes for LST decisions and their implementation decreased following the onset of COVID-19. When divided by hospital class, all codes in hospitals, nursing hospitals, and oriental medicine hospitals showed immediate increases before and after the COVID-19 outbreak. A separate interrupted time series analysis was conducted using the transition to a full-scale project (January 2022) as the reference point. While no immediate effects were observed before or after transitioning to full-scale projects, in the institution-specific data, the slopes of all codes in general, nursing, and oriental medicine hospitals increased. Conclusions: Our results reveal that COVID-19 and the transition to a full-scale project have significantly impacted LST decisions and their implementation. These findings can be used to evaluate and improve reimbursement programs.

Focal Nodular Hyperplasia within an Accessory Liver Lobe Presenting as a Gastric Subepithelial ...

Wed, 01 Apr 2026 00:00:01 +0100

A 33-year-old man was referred for evaluation of a 4-cm subepithelial mass located in the gastric fundus, initially suspected to be a gastrointestinal stromal tumor based on endoscopic findings. Abdominal computed tomography revealed a well-enhancing mass along the gastric wall, with no apparent anatomical continuity with the liver. Endoscopic ultrasonography demonstrated a well-circumscribed, hypoechoic lesion confined to the serosal layer, suggesting an extramural origin. Subsequent magnetic resonance imaging showed arterial phase enhancement with persistent delayed enhancement and a central hypointense area characteristic of focal nodular hyperplasia (FNH). Laparoscopic resection was performed, and intraoperative indocyanine green fluorescence confirmed the hepatic origin of the mass. Histopathological analysis confirmed FNH arising from an accessory lobe of the liver. This case underscores the importance of recognizing the atypical presentations of hepatic lesions and highlights the diagnostic value of sequential imaging modalities for distinguishing hepatic tumors from gastric subepithelial lesions.

Guidelines for Preventing Medical Disputes at Each Stage of Care: Internal Medicine

Mon, 01 Jun 2026 00:00:01 +0100

According to Medical Law, internal medicine is an essential medical course for the opening of a general hospital, and covers many departments of medical treatment under its jurisdiction. Due to the characteristics of the disease group and patients, patients with mild-to-severe disease are widely distributed. The uncertainty and difficulty in ensuring treatment outcomes, such as complex and multidisciplinary interventions for multiple diseases, have increased. As such, the increase in interventions in medical practice, specifically linked to patient survival, leads to an increase in the risk of medical accidents. Internal medicine also shows a high status in the initiation of mediation and medical evaluation. To help prevent and resolve medical disputes in the internal medicine field, this paper presents the current status of those disputes and the core legal principles of the Supreme Court for each medical practice, and suggests the author's opinion based on the experience of handling internal medicine cases.

Current Status and Institutional Challenges of Medical Disputes in Internal Medicine: An ...

Mon, 01 Jun 2026 00:00:01 +0100

Despite remarkable advances in medical technology, the increasing number of high-risk elderly patients and rising patient expectations have led to an increase in medical disputes in Korea. Internal medicine faces particularly high litigation risks owing to disease complexity and unpredictable outcomes, contributing to a decline in its attractiveness as a specialty. This study analyzed internal medicine disputes using the data from the Korea Medical Dispute Mediation and Arbitration Agency from 2020 to 2024. In 5 years, 1,468 internal medicine disputes were filed, representing 13.8% of the total disputes and ranking second after orthopedic surgery. Common causes included symptom deterioration (32.5%), delayed diagnosis (8.2%), and nerve injury (7.6%), with the highest frequency observed in patients aged 70-79 years. The average claimed amount was KRW 117 million, while the actual settlement averaged only KRW 11 million. The mean interval from incident to filing was 336.6 days. Korea's medical dispute system has evolved from requiring patients to prove negligence to imposing stronger explanatory duties on physicians based on reasonable probability. However, international comparisons reveal Korea's exceptionally high criminalization of medical practice, with prosecution rates approximately 15 times higher than those of Japan and 580 times higher than those of the United Kingdom. Current challenges, such as committee composition dominated by non-medical professionals, insufficient no-fault compensation, and low national health insurance reimbursement rates, are paradoxically driving litigation. Moreover, reforms are essential for sustaining essential medical services; hence, institutional improvements should include establishing objective advisory systems through medical societies, expanding no-fault compensation programs, and restricting criminal prosecution to gross negligence or intentional harm.

Endoscopic Diagnosis and Treatment of Gastric Subepithelial Lesions

Mon, 01 Jun 2026 00:00:01 +0100

The endoscopic diagnosis of gastric subepithelial lesions (SELs) relies primarily on gross features, including shape, color, surface characteristics, mobility, and size. However, endoscopic inspection alone is insufficient for a definitive diagnosis because SELs are covered by normal mucosa and originate from the deeper layers of the gastric wall. Recent guidelines from Korea, the United States, and Europe recommend endoscopic ultrasonography (EUS) to ascertain the lesion characteristics and layer of origin. The updated Korean guidelines recommend periodic endoscopic surveillance for asymptomatic lesions < 10 mm in size. In contrast, lesions ? 20 mm or those with highrisk features may warrant histologic confirmation, with tissue acquisition typically undertaken via mucosal incision-assisted biopsy (MIAB) and EUS-guided fine needle aspiration or biopsy (EUS-FNA/B). For lesions < 20 mm, MIAB demonstrates a superior diagnostic yield than EUS-FNA/B. The therapeutic options include endoscopic submucosal dissection, submucosal tunneling endoscopic resection, and endoscopic full-thickness resection. The treatment selection should be individualized based on lesion characteristics, operator expertise, and institutional resources to ensure safe and effective management.

Emerging Targeted Therapies for Sj

Mon, 01 Jun 2026 00:00:01 +0100

From Genes to Clinics: The Genomic Paradigm Shift in Chronic Kidney Disease Diagnosis and Care

Mon, 01 Jun 2026 00:00:01 +0100

Chronic kidney disease (CKD) is undergoing a paradigm shift as genetic insights have reshaped its diagnosis and management. Rare monogenic variants explain a growing number of early onset and familial cases, while polygenic risk scores offer new tools for risk stratification. Emerging research, especially from Korean cohorts, has revealed modifiable gene-environment interactions and integrates genomics with metabolomics to uncover disease-specific pathways. Genetic testing plays a pivotal role in clinical reclassification and therapeutic decision-making. With the expansion of kidney genetics clinics, generalists and specialists must adapt to this era of precision. The journey from genes to clinics is no longer conceptual; rather, it redefines CKD care.

A 25-Year-Old Male with Chronic Back Pain

Mon, 01 Jun 2026 00:00:01 +0100

A diagnosis of spondyloarthritis is often delayed because chronic back pain is frequently misidentified as mechanical in origin. Early recognition of inflammatory back pain and its extra-articular manifestations is crucial for preventing irreversible structural damage. In this report, the case of a 25-year-old male with a one-year history of insidious back pain and alternating buttock pain is presented. Despite normal Schober test results and ambiguous initial radiographs, the patient had classic features of spondyloarthritis, including peripheral arthritis, acute anterior uveitis, a positive family history, and HLA-B27 positivity. Although the 1984 modified New York criteria require radiographic evidence of sacroiliitis, modern diagnostic roadmaps use the 2009 Assessment of SpondyloArthritis International Society criteria. In this case, magnetic resonance imaging revealed significant subchondral bone marrow edema in the sacroiliac joints, confirming a diagnosis of axial spondyloarthritis. By integrating clinical features, laboratory markers, and advanced imaging findings, clinicians can navigate the diagnostic roadmap to ensure timely intervention and improve the long-term prognosis of young patients presenting with chronic back pain.

Radiologic Intervention for Endoscopy-Uncontrolled Bleeding in Ischemic Colitis: A Case Series

Mon, 01 Jun 2026 00:00:01 +0100

Ischemic colitis (IC), a common cause of lower gastrointestinal bleeding, is typically managed with conservative treatment. However, when hematochezia persists despite endoscopic hemostasis, radiologic intervention becomes a viable therapeutic alternative. This report aims to present three cases of IC associated with massive bleeding successfully treated using radiologic therapies. One patient with IC secondary to occlusive disease, characterized by significant stenosis at the superior mesenteric artery orifice, underwent stent placement, while the other two patients with non-occlusive IC were treated with embolization using microcatheters and Gelfoam. All cases resulted in technical and clinical success, with no procedure-related complications. This case series highlights the potential role of radiologic intervention as an effective, minimally invasive treatment option for select patients with IC who present with persistent hematochezia despite conservative or endoscopic management.

Toe Necrosis after Terlipressin Administration in a Patient with Hepatorenal Syndrome and Pedal ...

Mon, 01 Jun 2026 00:00:01 +0100

A 74-year-old woman with liver cirrhosis presented with hepatorenal syndrome and was treated with terlipressin and albumin. Despite a transient improvement in renal function, the patient developed bilateral toe cyanosis and necrosis during treatment. Computed tomography angiography revealed moderate and severe stenosis of the right and left dorsalis pedis arteries, respectively. Terlipressin was discontinued immediately, and surgical amputation was considered, but deferred because of poor cardiac and hepatic reserves. The patient received conservative wound care but eventually died of multi-organ failure. This case suggests that terlipressin-induced peripheral ischemia can be exacerbated in patients with pre-existing peripheral arterial stenosis or severe cardiac dysfunction. In such high-risk patients, careful evaluation of the vascular and cardiac status before therapy and close monitoring during treatment may help reduce the risk of this rare but serious complication.

Big Data in Internal Medicine: Sources and Challenges

Sat, 01 Aug 2026 00:00:01 +0100

Big data has become an important research resource in internal medicine. Major data sources in Korea include national claims databases, health screening records, registry data, mortality statistics, survey data, hospital electronic health records, and emerging biobig data resources. These datasets provide new opportunities for disease surveillance, outcome prediction, and evaluation of real-world practice across a wide range of chronic diseases. Nevertheless, large-scale data do not guarantee valid evidence. Diagnostic misclassification, limited clinical details, incomplete medication information, residual confounding, and difficulties in data linkage and standardization remain major challenges. Therefore, the value of big data in internal medicine depends not only on data volume but also on data quality, appropriate linkage, validated definitions, and rigorous study design. Big data should be recognized as a complementary tool that can strengthen, but not replace, clinical reasoning and conventional clinical research.

Updated Topics in the 2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease

Sat, 01 Aug 2026 00:00:01 +0100

The 2025 ESC/EACTS guidelines for the management of valvular heart disease will incorporate new clinical and randomized evidence published in 2021, resulting in major updates in diagnosis and treatment. The revised guidelines reinforce multidisciplinary heart-teambased, patient-centered decision-making and recommend the referral of complex cases to experienced, high-volume centers. Advanced multimodal imaging, including three-dimensional echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, is emphasized for an accurate mechanistic assessment and procedural planning. In cases of severe aortic stenosis, evidence supports earlier intervention, irrespective of symptoms or left ventricular function, with refined criteria for selecting transcatheter aortic valve implantation versus surgery based on age, anatomy, procedural risk, and lifetime management. New data have expanded the role of transcatheter aortic valve implantation in low-risk patients and selected bicuspid or aortic regurgitation cases. The updated recommendations also address mitral and tricuspid valve disease, anticoagulation, mixed valve pathology, structural valve deterioration, and sex-specific considerations, providing practical guidance for individualized care. This review article focuses on the new, revised recommendations.

Diagnosis of Antibiotic Resistance and Tailored Treatment Strategies for Helicobacter pylori ...

Sat, 01 Aug 2026 00:00:01 +0100

Helicobacter pylori (H. pylori) infection is a major cause of various gastrointestinal diseases, including gastric cancer, underscoring the need for effective eradication therapy. However, the increasing prevalence of antibiotic resistance and emergence of multidrug-resistant strains have progressively reduced the efficacy of conventional empirical eradication regimens, posing a substantial clinical challenge. This review discusses the current status and major mechanisms of antibiotic resistance in H. pylori, summarizes the available diagnostic methods and their limitations, and reviews tailored treatment strategies, including susceptibility-guided therapy and antibiotic exposure history-based approaches. In addition, the roles of bismuth-containing regimens and potassium-competitive acid blockers in improving eradication efficacy are reviewed. Future management of H. pylori infections warrants a precision medicine approach that integrates regional resistance patterns and individual patient characteristics. The combined application of accurate diagnostic tools and optimized treatment strategies will help improve eradication outcomes.

Nutritional Assessment and Nutritional Prescription for Hospitalized Patients

Sat, 01 Aug 2026 00:00:01 +0100

As Korea becomes an aging society, the importance of nutritional care for hospitalized patients is increasing. Nutritional status is closely related to clinical outcomes. For hospitalists managing patients throughout their hospitalization, from admission to discharge, assessing nutritional status and providing appropriate nutrition are essential. Hospitalists must diagnose and treat diseases and ensure that patients receive adequate nutritional support to improve recovery and health outcomes.

A 62-Year-Old Man with Weakness and Weight Loss for 3 Months

Sat, 01 Aug 2026 00:00:01 +0100

Metabolic dysfunction-associated steatotic liver disease (MASLD) is emerging as a major cause of hepatocellular carcinoma (HCC) worldwide, driven by the increasing prevalence of obesity and metabolic disorders. The pathogenesis of MASLD-related HCC is multifactorial, involving insulin resistance, chronic inflammation, oxidative stress, genetic susceptibility, and alterations in the gut microbiome. While surveillance is well established for patients with cirrhosis, optimal strategies for non-cirrhotic MASLD remain unclear despite a substantial proportion of HCC arising in this population. Non-invasive tests, biomarkers, and novel approaches such as liquid biopsy may improve risk stratification and early detection. Further prospective studies are needed to establish effective, cost-efficient surveillance strategies.

Clinical Utility of Stool DNA Testing

Sat, 01 Aug 2026 00:00:01 +0100

Recent advances in molecular diagnostics have established stool DNA testing as a robust diagnostic tool for infectious diarrhea and colorectal neoplasia in clinical practice. Multiplex polymerase chain reaction assays facilitate the rapid and simultaneous detection of numerous pathogens in stool samples, enhancing diagnostic accuracy and supporting the optimization of antibiotic therapy for infectious diarrhea. Stool DNA tests targeting cancer-specific epigenetic biomarkers provide superior sensitivity for the early detection of colorectal cancer compared to fecal immunochemical tests. As molecular diagnostic technologies continue to evolve, the integration of artificial intelligence and multi-omics targets such as RNA and microbiome may further enhance the clinical performance of stool-based testing in the near future.

Interpretation of Diagnostic Testing for Primary Aldosteronism

Sat, 01 Aug 2026 00:00:01 +0100

Primary aldosteronism (PA), the most common cause of endocrine hypertension, is increasingly recognized as a major contributor to cardiovascular and renal morbidity. Despite its high prevalence and the availability of effective, targeted therapies, PA remains substantially underdiagnosed in routine clinical practice. Accurate interpretation of the diagnostic evaluation is therefore critical for facilitating timely recognition, guiding subtype classification, and selecting appropriate treatment. Initial screening relies primarily on the aldosterone-to-renin ratio (ARR); however, the ARR should not be interpreted solely against fixed cutoff values because antihypertensive medications, dietary sodium intake, potassium status, age, and other clinical factors can substantially alter aldosterone and renin concentrations. Contemporary diagnostic approaches therefore emphasize determining whether aldosterone secretion is inappropriately elevated relative to the degree of renin suppression, rather than relying on the ARR as an isolated numerical threshold. The 2025 Endocrine Society guidelines introduced several notable changes, including a recommendation to screen all patients with hypertension, the adoption of lower ARR thresholds, and greater emphasis on probability-based diagnostic decision-making. Confirmatory aldosterone suppression testing is no longer considered universally necessary after a positive screening result; instead, its use should be individualized according to the pretest probability of PA, the likelihood of surgically remediable unilateral disease, and whether the patient is willing and eligible to undergo surgery. For subtype classification, adrenal computed tomography (CT) provides essential anatomical information, including the detection of adrenal masses and assessment of adrenal morphology; however, it cannot reliably establish functional lateralization because CT findings frequently conflict with adrenal venous sampling (AVS) results. AVS therefore remains the reference standard for differentiating unilateral aldosterone excess from bilateral disease, but its diagnostic accuracy depends on technically successful catheterization and careful interpretation of the selectivity and lateralization indices. Emerging functional imaging techniques, including 18F-metomidate positron emission tomography, may provide complementary information or serve as potential alternatives when AVS is unavailable, unsuccessful, or contraindicated; however, their indications, accessibility, and diagnostic performance remain insufficiently established for routine use. This review provides a practical framework for interpreting biochemical screening, confirmatory suppression tests, adrenal imaging, and AVS in patients with suspected PA. It also summarizes recent guideline updates and discusses the clinical and health-system considerations relevant to their implementation in Korea.

Hamman Syndrome as a Rare Complication of Diabetic Ketoacidosis in a Patient with Chronic Heavy ...

Sat, 01 Aug 2026 00:00:01 +0100

A 40-year-old man with altered mental status, abdominal pain, and vomiting was referred to our emergency department. Chest radiography revealed pneumomediastinum, raising concern for Boerhaave syndrome. Laboratory tests revealed high-anion-gap metabolic acidosis and hyperglycemic ketoacidosis, consistent with diabetic ketoacidosis (DKA). Endoscopic evaluation excluded esophageal perforation. Because the pneumomediastinum resolved with conservative management and DKA treatment, Hamman syndrome was diagnosed. The patient developed multiorgan dysfunction and required intensive care management, including mechanical ventilation and continuous renal replacement therapy. This case illustrates the diagnostic challenges of differentiating DKA from alcoholic ketoacidosis and Hamman syndrome from Boerhaave syndrome, highlighting the importance of a systematic approach and multidisciplinary critical care management for patients with severe metabolic derangements and multiorgan dysfunction.

Spontaneous Resolution of Left Atrial Dissection after Mitral Valve Replacement and ...

Sat, 01 Aug 2026 00:00:01 +0100

Left atrial dissection is a rare complication of cardiac surgery, particularly following mitral valve procedures. Its clinical presentation varies, and the optimal management remains uncertain. Here, we report the case of a 76-year-old woman who developed left atrial dissection after mitral valve replacement and endoatriectomy for circumferential eggshell calcification of the left atrium. Postoperative echocardiography and cardiac computed tomography revealed a false lumen along the left atrial wall without inflow obstruction or pulmonary venous compromise. Because the patient remained hemodynamically stable and prosthetic valve function was preserved, she was managed conservatively using serial imaging and clinical monitoring. Over the ensuing months, the false lumen progressively regressed, and follow-up imaging at 6 months confirmed complete resolution. This case highlights the potential for spontaneous healing of left atrial dissection and suggests that conservative management may be an appropriate treatment strategy in stable patients without hemodynamic deterioration.

Unique Features and Reforms of the Korean Healthcare System

Sat, 01 Feb 2025 00:00:01 +0100

Korea's healthcare system has forcibly incorporated private doctors and private medical institutions into the National Health Insurance, which is known as the Compulsory Designation System for Healthcare Institutions. This system is connected to multiple regulatory layers. In addition to these structural contradictions, increasing civil and criminal liabilities imposed on medical professionals have accelerated the exodus from essential medical services. The 2024 essential healthcare policy package proposed by the Ministry of Health and Welfare and the rapid expansion of medical school admissions completely ignored the structural problems of Korea's healthcare system. Primarily, the Korean healthcare system must restore systemic coherence. If regulations not imposed on the general public are applied to physicians in the name of public healthcare, a system must be created within which the advancement of medical services and the quality of life for physicians can be ensured. This is the only way to advance public healthcare in Korea.

2024 KSoLA Consensus on the Management of Secondary Dyslipidemia

Sat, 01 Feb 2025 00:00:01 +0100

Secondary dyslipidemia, characterized by elevated blood cholesterol and triglycerides, arises from various underlying conditions. The identification and appropriate handling of these causes is crucial for effective treatment. Major contributors include unhealthy diets, diseases impacting lipid metabolism, and medication side effects. Prioritizing the correction of secondary causes before initiating conventional lipid-lowering therapies is essential. Subsequent lipid profiles guide the selection of appropriate guideline-based lipid-lowering interventions.

Colorectal Cancer after Colonoscopy: Causes and Prevention Strategies

Sat, 01 Feb 2025 00:00:01 +0100

Colorectal cancer ranks second in incidence and third in cancer-related mortality in Korea, and screening colonoscopies are being used more frequently to facilitate early detection and treatment. Some cancers are diagnosed after colonoscopy but before the recommended surveillance interval: this is referred to as post-colonoscopy colorectal cancer (PCCRC). A recent meta-analysis revealed that interval cancers occur in 8.2% of cases, with proximal PCCRC accounting for 9.7% and distal PCCRC for 5.4%. The primary causes of PCCRC include inadequate bowel preparation, missed lesions, incomplete resection, and development of new lesions. Ensuring high-quality endoscopic procedures and achieving complete resection will be critical to addressing these causes and preventing PCCRC.

Non-Invasive Liver Fibrosis Test Using Shear Wave Elastography

Sat, 01 Feb 2025 00:00:01 +0100

Noninvasive liver fibrosis assessment is vital for chronic liver disease management. Although liver biopsy remains the gold standard, it is invasive with limited feasibility. Shear wave elastography (SWE) accurately evaluates liver stiffness, detecting liver fibrosis and cirrhosis across etiologies including viral hepatitis and metabolic dysfunction-associated steatotic liver disease. Despite confounders like obesity or elevated liver enzymes, SWE also aids in predicting portal hypertension and hepatocellular carcinoma risk, serving as a key tool in clinical decision-making.

Exercise in Korean Patients with Axial Spondyloarthritis: A Questionnaire-Based Study

Sat, 01 Feb 2025 00:00:01 +0100

Background/Aims: Exercise is a key component of the management of axial spondyloarthritis (axSpA), providing symptomatic relief and helping prevent ankylosis. However, there is a lack of quantitative studies evaluating daily exercise patterns in patients with axSpA. This study assessed the types, frequency, and duration of exercises performed by these patients through a structured questionnaire. Methods: This cross-sectional study included radiographic axSpA patients who visited a rheumatology clinic between September 2014 and March 2016 and provided informed consent to participate. The survey captured information on four types of exercise: high-intensity exercise, moderate-intensity exercise, strength training, and walking. Disease activity and functional status were evaluated using the Bath ankylosing spondylitis disease activity index (BASDAI) and the Bath ankylosing spondylitis functional index (BASFI), respectively. Results: A total of 645 patients participated in the study. Among them, 25.1% engaged in high-intensity exercise, 36.0% in moderate-intensity exercise, 81.2% in walking, and 32.8% in strength training. The median weekly exercise frequency was 3.0 days (interquartile range [IQR], 2.0-4.0) for high-intensity exercise, 3.0 days (IQR, 2.0-5.0) for moderate-intensity exercise, 5.5 days (IQR, 4.0-7.0) for walking, and 3.0 days (IQR, 2.0-5.0) for strength training. The median daily exercise duration was 60 minutes (IQR, 60-120) for high-intensity exercise, 60 minutes (IQR, 30-90) for moderate-intensity exercise, 30 minutes (IQR, 20-60) for walking, and 30 minutes (IQR, 20-60) for strength training. Comparisons by disease activity showed that BASFI scores were more strongly associated with differences in exercise patterns than BASDAI scores. Conclusion: Radiographic axSpA patients predominantly engaged in low-intensity activities, particularly walking, typically for short durations. Given the observed variations in exercise patterns based on disease activity, personalized exercise education and guidance should be prioritized in clinical practice to optimize axSpA management.

Diagnosis of Oral-Facial-Digital Syndrome I in a Patient with Suspected Polycystic Kidney Disease

Sat, 01 Feb 2025 00:00:01 +0100

Polycystic kidney disease (PKD) typically manifests as genetic disease, which is commonly attributed to mutations in PKD genes. In this particular case, however, genetic analysis revealed that the patients PKD is linked to a novel, likely pathogenic variant (c.2184del; p.Thr729Leufs*88) in the oral-facial-digital syndrome type I (OFD1) gene. This is the first confirmed genetic diagnosis of mutations in the OFD1 gene in Korea. This investigation emphasizes the critical utility of panel sequencing of PKD in offering precise diagnosis and understanding the genetic profiles of PKD.

Human Understanding is Expected of the Physician: Proposing a Model of Disease Development

Sat, 01 Feb 2025 00:00:01 +0100

Latest Insights into Long COVID Diagnosis and Treatment

Tue, 01 Apr 2025 00:00:01 +0100

Long coronavirus disease (COVID) is a condition in which coronavirus disease 2019 (COVID-19) symptoms persist for over 3 months, and currently poses a global public health challenge. Due to varying manifestations and lack of standardized definitions, diagnostic methods, and treatments, comprehensive clinical guidelines are required. This review article, summarizing research and expert consensus up to June 2023, provides recommendations for diagnosis and long-term management of long COVID symptoms. It emphasizes thorough patient evaluation, including medical history, physical examinations, and tests, and advocates vaccination and antiviral treatments to reduce risk. Guidelines for long COVID will be updated as new knowledge emerges.

Clinical Advances in Percutaneous Endoscopic Gastrostomy: A 2023 Clinical Practice ...

Tue, 01 Apr 2025 00:00:01 +0100

Percutaneous endoscopic gastrostomy (PEG) has become a standard method for enteral nutrition in patients with swallowing difficulties due to various medical conditions, including neurodegenerative diseases, stroke, and malignancies. While nutrition by PEG is superior to nasogastric nutrition in terms of patient comfort, long-term use, and nutritional efficiency, it requires selection of target patients, appropriate insertion methods, and appropriate management of complications. Appropriate use of prophylactic antibiotics can reduce wound infection and proper management of tube can reduced the possibility of complications such as tube malfunction and buried bumper syndrome. Even though most complications arising from PEG are not severe, we should do careful monitoring because sometimes life-threatening events which need surgical treatment or intensive medical care can be happened. Therefore, it is necessary to understand the indications of PEG, to properly select the method of insertion, and to know about complications that may occur during or after the PEG.

Recent Updates on the Renoprotective Effects of Glucagon-Like Peptide 1 Receptor Agonists

Tue, 01 Apr 2025 00:00:01 +0100

Glucagon-like peptide 1 receptor agonists (GLP-1RA) significantly reduce the risk of cardiovascular disease. However, whether GLP-1RA improves clinically important renal outcomes is still unclear. In cardiovascular outcome trials of GLP-1RA, renal outcomes have been evaluated as secondary outcomes; however, their benefits have not been clarified, except for the effect of reducing albuminuria. Recently, the FLOW trial evaluated the renal benefits of GLP-1RA as a primary outcome in patients with diabetes and chronic kidney disease and showed a significant renoprotective effect. In this review, we discuss the renoprotective effects of GLP-1RA, summarize recently published research results, and describe the known mechanism of renal benefit and outlook.

Understanding Cardiovascular-Kidney-Metabolic Syndrome and the Necessity of a Multidisciplinary ...

Tue, 01 Apr 2025 00:00:01 +0100

Cardiovascular-kidney-metabolic (CKM) syndrome is a progressive disorder resulting from the complex interaction between metabolic risk factors, chronic kidney disease, and cardiovascular disease (CVD), leading to multi-organ dysfunction. Given the increasing prevalence of metabolic syndrome, obesity, hypertension, dyslipidemia, and diabetes, a comprehensive approach to risk stratification and management is essential. The American Heart Association introduced the CKM staging system to classify disease progression and identify early intervention opportunities. Additionally, the predicting risk of cardiovascular disease EVENTs (PREVENT) equation was developed to enhance cardiovascular risk prediction by incorporating metabolic risk factors, estimated glomerular filtration rate, albuminuria, glycated hemoglobin (HbA1c), and social determinants of health. Unlike traditional risk models, PREVENT enables 10-year and 30-year risk prediction of both CVD and heart failure in individuals aged 30 to 79 years and integrates the social deprivation index for a more equitable and individualized risk assessment. However, as PREVENT is derived from United States population data, its applicability to Asian populations, including Koreans, remains uncertain. Developing a region-specific risk prediction model using local cohort data is crucial for optimizing CKM syndrome management. Furthermore, effective prevention and treatment require a multidisciplinary approach involving nephrologists, cardiologists, endocrinologists, dietitians, and social workers. Implementing CKM staging and PREVENT in clinical practice can facilitate early risk identification and personalized interventions, ultimately improving cardiovascular and renal health outcomes.

Treatment Approaches for Philadelphia Chromosome-Like Acute Lymphoblastic Leukemia

Tue, 01 Apr 2025 00:00:01 +0100

Philadelphia chromosome-like acute lymphoblastic leukemia (ALL) is a group of diseases that possess similar gene expression patterns to those of Philadelphia chromosome-positive ALL, but lack the BCR-ABL1 gene rearrangement and exhibit diverse genetic characteristics. These cases are associated with a poorer prognosis than that of other B-cell ALL cases and require novel therapeutic approaches. Philadelphia chromosome-like ALL can be categorized into ABL-activated, Janus kinase-signal transducer and activator of transcription (JAK-STAT) pathway-altered, and other subtypes based on genetic alterations. For the ABL-activated subtype, treatment with ABL-directed tyrosine kinase inhibitors may improve outcomes, whereas JAK-directed tyrosine kinase inhibitors have been proposed as a combination therapy for patients with JAK-STAT pathway mutations. In this review, we discuss treatment approaches for each subtype of Philadelphia chromosome-like ALL.

Diagnosis and Treatment of HER2-Positive Breast Cancer

Tue, 01 Apr 2025 00:00:01 +0100

Human epidermal growth factor receptor-2 (HER2)-positive breast cancer accounts for approximately 20% of all breast cancer cases. The advent of therapies targeting HER2 has significantly improved the prognosis for HER2-positive breast cancer. Neoadjuvant/adjuvant chemotherapy with HER2-targeted agents is recommended for early and locally advanced breast cancer. The appropriate use of novel HER2-targeted therapies is recommended for metastatic breast. We aimed to examine the diagnosis and personalized treatment for HER2-positive breast cancer.

A 55-Year-Old Man Presenting with Recurrent Upper Abdominal Pain

Tue, 01 Apr 2025 00:00:01 +0100

IgG4-related autoimmune pancreatitis (IgG4-AIP) is an immune-mediated disease that can present as recurrent acute pancreatitis with biliary involvement. We report a case of a 55-year-old male with recurrent acute pancreatitis and obstructive jaundice of unknown cause. Laboratory tests revealed elevated IgG and IgG4 levels, while imaging showed pancreatic swelling, main pancreatic duct stricture, and distal bile duct stenosis. Endoscopic ultrasound-guided biopsy confirmed IgG4-positive plasma cell infiltration and fibrosis, leading to a diagnosis of IgG4-AIP. The patient responded well to corticosteroid therapy, with clinical and radiologic improvement, and was placed on low-dose maintenance therapy to prevent recurrence. IgG4-AIP should be considered in patients with idiopathic recurrent pancreatitis, and early recognition is crucial to avoid unnecessary interventions. Corticosteroids remain the mainstay of treatment, but long-term monitoring is essential due to the risk of recurrence and potential complications.

Treatment Refractory Nausea and Vomiting due to Duodenal Obstruction caused by Annular ...

Tue, 01 Apr 2025 00:00:01 +0100

Annular pancreas is a rare congenital abnormality characterized by a ring of pancreatic tissue encircling the descending part of the duodenum. It is considered to originate from incomplete ventral pancreatic bud rotation. A 39-year-old male with refractory nausea and vomiting despite receiving appropriate medical treatment underwent contrast-enhanced computed tomography; it revealed an annular pancreas encircling the descending part of the duodenum. We found that surgical resection of the annular pancreas relieved nausea and vomiting due to duodenal obstruction.

Infected Renal Cyst: A Case Requiring Prompt Percutaneous Management

Tue, 01 Apr 2025 00:00:01 +0100

Benign renal cysts are fluid-filled sacs that originate from the kidneys. Infected renal cysts are a rare manifestation of benign renal cysts, that can be managed with antibiotic therapy, drainage, and surgery. A 74-year-old man was admitted to our hospital with an infected renal cyst. Initial treatment managed with only broad-spectrum antibiotics, as percutaneous drainage was postponed due to apparent clinical improvement. However, his condition deteriorated, leading to cardiac arrest. Radiological intervention with cyst drainage resulted in rapid improvement. The patient recovered successfully and was discharged 16 days later. A follow-up computed tomography revealed a marked reduction in cyst size, with normal blood and urine tests, and the patient remained asymptomatic.

Why Young Doctors are not Choosing Internal Medicine

Sun, 01 Jun 2025 00:00:01 +0100

Internal medicine plays a critical role in providing comprehensive healthcare; however, in recent years, there has been a significant decline in the number of young doctors choosing this specialty. This trend is not limited to Korea but is also observed globally, which raises concerns about the sustainability of core healthcare systems. The declining interest in internal medicine reflects not merely a shift in preference, but a complex issue that is influenced by workload, insufficient compensation, and the high legal risks associated with critical care responsibilities. Younger generations prioritize work-life balance, financial stability, and lower legal exposure, which leads them to select specialties that offer better conditions. Transparency in working environments, compensation, and legal risks through online networks allows young physicians to make informed decisions. In addition, increasing societal expectations and legal burdens in medical practice discourage them from choosing internal medicine. Addressing this issue requires comprehensive and systematic changes, including reducing workload, improving compensation, and implementing measures to mitigate legal risks for healthcare professionals. The Korean Association of Internal Medicine must lead these reforms with a clear roadmap and tangible strategies to restore the appeal of internal medicine to young doctors as a rewarding and sustainable career path.

Novel Immunotherapy for Advanced Hepatocellular Carcinoma

Sun, 01 Jun 2025 00:00:01 +0100

With the advent of immunotherapy, the treatment paradigm for advanced hepatocellular carcinoma (HCC) has undergone a significant shift, surpassing that based on traditional first-line therapies such as sorafenib and lenvatinib. The findings of the IMbrave150 trial revealed that compared with sorafenib, the administration of atezolizumab plus bevacizumab can contribute to significant improvements in median overall survival (mOS) and progression-free survival. Similarly, the HIMALAYA trial revealed that compared with sorafenib, treatment with durvalumab plus tremelimumab achieved a superior mOS. On the basis of the findings of these pivotal phase III trials, both regimens have received approval from the Food and Drug Administration and the Korean Ministry of Food and Drug Safety as first-line therapies for the treatment of advanced HCC. Nevertheless, for patients who are ineligible for immunotherapy, sorafenib and lenvatinib, which were previously established as first-line therapies, remain viable options. Currently, however, there are no well-established second-line therapies for patients who progress having initially received first-line immunotherapy. In Korea, sorafenib and lenvatinib are permitted as second-line options subsequent to treatment with atezolizumab-bevacizumab, although their use is limited to non-reimbursed settings. Although the introduction of immunotherapy has revolutionized the therapeutic landscape for the treatment of advanced HCC, long-term data on safety and efficacy are essential, and there remains an urgent need for clinical studies for the development of effective second-line treatments. Addressing these issues will be essential for improving the outcome of patients with advanced HCC.

Hyperuricemia: Does it Matter in Chronic Kidney Disease?

Sun, 01 Jun 2025 00:00:01 +0100

Chronic kidney disease (CKD) affects approximately 10-15% of adults globally and is a significant public health issue owing to its association with cardiovascular disease, end-stage kidney disease, and high healthcare costs. Hyperuricemia has emerged as an important modifiable risk factor influencing CKD progression. Elevated uric acid (UA) levels contribute to kidney injury through crystal-dependent mechanisms, including monosodium urate crystal deposition and NLRP3 inflammasome activation, and crystal-independent pathways, such as endothelial dysfunction, activation of the renin-angiotensin-aldosterone system, and oxidative stress. Observational studies have consistently linked hyperuricemia to an increased risk of CKD onset and accelerated disease progression. Nevertheless, randomized controlled trials and meta-analyses investigating UA-lowering therapy (ULT) for asymptomatic hyperuricemia have yielded conflicting results regarding its effectiveness in slowing CKD progression. Clinical guidelines also differ: Japanese guidelines recommend ULT for serum UA levels exceeding 8.0 mg/dL, whereas Western guidelines generally do not support routine treatment of asymptomatic hyperuricemia. Thus, there remains a clear need for large-scale, long-term studies to define patient subgroups most likely to benefit from ULT and guide individualized treatment approaches.

Molecular Methods for Tuberculosis Diagnosis and Drug Resistance Assessment

Sun, 01 Jun 2025 00:00:01 +0100

This article reviews the principles and clinical interpretation of molecular diagnostic tests for tuberculosis, focusing on Xpert MTB/RIF Ultra, line probe assays, whole genome sequencing, and targeted next-generation sequencing. These molecular tools provide rapid and accurate detection of Mycobacterium tuberculosis and its drug resistance profiles. Special attention is given to the discordance between genotypic and phenotypic drug susceptibility testing, including borderline resistance, heteroresistance, and rare genetic mutations. Understanding the strengths and limitations of each method is critical for accurate diagnosis, appropriate treatment selection, and improving patient outcomes.

A Case of IgG4-Related Disease of Gastrointestinal Origin Suspected to be Lymphoma and ...

Sun, 01 Jun 2025 00:00:01 +0100

Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory condition characterized by the tendency to form tumefactive lesions. However, the disease has highly variable clinical manifestations, as IgG4-RD can affect any organ. The biliary tree and major salivary glands are commonly affected; however, bowel mucosa is rarely affected. A 41-year-old man presented to our hospital complaining of abdominal pain. Computed tomography and endoscopy were performed at another hospital, and a biopsy was performed on a lesion suspected to be malignant. Biopsy revealed no remarkable findings other than lymphoid hyperplasia. Subsequently, IgG4-RD was confirmed via surgical biopsy. The disease and its symptoms were successfully treated with steroid therapy.

Sodium Phosphate-Induced Acute Phosphate Nephropathy after Colonoscopy: A Case Report

Sun, 01 Jun 2025 00:00:01 +0100

Acute phosphate nephropathy is caused by exposure to excess sodium phosphate. Calcium phosphate is deposited in the renal tubular epithelial cells, leading to tubulointerstitial nephritis. We report the case of a 71-year-old female who developed acute kidney injury after undergoing a colonoscopy. She had taken 28 sodium phosphate tablets, equivalent to 42 g of sodium phosphate, as bowel purgatives prior to the colonoscopy. A biopsy of the native kidney revealed acute tubular injury with calcium phosphate deposits. This case report suggests that sodium phosphate tablets can induce acute phosphate nephropathy, particularly in patients with predisposing factors. Therefore, physicians should be vigilant of kidney injury when choosing sodium phosphate as a pre-colonoscopy bowel purgative.

2024 KSoLA Consensus on the Management of Secondary Dyslipidemia

Sun, 01 Jun 2025 00:00:01 +0100

The Future of Specialist-Centered Hospitals: The Hospitalist System

Fri, 01 Aug 2025 00:00:01 +0100

The hospitalist system is a specialist care model designed to meet the growing complexity and continuity demands of inpatient care amid the contexts of aging and multimorbidity. It addresses the limitations of resident-centered care by positioning specialists as primary providers, serving as a practical step toward a specialist-centered hospital model. Hospitalists improve care efficiency, ensure consistent clinical decisions, distribute medico-legal and educational burdens, and enable effective team-based care. Institutionalizing inpatient medicine through this model is a key step toward realizing a sustainable, specialist-led hospital structure. As both generalists and specialists, hospitalists manage complex patients across various disciplines, setting a new standard for patient-centered care. This paper argues that the hospitalist model is not merely a role expansion, but a strategic foundation for redefining inpatient care in Korea.

Kidney Transplantation in the Elderly: Necessity and Considerations

Fri, 01 Aug 2025 00:00:01 +0100

As global aging accelerates, the prevalence of chronic diseases, including hypertension and diabetes mellitus, is increasing, leading to a growing number of elderly patients with end-stage kidney disease (ESKD). In South Korea, between 2003 and 2023, the proportion of ESKD patients aged 65 and older more than doubled from 24.5% to 57.2%. Consequently, the number of elderly patients considered for kidney transplantation is rising. However, transplantation among individuals in this population remains limited due to a lack of standardized selection criteria and concerns regarding post-transplant outcomes. In this review, we address three major considerations with respect kidney transplantation for elderly patients: post-transplant clinical outcomes, appropriate evaluation criteria for transplant eligibility, and equitable access to transplantation. Despite early postoperative risks, the findings of previous studies have revealed improvements in long-term survival and quality of life among carefully selected elderly transplant recipients. Given that chronological age alone is an insufficient predictor of transplant outcomes, physiological assessments, including those for frailty, sarcopenia, and cognitive function, are increasingly being emphasized, and tools such as the Comprehensive Geriatric Assessment and predictive models such as K-EPTS are being developed to provide better guidance for decision-making. Notably, however, disparities in transplant access persist, thereby highlighting the necessity for policy efforts to enhance awareness and streamline allocation systems. In this regard, programs such as the Eurotransplant Senior Program and the KDPI-based allocation in the US serve as good models. Our finding in this review indicate that kidney transplantation can be a viable treatment option for elderly ESKD patients, provided that individualized assessments and equitable allocation policies are implemented.

Iron Deficiency and Anemia in Heart Failure

Fri, 01 Aug 2025 00:00:01 +0100

Anemia and iron deficiency are highly prevalent and prognostically important comorbidities among patients with heart failure. Iron deficiency, in both the absolute and functional forms, affects up to 50-60% of patients with heart failure, even in the absence of anemia, and contributes to worsening symptoms, impaired exercise capacity, and increased morbidity and mortality. Iron plays central roles in oxygen transport, myocardial energetics, and skeletal muscle function. Mechanistically, inflammation, impaired iron absorption, hepcidin overproduction, and reduced erythropoiesis contribute to the complex pathophysiology of iron deficiency in heart failure. The diagnostic criteria for anemia are generally serum ferritin < 100 ng/mL or ferritin 100-299 ng/mL with transferrin saturation < 20%. Although oral iron supplementation has shown limited efficacy in clinical trials, intravenous iron therapy -particularly ferric carboxymaltose and ferric derisomaltose therapy- has demonstrated benefits in improving symptom burden and quality of life and reducing hospitalization for heart failure in patients with reduced or mildly reduced ejection fraction. However, large trials such as the HEART-FID and FAIRHF2 failed to show significant reductions in cardiovascular events, highlighting the need for further research. Moreover, key challenges remain, including identifying responders, optimizing iron dosing and monitoring strategies, and evaluating the long-term effects of iron repletion on clinical outcomes. This review summarizes the current evidence and emphasizes the need for more refined diagnostic criteria, individualized treatment approaches, and robust long-term data to guide iron therapy in cases of heart failure.

Managing Adverse Effects Associated with Long-Term Glucocorticoid Use

Fri, 01 Aug 2025 00:00:01 +0100

The primary steroids produced by the adrenal cortex include glucocorticoids, mineralocorticoids, and androgen precursors. Glucocorticoids are widely used to treat a variety of endocrine and non-endocrine conditions due to their anti-inflammatory and immunosuppressive properties. Approximately 1% of the population undergoes chronic glucocorticoid therapy, and this number is increasing. However, prolonged glucocorticoid use can lead to significant side effects, including adrenal insufficiency, hypertension, diabetes, and osteoporosis. Predicting and managing the adverse effects of glucocorticoids is important for maximizing their benefits while minimizing their risks. In addition, providing thorough education and support to affected patients is essential. Therefore, this review focuses on the management of glucocorticoid-related side effects, particularly the most commonly occurring ones.

Uncontrolled Asthma with Hypereosinophilia

Fri, 01 Aug 2025 00:00:01 +0100

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare inflammatory disease characterized by asthma, necrotizing vasculitis, extravascular granulomas, and blood and tissue eosinophilia. EGPA progresses through prodromic, eosinophilic, and vasculitic phases. These phases often overlap and sometimes do not progress in the expected sequence. A diagnosis of EGPA should be considered in patients who present with asthma, chronic rhinosinusitis, and eosinophilia, especially when evidence of end-organ involvement such as peripheral neuropathy, lung infiltrates, cardiomyopathy, or issues affecting the skin, gastrointestinal tract, or kidneys is present.

Cutaneous Clues to Systemic Diseases: A Diagnostic Perspective

Fri, 01 Aug 2025 00:00:01 +0100

The skin serves not only as a protective barrier but also as a visible marker of various internal diseases, often providing early diagnostic clues before systemic symptoms manifest. Many internal diseases have distinct dermatological manifestations, and in some cases, skin changes serve as early indicators of underlying conditions. Recognizing dermatologic signs can facilitate timely diagnosis and management in internal medicine. Therefore, careful observation and interpretation of skin findings are essential for early diagnosis and effective management of systemic diseases. This article highlights key cutaneous manifestations of systemic diseases and their clinical significance.

Assessment and Interpretation of Bone Turnover Markers for the Diagnosis and Treatment of ...

Fri, 01 Aug 2025 00:00:01 +0100

Bone turnover markers have gained increasing attention as valuable supplementary tools for the diagnosis and clinical management of osteoporosis. Unlike bone mineral density, which provides a static measure of bone mass, bone turnover markers offer dynamic information regarding the ongoing processes of bone remodeling, including those related to both bone formation and bone resorption. By reflecting the metabolic activity of bone tissue in real time, these biochemical markers complement traditional imaging-based assessments and contribute to a more comprehensive understanding of skeletal health. This article aimed to evaluate the clinical applications and interpretive challenges related to the use of bone turnover markers in osteoporosis care.

Susceptibility Assessment and Review of Novel Beta-Lactam/Beta-Lactamase Inhibitor against ...

Fri, 01 Aug 2025 00:00:01 +0100

Background/Aims: Carbapenem-resistant Enterobacterales (CRE) infections represent a significant global health concern, characterized by low susceptibility rate- and adverse effect-related high mortality and limited treatment options. Novel beta-lactam/beta-lactamase inhibitors (BLBLIs) are first-line therapeutic agents against specific carbapenemase (CP)-producing CREs. We assessed current CRE susceptibility to these novel BLBLIs to aid optimal antimicrobial stewardship, emphasizing the need for continuous resistance surveillance. Methods: In total, we identified 71 CRE isolates based on the imipenem minimum inhibitory concentration and disk diffusion susceptibility testing for imipenem, meropenem, and ertapenem. We performed antimicrobial susceptibility testing for novel BLBLIs, including ceftazidime-avibactam, imipenem-relebactam, and meropenem-vaborbactam as well as CP gene molecular characterization for all CRE isolates. Results: We analysed a total of 71 CRE isolates and our CP genotypic analysis identified 46 Klebsiella pneumoniae CP (KPC)-producing, 10 New Delhi metallo-beta-lactamase-producing, and two oxacillinase-48-like producing isolates. We identified the remaining 13 isolates as non-CP-producing CREs. The susceptibility rates for ceftazidime-avibactam, imipenem-relebactam, and meropenem-vaborbactam were 84.5%, 80.3%, and 83.1%, respectively. Among the CP-producing isolates, KPC producers exhibited susceptibility rates of 97.8%, 93.5%, and 95.7% to ceftazidime-avibactam, imipenem-relebactam, and meropenem-vaborbactam, respectively. Conclusions: Novel BLBLIs generally yielded high CRE susceptibility rates, with the latter exceeding 90% in KPC-producing isolates. Although these findings indicate the efficacy of novel BLBLIs in treating CRE infections, ongoing surveillance is essential to detect and mitigate resistant strain emergence.

A Case of Acute Tubulointerstitial Nephritis Manifesting Steroid Dependence Successfully ...

Fri, 01 Aug 2025 00:00:01 +0100

Acute tubulointerstitial nephritis (ATIN) is a prominent cause of acute kidney injury that is often triggered by drug reactions and autoimmune diseases. Although the treatment of ATIN should ideally target the underlying cause, in cases of progression, a consideration of immunosuppressive therapy is warranted. Glucocorticoids are typically the first-line therapeutic agents, with discontinuation following a response. In the case described herein, glucocorticoid therapy was initiated after diagnosing ATIN with an undetermined etiology. Although, the patient showed an initial response to the glucocorticoids, recurrent episodes of ATIN occurred upon the tapering of these drugs. Given the necessity for an alternative immunosuppressive agent, cyclosporine was administered, leading to the recovery of renal function. Notably, even after the cessation of steroid treatment, the patient continued to experience favorable outcomes when administered cyclosporine alone. This case highlights the importance of transitioning to alternative immunosuppressive agents when glucocorticoid therapy either fails or presents challenges regarding tapering during the initial management of ATIN. Moreover, it indicates that cyclosporine can be a viable option for the treatment of this condition.

Preserving Critical Thinking in the Age of Large Language Models: The Paradox of Cognitive Load ...

Wed, 01 Oct 2025 00:00:01 +0100

Rapid advancements in large language models (LLMs) have fundamentally transformed research practices across academic disciplines, with considerable adoption rates among researchers. While empirical studies have demonstrated the substantial positive effects of LLMs on learning outcomes and cognitive performance, these technological advances present a paradoxical challenge in maintaining critical thinking capabilities. LLMs offer unprecedented efficiency in research tasks in literature reviews, analysis, and writing, by significantly reducing task completion time while improving output quality. However, this efficiency stems largely from cognitive offloading, which is the delegation of mental processes to external systems, raising concerns about the potential weakening of human analytical abilities. Cognitive load theory provides a framework for distinguishing between the beneficial reduction of unnecessary cognitive burden and problematic offloading of essential cognitive processes required for deep understanding and critical analysis. Experimental evidence suggests that while LLM users experience reduced cognitive load across multiple dimensions, their critical reasoning performance may suffer compared with traditional search methods. The fundamental challenge lies in balancing the efficiency gains of LLM integration while preserving rigorous analytical thinking. Medical researchers must develop strategic approaches that leverage LLM capabilities while maintaining active engagement with primary sources and complex reasoning tasks. Success lies in recognizing that traditional research methods may represent essential investments in preserving critical thinking skills, suggesting LLM integration involves selective application rather than wholesale cognitive offloading.

Present and Future of Cardiovascular Diseases in Korea: Prevention, Management, and Policy ...

Wed, 01 Oct 2025 00:00:01 +0100

This study examined the current state of cardiovascular diseases (CVDs) in South Korea, highlighting their increasing prevalence due to rapid aging and lifestyle changes. It also identified key issues in the management of hypertension, dyslipidemia, ischemic heart disease, arrhythmia, heart failure, and valvular heart disease. This study emphasizes the need for tailored public health interventions, early detection, and equitable access to medical resources. Policy recommendations include enhancing preventive measures, adjusting national health-screening intervals, improving treatment adherence through education, and fostering multidisciplinary collaboration. These strategies aim to reduce the societal and economic burdens of CVD and promote sustainable public health initiatives.

Clonal Hematopoiesis in Human Disease: An Essential Immunologic Phenomenon in Aging Populations

Wed, 01 Oct 2025 00:00:01 +0100

Clonal hematopoiesis denotes a condition involving acquired genetic mutations in hematopoietic stem cells, and is recognized as precancerous lesion for hematologic malignancy (e.g., myelodysplastic syndrome or acute myeloid leukemia). Recent scientific advances indicate that clonal hematopoiesis rather represents an immunologic alteration of myeloid lineage-derived cells upon genetic mutations that can affect the course of various chronic diseases. The role of clonal hematopoiesis in chronic disease has been actively studied in cardiovascular and degenerative brain diseases as well as solid tumors. These discoveries consistently imply that the role of clonal hematopoiesis differs mutated gene- and involved target organ-dependently. Mutated immune cells infiltrate into the diseased organ to affect the disease.

Tailored Strategies for Applying Large Language Models in Clinical Settings and Addressing Data ...

Wed, 01 Oct 2025 00:00:01 +0100

Since the advent of ChatGPT in 2022, large language models (LLMs) have rapidly evolved, and their clinical applications are currently being explored. This paper introduces three practical strategies for applying LLMs in healthcare settings: text-to-text, any-to-text, and retrieval-augmented generation. Each strategy is described using real-world examples and analyzed for potential data security risks. Although LLMs offer promising efficiency and performance benefits, they also pose new challenges regarding privacy and information leakage, particularly when trained using sensitive patient data. We propose tailored learning and governance approaches to mitigate such risks, emphasizing the necessity of de-identification techniques and robust guardrails for ensuring safe and effective deployment in clinical settings.

Recent Advances in Imaging Analysis for Interstitial Lung Disease

Wed, 01 Oct 2025 00:00:01 +0100

Interstitial lung disease (ILD) encompasses a heterogeneous group of pulmonary disorders with variable etiologies, clinical courses, and prognoses. Recent advances in imaging analysis, particularly automated quantification and artificial intelligence-based technologies, have significantly enhanced diagnostic precision and prognostic modeling. Quantitative high-resolution computed tomography allows objective assessment of disease extent, pattern classification, and regional distribution of fibrotic lesions, providing essential information for staging and treatment decisions. Deep-learning-based segmentation and pattern recognition techniques can extract high-dimensional imaging features, facilitating phenotype clustering, risk stratification, and longitudinal monitoring. Recent efforts to integrate imaging data with clinical parameters and multi-omics profiles have further advanced the field of precision medicine. This review discusses the current state of imaging analysis technologies for ILD, emphasizing clinical applications, disease-specific use cases, and emerging directions for biomarker discovery and individualized patient care.

Patent Foramen Ovale Closure for Secondary Stroke Prevention

Wed, 01 Oct 2025 00:00:01 +0100

Patent foramen ovale (PFO) is a common congenital cardiac anomaly that may serve as a conduit for paradoxical embolism, potentially leading to ischemic stroke. Randomized controlled trials have demonstrated that PFO closure effectively reduces stroke recurrence, with particularly favorable outcomes in patients with high-risk PFO features such as a large shunt size or atrial septal aneurysm. However, real-world clinical data have shown inconsistent findings, raising concerns regarding the generalizability of these results. Additionally, post-procedural atrial fibrillation remains a significant issue and requires careful patient selection. While recent studies have refined the criteria for identifying patients most likely to benefit from PFO closure, direct comparisons between PFO closure and non-vitamin K antagonist oral anticoagulants (NOACs) remain lacking. Further research is required to optimize long-term management strategies and evaluate treatment outcomes across diverse patient populations.

Diagnostic Approach and Therapeutic Strategies for Ambiguous Thyrotoxicosis

Wed, 01 Oct 2025 00:00:01 +0100

Thyrotoxicosis is a clinical syndrome caused by elevated circulating thyroid hormones, most commonly due to Graves disease but also seen in thyroiditis or nodular disease. Differentiating the etiology is crucial because treatment strategies vary, yet in practice, clinical features may overlap, making diagnosis challenging. We describe two illustrative cases: a young woman with recurrent Graves disease presenting with palpitations, weight loss, and positive thyroid stimulating hormone receptor antibody, and a man with rapid weight loss but no typical symptoms or eye signs who was initially misdiagnosed and treated with antithyroid drugs, later confirmed as painless thyroiditis with spontaneous recovery. These cases underscore the importance of integrating clinical history, physical findings, thyroid function tests, autoantibody assays, ultrasonography, and thyroid scan in the diagnostic process, while emphasizing that short-term follow-up can be decisive in ambiguous cases. Indiscriminate use of antithyroid drugs should be avoided, as careful stepwise evaluation and observation are essential for accurate diagnosis and safe management of patients with thyrotoxicosis.

Diagnosis of Pancreatic Cystic Neoplasms: Clinical Utility of Endoscopic Ultrasound

Wed, 01 Oct 2025 00:00:01 +0100

Pancreatic cystic neoplasms (PCNs) are being detected with increasing frequency due to advances in imaging technology. The challenge for clinicians is accurately differentiating benign lesions from those with malignant potential, which is a crucial step in appropriate patient management. While modern cross-sectional imaging modalities, such as computed tomography and magnetic resonance imaging, are essential for initial screening, they often do not have the specificity required for a definitive diagnosis. Endoscopic ultrasound (EUS) has emerged as an invaluable tool that provides high-resolution images of internal cystic structures. However, the major advantage of EUS is the ability to facilitate a suite of advanced diagnostic techniques. This review explores the current landscape of EUS-based modalities for evaluating PCNs, including cyst fluid analysis, contrast-enhanced EUS, through-the-needle biopsy, and advanced visualization methods, such as needle-based confocal laser endomicroscopy and cystoscopy. We focused on the advantages, diagnostic performance, and limitations of each technique to provide a practical overview for clinical application.

Efficacy of Radiotherapy in Combination with Immune Checkpoint Blockade for Hepatocellular ...

Wed, 01 Oct 2025 00:00:01 +0100

Background/Aims: Hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is associated with poor prognosis and low response rates to standard atezolizumab plus bevacizumab therapy (atezo/bev). This study aimed to evaluate the safety and efficacy of radiation therapy (RT) in patients with HCC and PVTT receiving atezo/bev treatment. Methods: This retrospective cohort study included patients with HCC and PVTT treated at a tertiary referral center in Korea. Eligible patients had Child-Pugh class A liver function and an Eastern Cooperative Oncology Group performance status of ? 1, and were not candidates for surgical resection or loco-regional therapies. Cox regression analysis was used to identify predictors of progression-free survival (PFS) and overall survival (OS). Results: A total of 85 patients were included, 55 of whom received atezo/bev alone and 30 received atezo/bev combined with RT. There was no significant difference in disease control rate between the two groups (25% vs. 30%, p = 0.65), nor in PFS or OS (median PFS, 143 vs. 289 days, p = 0.17; median OS, 293 vs. 416 days, p = 0.16). However, subgroup analysis, excluding patients with main portal trunk invasion, showed that the addition of RT significantly improved both PFS (adjusted hazard ratio [aHR], 0.29; p = 0.002) and OS (aHR, 0.33; p = 0.01). No clinical or laboratory deteriorations were observed after RT. Conclusions: These findings suggest that the addition of RT to PVTT may be beneficial in patients with preserved liver function without main portal vein involvement.

Factitious Fever Presenting as Fever of Unknown Origin in a Young Woman: A Case Report

Wed, 01 Oct 2025 00:00:01 +0100

A 23-year-old woman presented with refractory anemia and a 1-month history of relapsing fever. The patient had been followed up at another hospital for fever of unknown origin and refractory anemia for 2 years. Upon admission to our hospital, repeated body temperature measurements and a nurses inspection revealed that the patient had been artificially heating the external auditory canal where the temperature was measured to simulate fever. No temperatures exceeding 38? were recorded after the nursing staff removed objects capable of altering measurements, confirming factitious fever as the cause. We report this case to highlight the importance to clinicians who care for patients with fever of unknown origin despite careful and appropriate evaluation.

Optimal Choice of Biologics and Small Molecules for Treating Women of Childbearing Age with ...

Mon, 01 Dec 2025 00:00:01 +0100

Inflammatory bowel disease (IBD), comprising Crohns disease and ulcerative colitis, commonly affects women of reproductive age. Therefore, the safety of therapeutic agents during pregnancy and lactation is a major clinical concern. Among available treatments, anti-tumor necrosis factor (TNF) agents are the most extensively studied, and recent large cohort studies and meta-analyses have demonstrated no significant increase in adverse outcomes such as miscarriage, preterm birth, congenital malformations, or neonatal infections with continued use during pregnancy. Evidence for newer biologics, including the anti-integrin agent vedolizumab and the anti-interleukin-12/23 agent ustekinumab, is more limited but increasingly reassuring, with population-based studies and registry data indicating safety profiles comparable to those of anti-TNF agents. In contrast, small molecule agents, such as Janus kinase (JAK) inhibitors (tofacitinib, filgotinib, upadacitinib) and sphingosine-1-phosphate (S1P) receptor modulators (ozanimod), raise greater concern due to their low molecular weight, potential for placental transfer, and teratogenic findings in animal studies, while human data remain scarce. Current international guidelines, including European and Australian consensus statements, recommend discontinuation of these small molecules prior to conception and avoidance during pregnancy and breastfeeding. In summary, current evidence supports the relative safety of biologics, particularly anti-TNF agents, for use during pregnancy in patients with IBD, while newer biologics require further confirmation, and small molecules are not recommended. Treatment decisions should be individualized, balancing maternal disease control, fetal safety, and patient preference to optimize outcomes in pregnant women with IBD.

Molecular Residual Disease Monitoring and Early Recurrence Prediction in Solid Tumors: Clinical ...

Mon, 01 Dec 2025 00:00:01 +0100

Recent advances in liquid biopsy technologies, particularly circulating tumor DNA (ctDNA) analysis, have enabled the sensitive and non-invasive detection of molecular residual disease (MRD) in solid tumors. This review summarizes the current clinical evidence and applications of MRD monitoring in solid cancers, focusing on colorectal cancer and non-small cell lung cancer (NSCLC). Tumor-informed and tumor-uninformed ctDNA assays are compared, highlighting their respective advantages and limitations. Landmark studies such as the DYNAMIC and GALAXY trials in colorectal cancer, and the TRACERx study in NSCLC, have demonstrated the prognostic value of ctDNAbased MRD detection for recurrence risk stratification and for guiding adjuvant therapy decisions. Ongoing research and standardization efforts are expected to further establish MRD assessment as an integral component of precision oncology.

Roles of Internal Medicine Physicians in Antimicrobial Stewardship

Mon, 01 Dec 2025 00:00:01 +0100

Antimicrobial resistance (AMR) is a global health concern. Antimicrobial stewardship programs (ASPs) are essential for combating AMR. However, the implementation of an ASP in Korea is still in the early stages. Internal medicine (IM) physicians are crucial as both prescribers and ASP leaders within healthcare institutions given the lack of infectious disease (ID) physicians. This review explores the key roles of IM physicians in ASPs, drawing from various successful international cases in which IM physicians engaged in ASPs with and without ID physician involvement. Targeted and detailed education is vital to widen the roles of IM physicians in ASPs and foster appropriate antibiotic prescribing behaviors. Furthermore, ID-physician-guided networks can facilitate the nationwide expansion of ASPs. Finally, reforming the reimbursement system and introducing incentives are necessary to promote ASP adoption and sustainability in Korea.

Diagnosis and Treatment of Multidrug/Rifampicin-Resistant Tuberculosis

Mon, 01 Dec 2025 00:00:01 +0100

To rapidly diagnose multidrug/rifampicin-resistant tuberculosis (MDR/RR-TB), all individuals suspected of having tuberculosis should undergo the Xpert MTB/RIF assay or an equivalent test capable of simultaneously detecting Mycobacterium tuberculosis and rifampicin resistance. Upon confirmation of rifampicin resistance, treatment for MDR/RR-TB should be initiated promptly, with preference given to shorter treatment regimens, such as BPaLM, MDR-END, or BPaL. Medications included in each regimen should be administered at the recommended dosages and for the entire treatment duration. Careful monitoring and management of potential adverse effects, including bone marrow suppression, peripheral neuropathy, optic neuritis, and QT interval prolongation are essential. The advent of shorter regimens has made MDR/RR-TB treatment more convenient and accessible for many patients. However, to further improve treatment outcomes and reduce the prevalence of MDR/RR-TB in Korea, comprehensive patient-centered management should be integrated across all stages of diagnosis and treatment.

Diagnosis Using Dynamic Renal Scintigraphy

Mon, 01 Dec 2025 00:00:01 +0100

Renal scintigraphy is a non-invasive, widely available diagnostic tool that provides critical information on genitourinary system function and morphology. Dynamic renal scintigraphy evaluates renal function by imaging renal perfusion, glomerular filtration, or tubular function, and by providing time-activity curves. A notable application is diuretic renal scintigraphy, which distinguishes between obstructive and nonobstructive systems by inducing increased urine flow via diuretic administration. Comprehensive understanding of the preparation, image acquisition, and analytical methodologies associated with dynamic renal scintigraphy is thus essential. Familiarity with and access to dynamic renal scintigraphy is invaluable for diagnosing and managing patients, and ultimately improving clinical outcomes.

Trends in the Characteristics of Patients with Lung Cancer in Incheon, Republic of Korea: A ...

Mon, 01 Dec 2025 00:00:01 +0100

Background/Aims: This study aimed to analyze the changes in the demographic and clinical characteristics of patients with lung cancer in Incheon, South Korea from 2013 to 2020. By examining these trends, this study aimed to uncover regional patterns of lung cancer incidence and inform public health strategies and screening policy. Methods: A population-based sample of 1,152 patients with lung cancer was obtained from the Incheon Cancer Registry. Patient data included age, sex, smoking history, histology, clinical stage, and epidermal growth factor receptor (EGFR) mutation status. Histological subtypes were classified according to the International Classification of Diseases for Oncology, 3rd edition. Temporal trends in demographic and tumor characteristics were analyzed using the linear-by-linear association test. Results: The median age of patients with lung cancer was 70 years, with a significant increase in the proportion of patients aged ? 60 years (p < 0.001). The proportion of female patients slightly increased from 22.0% to 35.5% during the study period (p = 0.130). Adenocarcinoma was the predominant histological subtype (56.9%), with its proportion increasing to 62.7% by 2020 (p = 0.035). Early stage diagnoses (stage I) significantly increased over time (p < 0.001), whereas smoking history (p = 0.189) and EGFR mutation (p = 0.054) prevalence showed no significant changes. These trends were similar to those observed in the Korea Central Cancer Registry. Conclusions: The findings revealed significant demographic and clinical shifts in patients with lung cancer in Incheon, including an increasing proportion of older and female patients, increased early stage diagnoses, and growing adenocarcinoma prevalence. These trends underscore the need for tailored public health interventions, expanded low-dose computed tomography screening programs, and strategies targeting non-smoking-related risk factors to optimize lung cancer prevention and management.

A Lethal Case of Monomorphic Epitheliotropic Intestinal T-Cell Lymphoma Presented as ...

Mon, 01 Dec 2025 00:00:01 +0100

Intestinal T-cell lymphoma is an uncommon type of non-Hodgkin lymphoma that primarily affects the gastrointestinal tract. Among the known subtypes, monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) is a particularly aggressive form characterized by poor prognosis and high mortality. Its rarity and diverse clinical presentations hinder clinical research and the establishment of standardized treatment protocols. Additionally, the treatment response and overall survival rates are typically very low. Herein, we report the case of a 70-year-old man who was referred for evaluation of an asymptomatic colonic ulcer that could not be diagnosed by colonoscopic biopsy but was finally identified as MEITL following surgical resection. Although the patient was diagnosed relatively early during clinical evaluation, treatment initiation was delayed owing to intestinal perforation. Several clinical findings should be considered when diagnosing MEITL. First, early diagnosis is necessary for prompt treatment. Second, gastrointestinal lymphoma should be suspected in patients with atypical or unexplained gastrointestinal findings. When endoscopic biopsy is feasible, like in this case, careful sampling is essential. Lastly, even with early diagnosed, prompt therapeutic intervention is crucial, as MEITL can progress rapidly.

Do We Really Need More Medical Schools or Doctors in Korea?

Thu, 01 Feb 2024 00:00:01 +0100

Recently, several social issues have raised public concerns about a deficiency of doctors. The government says it will solve the problem by increasing the number of doctors, saying essential medical service is collapsing. However, the medical community argues that there is a fundamental problem with Koreas health care delivery system. The government needs to take advice from the medical community to make policies in the right direction. And the press should no longer provide the public with misinformation that doctors and the public are opposed to. In this article, I would like to mention problems among current medical services and suggest healthcare policies for them.

Trends of Endoscopic Palliation for Advanced Malignant Hilar Biliary Obstruction

Thu, 01 Feb 2024 00:00:01 +0100

Malignant hilar biliary obstruction (MHO), an aggressive type of perihilar biliary obstruction caused by cholangiocarcinoma, gallbladder cancer, or other metastatic malignancies, has a poor prognosis. Surgical resection is the only curative treatment for biliary malignancies. However, most patients with MHO cannot undergo surgery upon presentation because of their advanced inoperable state or poor performance resulting from old age or comorbid diseases. Therefore, palliative biliary drainage is required to improve symptomatic jaundice and quality of life. Preoperative biliary drainage is controversial in resectable cases of MHO. Preoperative biliary drainage should be considered according to specific selection criteria. Palliative drainage is currently the mainstay of symptomatic treatment. Compared with percutaneous access, primary endoscopic palliation using plastic or metal stents has recently shown higher technical feasibility and clinical success without increasing the frequency of adverse events, even in high-degree MHO. However, the use of stents still has numerous limitations, including challenges in determining the optimal type of stent, number of stents, deployment method, and additional local therapies. Therefore, this report presents the current optimal endoscopic drainage status for MHO based on recent guidelines and published literature.

Diagnosis and Treatment of Myelodysplastic Syndrome in the Era of Genetic Testing

Thu, 01 Feb 2024 00:00:01 +0100

Myelodysplastic syndrome (MDS) is a heterogeneous disorder with diverse prognoses influenced by cytopenias, genetic variants, and myeloblast proportions in the bone marrow. Accurate prognosis prediction and tailored treatment plans are essential. The International Prognostic Scoring System-Molecular (IPSS-M), which additionally reflects the impact of MDS-related genetic mutations to the clinical and laboratory information, is anticipated to offer superior prognostic accuracy compared to existing systems like the Revised International Prognostic Scoring System (IPSS-R). Despite its statistical complexity, its web-based calculation and ease of discussing results with patients using intuitive data sets provide notable advantages. Progress in MDS treatment, exemplified by effective anemia correction with an erythropoiesis-maturation agent in SF3B1-mutated cases and efforts to refine poor prognoses in TP53-mutated cases, reflects the evolving landscape of genetic-based interventions in MDS. Advancements in genetic diagnostic technology, combined with enhanced knowledge of the bone marrow niche, are anticipated to lead to significant improvement in MDS treatment outcomes in the future.

Diagnosis and Treatment of Premature Atrial or Ventricular Complexes

Thu, 01 Feb 2024 00:00:01 +0100

Premature atrial complex (PAC) and premature ventricular complex (PVC) are the most common arrhythmias. Most of them are benign, whereas some could be an initial sign of any underlying significant heart disease. Evaluation of daily burden and the presence of any association with underlying medical conditions are essential for proper assessment. Recently, newly developed electrocardiogram smart devices are widely available to document arrhythmias and identify correlations with symptoms. Management is required if the daily burden is high, patients are highly symptomatic, or significant structural heart disease is present. Antiarrhythmic drugs (AADs) are the first-line treatment, but if arrhythmias are drug-refractory or the patients are intolerable to AADs, catheter ablation is considered a good alternative in selected cases. In this paper, the proper diagnosis and management for PAC and PVC will be comprehensively reviewed.

A 32-Year-Old Female with Incidentally Detected Multifocal Cystic Pulmonary Lesions on Chest ...

Thu, 01 Feb 2024 00:00:01 +0100

Lymphangioleiomyomatosis (LAM) is a rare condition that exclusively affects women and is characterized by lung parenchymal destruction and the formation of cysts due to infiltration by LAM cells. It can also impact the lymphatic system, leading to the development of fluid-filled cystic structures and abdominal involvement, including renal angiomyolipomas (AML) or lymphangioleiomyoma. LAM can occur sporadically or be associated with tuberous sclerosis complex. Common symptoms include respiratory issues such as dyspnea, pneumothorax, chylothorax, along with other manifestations like renal AML and lymphatic involvement. The diagnosis of LAM relies on a combination of clinical, radiological, and laboratory findings, and treatment options vary depending on symptoms and patient status, with mTOR inhibitors being considered as a treatment option. This case outlines the diagnostic journey and clinical course of a 32-year-old female patient with LAM.

Diagnosis of Human Immunodeficiency Virus Infection

Thu, 01 Feb 2024 00:00:01 +0100

Early diagnosis and early treatment of human immunodeficiency virus (HIV) infection are essential for clinical and public health benefits. Diagnostic algorithms for early diagnosis are being emphasized, and rapid tests at the point of care have been expanded to improve voluntary testing rates. Despite advances in laboratory diagnostic tests, early HIV infection can still be missed due to window periods, and it is crucial to recognize the limitations of testing methods and the potential for false negative and false positive results.

Single-Center Real-World Experience with Primary Central Nervous System Lymphoma in the 21st Century

Thu, 01 Feb 2024 00:00:01 +0100

Background/Aims: In Korea, the incidence of primary diffuse large B-cell lymphoma of the central nervous system (PCNSL) is increasing and autologous stem cell transplantation (ASCT) has improved the survival of younger patients. We explored our real-world experience with PCNSL at Asan Medical Center (AMC). Methods: We used the AMC lymphoma registry to collect patient data prospectively. We analyzed 279 patients diagnosed from 2002 until August 2019. Results: The PCNSL incidence at AMC increased progressively and comprised 7.4-8.9% of new non-Hodgkin lymphoma patients annually during the most recent 4 years. The median age was 60 years (range, 17-85) and males comprised 55%. Patients under 65 years of age (n = 183) had no significant differences in characteristics compared to those aged 65 years or over, with the exception of less occipital lobe involvement and lower beta-2 microglobulin levels. Rituximab, methotrexate, procarbazine, and vincristine (R-MPV) combination induction had the best overall response, of 95%. The median overall survival was 3.8 years with 5- and 10-year survival rates of 41.5% and 30.2%, respectively. Survival was better in younger patients and those treated with ASCT. Thiotepa, busulfan, and cytoxan (TBC) conditioning chemotherapy had better survival than other combinations. The International Extranodal Lymphoma Study Group and Memorial Sloan Kettering Cancer Center prognostic score systems were valid in this cohort. Age and performance status were independent prognostic factors. Exclusive extra-central nervous system failure occurred in six patients (5.6%) among 107 failures. Conclusions: The incidence of PCNSL is rising. R-MPV induction therapy followed by ASCT with TBC has improved the survival of young, fit PCNSL patients.

Multiple Intramuscular Abscesses Caused by Nocardia abscessus in a Patient with Chronic ...

Thu, 01 Feb 2024 00:00:01 +0100

Nocardiosis is uncommon. Immunocompromising conditions predispose individuals to pulmonary and disseminated nocardiosis of the brain, skin, and subcutaneous tissues. The most common pathogens are Nocardia cyriacigeorgica, Nocardia nova, and Nocardia farcinica. The speciation of Nocardia to determine antimicrobial susceptibility is difficult using traditional biochemical methods. Here, we report the case of a 73-year-old man with chronic obstructive lung disease who developed a rapidly progressing intramuscular abscess around the left hip and thigh. Within 3 days, the lesions progressed to an epidural abscess at the L4 to S1 level. Although he was treated with broad-spectrum antibiotics and extensive incision and drainage, he died of rapidly progressive respiratory failure. Nocardia abscessus (N. abscessus) was identified in pus samples using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). This case shows that the diagnosis of an intramuscular abscess caused by N. abscessus is challenging and that using MALDI-TOF MS may facilitate the diagnosis and ensure appropriate treatment.

Establishing a Practical Loco-Regional Transfer System for Patients with Acute Cardiac Chest Pain

Mon, 01 Apr 2024 00:00:01 +0100

Cardiac disease is the second leading cause of mortality in Korea and the main cardiac disease is acute myocardial infarction (MI). Timely primary coronary intervention is the main treatment for acute MI and delay from symptom onset to intervention is the most important determinant of the prognosis and incidence of ischemic cardiomyopathy after acute MI. Treatment delay includes patient delay and system delay. The latter includes transfer and in-hospital delays. In-hospital delay improved greatly after introducing the critical pathway to Korea. However, there is still much room to improve patient and transfer delay.

Sodium-Glucose Cotransporter 2 Inhibitors for Chronic Kidney Disease: A Comprehensive Review

Mon, 01 Apr 2024 00:00:01 +0100

Chronic Kidney Disease (CKD) is a major global health burden. Sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated potential in slowing CKD progression. We evaluated the expanding role of SGLT2 inhibitors, emphasizing their renoprotective benefits in diabetic and non-diabetic CKD patients. We also investigated the underlying mechanisms, including the reduction of glomerular hypertension via modulation of tubuloglomerular feedback. Our study critically analyzed current indications for SGLT2 inhibitor therapy based on recent clinical trial data. To optimize patient outcomes, we present a comprehensive analysis of practical considerations for the prescription of SGLT2 inhibitors, including the potential initial decline in the estimated glomerular filtration rate and a review of adverse events.

Diagnosis, Clinical Course and Treatment of Hypersensitivity Pneumonitis

Mon, 01 Apr 2024 00:00:01 +0100

Hypersensitivity pneumonitis (HP) is an inflammatory and fibrosing interstitial lung disease caused by inhaled antigens in susceptible individuals. Various environmental materials can serve as inciting agents of HP. Recent guidelines have defined typical radiologic and histopathologic findings of HP, classifying it into nonfibrotic and fibrotic HP categories, as this classification better correlates with clinical outcomes. Diagnosing HP poses challenges, necessitating multidisciplinary discussions based on clinical assessments and radiologic or histopathological features. The cornerstone of treatment lies in avoiding the causative antigen. Oral glucocorticoids serve as the initial treatment for symptomatic HP. Immunosuppressants may be employed in patients who do not respond to initial treatment, and antifibrotics could be considered for patients displaying progressive fibrosis. This review outlines the clinical features, diagnostic evaluation, and treatment of HP.

Recent Progression of Incretin-Based Obesity Treatment

Mon, 01 Apr 2024 00:00:01 +0100

Incretin-based obesity treatments are making remarkable progress, marking a new era in the field of obesity pharmacotherapy. These treatments not only meet the long-standing demands for safety and sustainability in obesity medications but also go beyond, significantly improving complications associated with obesity, such as cardiovascular diseases. This review explores the advancement in obesity treatments through the latest research findings on semaglutide and tirzepatide, two incretin-based obesity treatments currently receiving considerable attention.

Human Understanding is Expected of the Physician: Proposing a Model of Disease Development

Mon, 01 Apr 2024 00:00:01 +0100

In Harrisons Principles of Internal Medicine, human understanding is emphasized as one of three necessary characteristics that a physician must have. Inflammation, which is caused by inflammatory inducers (inf-ids), is a fundamental feature of disease at the cellular and molecular levels. Inflammation protects the body, but excessive or prolonged inflammation can be damaging and can cause disease. Humans are repeatedly exposed to external and internal environmental factors that generate inf-ids throughout their lives. External environmental factors include microbial and non-microbial inf-ids, as well as stressors that inevitably arise during social interactions. Internal environmental factors include the adaptive physiological response that is present from birth. Inf-ids may also be produced by the four-step habit loop, which consists of a cue (e.g., stressor), emotions, routine act (adaptive response), and a reward. Immune cells in the circulatory system and in tissues may have positive and negative effects in inflammatory responses. However, low-grade inflammation may be difficult to detect. We propose a model of disease development that integrates external and internal environmental factors from the perspective of human understanding.

Targeted Therapy of Advanced Non-Small Cell Lung Cancer

Mon, 01 Apr 2024 00:00:01 +0100

Lung cancer is the leading cause of cancer death in Republic of Korea. After their initial diagnosis, only 10-20% of patients with advanced non-small cell lung cancer (NSCLC) survive for 5 years of longer. Given enormous advances in therapeutics such as novel targeted therapies and immunotherapies, survival rates are improving for advanced patients with NSCLC; 5-year survival rates range from 15% to 50%, contingent upon the biomarker. Detection of the specific molecular alteration as biomarker is thus crucial for identifying subgroups of NSCLC that contain therpapeutically targetable oncogenic drivers. This review examines the process of diagnosing lung adenocarcinoma with dominant biomarkers in order to customize treatment with appropriate targeted therapy.

Various Diagnostic Methods for Helicobacter pylori Infection

Mon, 01 Apr 2024 00:00:01 +0100

Helicobacter pylori (H. pylori) is a bacterium that colonizes the human stomach, leading to various gastrointestinal diseases including gastritis, peptic ulcers, and gastric cancer. There is no gold standard test that relies entirely on one method in H. pylori diagnosis. We must be aware of the pros and cons of various testing methods to perform an appropriate test according to the situation. Accurate diagnosis and eradication therapy are essential for disease management. Diagnostic methods include invasive techniques like tissue biopsy and rapid urease test, as well as non-invasive tests such as urea breath test, serology test, and stool antigen test. Each method has its advantages and limitations, requiring careful consideration in clinical practice. Understanding these diagnostic tools is crucial for effective H. pylori management and prevention of associated complications.

A Case of Metapneumovirus Pneumonia-Related Acute Respiratory Distress Syndrome in a Young ...

Mon, 01 Apr 2024 00:00:01 +0100

Human metapneumovirus (hMPV) infections commonly present as mild upper respiratory tract infections in healthy adults, although severe respiratory complications have been observed, particularly in elderly and immunocompromised patients. We report a case in whom pneumonia caused by hMPV progressed to acute respiratory distress syndrome (ARDS) in a healthy adult without underlying diseases. A 31-year-old female presented with fever and dyspnea, prompting transfer to our hospital for mechanical ventilation 3 days after symptom onset. Auscultation revealed coarse breath sounds and crackles in both lung fields, and chest X-ray showed non-specific infiltrative nodules with poorly defined borders throughout both lungs. ARDS caused by community-acquired pneumonia was diagnosed. hMPV was identified via rapid testing of respiratory samples for genes that encode pneumonia pathogens and drug resistance markers; we employed reverse transcription polymerase chain reactions to these ends. Six days later, the patient was weaned off the mechanical ventilator, and discharged from the hospital in good clinical condition.

Polyarteritis Nodosa Confined to the Kidneys in a Patient with Proteinuria and Mild Renal Impairment

Mon, 01 Apr 2024 00:00:01 +0100

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis predominantly involving medium- or small-sized arteries, typically of the kidneys and other internal organs. Given the rarity of PAN and the variable clinical presentation, diagnosis is challenging and, to date, no definitive diagnostic marker has been identified. A patient diagnosed with immunoglobulin A nephropathy was observed to exhibit deterioration in renal function. To determine whether new structural abnormalities had developed, computed tomography scans of the kidneys, ureters, and bladder were obtained. Both kidneys exhibited multiple cortical defects, and a renal angiogram was performed to determine the cause. Angiography revealed partial obliteration of the left distal renal artery branches and multifocal extensive infarctions in both kidneys, and the patient was diagnosed with renal-limited PAN. Following steroid monotherapy, an improvement in renal function was observed. We believe that this case report may be helpful to physicians who assess and treat patients with suspected renal-limited PAN.

Missed Opportunities for Urate Lowering Therapy after Gout Flares in Frail Patients Living Alone

Mon, 01 Apr 2024 00:00:01 +0100

The Opportunity for Educational Innovations and Requirements in Academic System Reform of ...

Sat, 01 Jun 2024 00:00:01 +0100

The amendment to the Higher Education Act enforced on February 20, 2024, abolishing the traditional 2-year pre-med and 4-year medical school programs, marks a significant shift in medical education in Korea. The academic system reform is expected to be a driving force for large-scale curriculum revision, presenting an opportunity to introduce new educational innovations not only in curriculum but also in student assessment and support systems. Addressing these challenges requires collaborative efforts among educators, students, and communities to navigate the evolving landscape of medical education effectively. In this regard, I will illustrate the recruitment and development of educators to implement the reform and the collaboration between communities and medical schools to innovate medical education.

Diagnosis and Management of Subclinical Hypothyroidism: The 2023 Clinical Practice Guideline, ...

Sat, 01 Jun 2024 00:00:01 +0100

Subclinical hypothyroidism (SCH) is characterized by elevated serum thyroid-stimulating hormone (TSH) levels and normal free thyroxine levels. The Korean Thyroid Association recently issued guidelines for managing SCH. Based on the Korea National Health and Nutrition Examination Survey (2013-2015), a serum TSH level of 6.8 mIU/L is the reference value for SCH. SCH is classified as mild (TSH 6.8-10.0 mIU/L) or severe (TSH > 10.0 mIU/L), and patients are categorized as adult (age < 70 years) or elderly (age ? 70 years). Levothyroxine treatment (LT4-Tx) is not recommended for mild or even severe SCH in elderly patients. Immediate LT4-Tx can be given to adults in most cases, but not to women who are pregnant, patients with progressive disease, or patients with underlying coronary artery disease, heart failure, or dyslipidemia.

Updated Guidelines for Acute Coronary Syndrome

Sat, 01 Jun 2024 00:00:01 +0100

Despite medical and invasive advancements, cardiovascular mortality attributable to ischemic heart disease, including acute coronary syndrome (ACS), persists at a substantial level. Clinical guidelines have been issued by the European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association to support clinicians in making appropriate decisions and improving the prognosis of ACS patients. ESC recently introduced a new ACS guideline in August 2023. This review discusses the recent modification in the diagnosis and management of early-phase ACS in the 2023 ESC guideline.

Jaundice That Has Persisted for 5 Days

Sat, 01 Jun 2024 00:00:01 +0100

Hepatitis B virus (HBV) reactivation associated with various therapeutic interventions is a significant cause of morbidity and mortality among patients with current or resolved HBV infection. Since no curative treatment for HBV infection is currently available, a large number of individuals in the general population are at risk for HBV reactivation. Populations vulnerable to HBV reactivation include those currently infected with HBV or those who have had past exposure to the virus. The potential consequences of HBV reactivation are particularly concerning when these populations undergo anti-cancer chemotherapy, immunosuppressive or immunomodulatory therapies for managing various malignancies, rheumatologic diseases, inflammatory bowel disease, or undergo solid-organ or hematologic stem cell transplantation. This article aims to increase awareness of HBV reactivation and to elucidate the mechanisms and risks associated with HBV reactivation in various clinical settings.

Clinical Significance and Interpretation of Allergen-Specific IgE Testing in Regard to Food Allergy

Sat, 01 Jun 2024 00:00:01 +0100

Food allergy is an adverse reaction that occurs after ingesting food and is caused by an aberrant immune response. Taking a detailed medical history is the most important part of diagnosing food allergies. When an immunoglobulin E (IgE)-mediated food allergy is suspected, food-specific IgE testing can confirm the diagnosis. Allergen skin-prick tests or serum tests for specific IgE should be considered as the first line of testing, and depending on the offending food, a further prick-to-prick test with fresh food or a component-resolved diagnostic test may be helpful. Interpretation of the results should be based on the patients medical history.

Non-carbapenem Drugs for Patients with Bacteremia caused by Extended-Spectrum ...

Sat, 01 Jun 2024 00:00:01 +0100

Background/Aims: Carbapenems are recommended for treating bacteremia caused by extended-spectrum ?-lactamase (ESBL) producing Enterobacteriaceae (ESBL-E). However, this has resulted in a significant rise in the utilization of carbapenems in cases of ESBL-E infection. We evaluated the clinical outcomes of patients with ESBL-E bacteremia treated with non-carbapenem antimicrobials. Methods: We conducted a retrospective case-control study of a cohort of patients with documented ESBL-E bacteremia from January 2021 to December 2021. The patients were divided into two groups according to whether they received non-carbapenem or carbapenem therapy. The rates of treatment failure, 30-day mortality and microbiologic failure, and the durations of hospitalization and of antimicrobial therapy were compared between the two groups. Antimicrobial susceptibility testing and phenotypic identification of ESBL-E were performed using the Vitek 2 system. Results: Of 118 patients with ESBL-E bacteremia, 54 received non-carbapenem drugs (non-carbapenem group [NCG]) and 64 received carbapenems (carbapenem group [CG]). Treatment failure at 30 days occurred in 16.7% of the patients in the NCG and in 18.8% in the CG (p = 0.65). The 30-day mortality rate was 14.8% in the NCG and 17.2% in the CG (p = 0.63). Extra-urinary tract infection and prior antimicrobial therapy within 30 days were risk factors for treatment failure in patients with ESBL-E bacteremia. The clinical outcomes did not differ significantly between the two groups, challenging the prevailing preference for carbapenems in the treatment of ESBL-E bacteremia. Conclusions: Non-carbapenem antimicrobials such as piperacillin/tazobactam are recommended for patients with mild ESBL-E bacteremia in South Korea.

A Rare Case of Acute Pyelonephritis Leading to Bilateral Subcapsular Renal Hematoma: A Case Report

Sat, 01 Jun 2024 00:00:01 +0100

This case underscores the rarity of bilateral subcapsular renal hematoma (SCH) as a complication of acute pyelonephritis, and this is the first reported case in South Korea. SCH can have various underlying causes, including cysts, bleeding tendencies, cancer, vascular diseases and, less commonly, infections. A patient with uncontrolled diabetes mellitus and alcohol dependency presented with weakness. Bilateral SCH from acute pyelonephritis was diagnosed and treated with antibiotics and renal replacement therapy. Despite improved renal function, 30-day bilateral percutaneous drainage was necessary due to a persistent fever and elevated infection markers, resulting in a bloody, pus-like discharge. This case report sheds light on the rare etiology of bilateral SCH as a result of acute pyelonephritis. It serves as a reminder of the critical importance of timely intervention, to prevent deteriorating outcomes.

Various Diagnostic Methods for Helicobacter pylori Infection

Sat, 01 Jun 2024 00:00:01 +0100

Do Elderly Patients Need Dialysis?

Thu, 01 Aug 2024 00:00:01 +0100

Initiating dialysis at an advanced age is both a clinical challenge and an ethical dilemma, because the benefits in older adults with advanced chronic kidney disease may be offset by high rates of dialysis-related morbidity. Geriatric conditions, such as aging, frailty, functional impairment, and cognitive impairment, significantly influence the prognosis of elderly patients. Therefore, it becomes important to provide patients and families with prognostic information regarding timing of initiation, which is further complicated by the competing mortality risk. Shared decision-making by clinicians and patients can yield better clinical outcomes and quality of life. Through this approach, patients can opt for the most appropriate treatment based on their personal values, which often entails conservative management.

Immunopathogenesis of Non-Tuberculous Mycobacteria Lung Disease

Thu, 01 Aug 2024 00:00:01 +0100

In recent years, the incidence and prevalence of non-tuberculous mycobacteria lung disease (NTM-LD) has been increasing worldwide. In Korea, Mycobacterium avium complex (MAC) and Mycobacterium abscessus complex account for most common cause of NTM-LD. It is essential to elucidate the pathophysiology of NTM-LD. The pathophysiology of NTM-LD has not been fully understood, however, it can be divided into bacterial and host-side factor. Among the host factor, innate immunity plays an essential role in the initial host immune response against intracellular non-tuberculous mycobacteria (NTM), and adaptive immunity also has a role. However, the role of these immunity in mycobacterial disease has been mainly studied in tuberculosis, but studies on its role in NTM are limited. In this review, I focus on NTM innate and adaptive immunity, the role of macrophages and neutrophils, and host interaction in NTM infection.

What is Different about Recombinant Herpes Zoster Vaccine?

Thu, 01 Aug 2024 00:00:01 +0100

Herpes zoster (HZ) affects about one in three persons in their life time. Compared with the general population, older adults with immune senescence and individuals who are immunocompromised therapy are at increased risk for HZ, and its debilitating complications. To prevent HZ, two HZ vaccines, zoster vaccine live (ZVL) and recombinant zoster vaccine (RZV) are available. RZV is The Korean Society of Infectious Diseases revised guidelines for HZ vaccine in 2023, and recommended to vaccinate with RZV for adults ? aged 50 years and for severely immunocompromised adults aged ? 18 years. RZV is more effective for prevention of HZ than ZVL. RZV is nonreplicating and is thus safe in immunocompromised patients. RZV has clinically acceptable safety profile. This review will help clinicians update knowledge about RZV and identify eligible subjects who may benefit from HZ vaccinations.

A New Korean Nomenclature for Steatotic Liver Disease

Tue, 23 Jul 2024 00:00:01 +0100

Role of Hospital Medicine in Perioperative Patients: Surgery 101

Thu, 01 Aug 2024 00:00:01 +0100

Due to their increasing role, many hospitalists will in the future encounter perioperative patients, either through surgical co-management or when an admitted patient requires surgery. If given the responsibility, hospitalists should focus not only on assessing and addressing daily acute issues related to medical comorbidities, but also possess basic knowledge of the typical physiological responses after surgery, prediction, evaluation, and management of perioperative bleeding, and identification of postoperative complications. Understanding these topics may help mitigate complications and improve the management of perioperative patients.

Endoscopic Diagnosis and Treatment of Benign Small Bowel Stricture

Thu, 01 Aug 2024 00:00:01 +0100

Benign small bowel strictures can occur in association with various conditions, including small bowel Crohns disease, nonsteroidal anti-inflammatory drug-induced enteritis, ischemic enteritis, intestinal tuberculosis, radiation enteritis, postoperative adhesions, and anastomotic strictures. Benign small bowel strictures are classified into two categories, low-grade and high-grade. Low-grade small bowel strictures involve a partial reduction of the internal diameter of the small intestine, causing slight obstruction of the passage of food and digestive fluids without significant bowel obstruction symptoms. By contrast, high-grade small bowel strictures involve a severe narrowing of the intestinal lumen, leading to marked obstruction of the passage of food and digestive fluids and pronounced bowel obstruction symptoms. Small bowel strictures can be diagnosed using various methods, including abdominal plain radiography, abdominal computed tomography, computed tomography enterography, magnetic resonance enterography, balloon-assisted enteroscopy, and abdominal ultrasound. Each diagnostic method has unique advantages and disadvantages as well as differences in diagnostic specificity and sensitivity. Therefore, even if small bowel strictures are not observed using a single imaging technique, their presence cannot be completely excluded. A comprehensive diagnosis that combines clinical information from multiple diagnostic modalities is necessary. Therapeutic approaches for managing small bowel strictures include medical therapy, endoscopic balloon dilation using balloon-assisted enteroscopy, and surgical methods such as strictureplasty and segmental resection. Endoscopic balloon dilation, in particular, can help reduce complications associated with repeated surgeries for strictures.

Diagnosis of Narrow QRS Tachycardia

Thu, 01 Aug 2024 00:00:01 +0100

Narrow QRS tachycardia is a common clinical condition characterized by a heart rate exceeding 100 beats per minute and a QRS complex duration of less than 120 ms. This article provides an overview of the diagnostic approach to narrow QRS tachycardia, focusing on the differentiation between various supraventricular tachycardias, such as atrioventricular nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), atrial tachycardia (AT), and sinus tachycardia. The discussion includes an analysis of the presenting symptoms, electrocardiographic (ECG) findings, and the use of vagal maneuvers and pharmacological agents in diagnosis.

Gastrointestinal Symptoms in Diabetes Occur Long before Diabetic Complications

Thu, 01 Aug 2024 00:00:01 +0100

Background/Aims: Gastrointestinal (GI) manifestations are common in patients with diabetes complications, such as autonomic neuropathy. However, the prevalence of GI symptoms before the development of diabetes complications is unclear. Methods: We conducted an interview survey of functional GI disorders among patients with diabetes visiting the endocrinology clinic of a general hospital using the Rome III criteria. The survey consisted of questions regarding functional dyspepsia, irritable bowel syndrome, and functional constipation, including functional defecation disorder. Results: In total, 509 patients were included in the analysis. The patients were divided into three groups: prediabetes (n = 115), diabetes without neuropathy (n = 275), and diabetes with neuropathy (n = 119). With regard to GI symptoms, the prevalences of functional dyspepsia in the prediabetes, diabetes without neuropathy, and diabetes with neuropathy groups were 16.52%, 27.27%, and 23.53%, respectively; those of irritable bowel syndrome were 8.70%, 11.68%, and 16.81%, respectively, and those of functional constipation were 8.85%, 11.85%, and 15.25%, respectively. In the subgroup analysis, symptoms of postprandial distress syndrome (e.g., postprandial fullness and early satiety) were more prevalent than symptoms of epigastric pain. In the constipation group, symptoms of pelvic outlet obstruction (such as the sensation of anorectal obstruction or blockage and the need for manual maneuvers to facilitate defecation) were more prevalent than symptoms of slow-transit constipation. Conclusions: The prevalence of functional GI disorders increases with diabetes severity. Diabetes-related GI symptoms appear long before the onset of diabetes complications.

Emphysematous Prostatitis with an Abscess in a Hemodialysis-Dependent Patient with End-Stage ...

Thu, 01 Aug 2024 00:00:01 +0100

Emphysematous prostatitis with an abscess is an extremely rare but lethal infection, characterized by the accumulation of gas and purulent exudates. Due to its rarity, severity, and nonspecific presentation, prompt diagnosis and treatment are crucial to achieve favorable clinical outcomes. This report presents a 43-year-old male with hemodialysis-dependent end-stage kidney disease who reported a 3-day history of fever, urinary incontinence, dysuria, and dyspnea. His condition rapidly deteriorated due to septic shock caused by emphysematous prostatitis with an abscess. Following extensive treatment including long-term parenteral antibiotics, polymyxin B hemoperfusion filter treatment, abscess drainage via transurethral resection of the prostate, and suprapubic cystostomy, the patient successfully recovered.

Non-Invasive Evaluation of Liver Fibrosis

Thu, 01 Aug 2024 00:00:01 +0100

Proposed Solutions and Associated Problems Regarding the Shortage of Doctors in Essential ...

Tue, 01 Oct 2024 00:00:01 +0100

Recently, a sudden increase of 2,000 in the number of medical students has led to massive and prolonged strikes in medical fields. Although it remains controversial whether there is actually a shortage of doctors, many people, including physicians, agree that there is a shortage in essential medical fields. Recently, both the government and the Supreme Court have proposed several solutions in response to the problem. In this article, I would like to discuss the suggested solutions and their problems regarding the issue.

Recent Trends in Noninvasive Tests for Assessing Hepatic Fibrosis in Patients with Chronic ...

Tue, 01 Oct 2024 00:00:01 +0100

Hepatic fibrosis is a critical factor in predicting hepatocellular carcinoma occurrence and prognosis in patients with liver disease, making its accurate assessment essential for managing chronic liver disease. Traditionally, liver biopsy has been the standard method for evaluating hepatic fibrosis. However, due to its invasive nature and the limitation of sampling only a small portion of the liver, it is not suitable for widespread use in chronic liver disease patients. Recently, there has been growing interest in noninvasive tests for assessing hepatic fibrosis, including imaging techniques and serum biomarkers. These noninvasive tests are being continuously developed and are increasingly being utilized to evaluate the prognosis of chronic liver disease patients and to inform clinical practice. This paper reviews the recent trends in noninvasive methods for assessing hepatic fibrosis in patients with chronic liver disease, based on studies published to date.

Clinical Outcomes of Peptic Ulcer Bleeding

Tue, 01 Oct 2024 00:00:01 +0100

Despite advancements in endoscopic technology and drug therapy, the high mortality and rebleeding rates associated with hemorrhagic peptic ulcers remain a concern. Although further research is needed to validate contributing factors, I recommend use of the Rockall score to predict the rebleeding risk in patients with peptic ulcers. Greater caution should be exercised, particularly in hospitalized patients, those who have undergone pancreatic surgery, and those with bleeding due to Dieulafoys lesions. Delaying resumption of an oral diet for at least 24 hours after endoscopic bleeding control is also advisable.

Diagnosis and Treatment of Hematuria

Tue, 01 Oct 2024 00:00:01 +0100

Hematuria is a common manifestation caused by various factors such as infection, inflammation, trauma, urinary stone and malignancy. Hematuria reflects pathological state of urinary system. Isolated microscopic hematuria without any abnormalities besides of hematuria on urine microscopic examination usually presents a good clinical course or outcome. However, significant proteinuria or hypertension, which accelerates renal dysfunction, can often develop during follow-up period in patients with isolated microscopic hematuria. Compared with non-glomerular hematuria, glomerular hematuria shows several characteristic findings such as dysmorphic red blood cell (RBC) or RBC casts or significant proteinuria on urinalysis. If glomerular hematuria is strongly suspected, a kidney biopsy may be required to differentiate the cause of glomerulonephritis. In this review, we tried to review the differential diagnosis and diagnostic approach and treatment of hematuria.

Comparison of Clinical Outcomes between Drug-Eluting Balloons and Drug-Eluting Stents in ...

Tue, 01 Oct 2024 00:00:01 +0100

Background/Aims: Drug-eluting balloons (DEBs) represent a novel therapeutic approach for patients with small coronary artery disease. However, further studies are needed to compare the clinical efficacy of DEBs versus drug-eluting stents (DESs). Methods: In total, 492 patients (age, 67.9

Enterococcus hirae Bacteremia Secondary to Urinary Tract Infection: A Case Report

Tue, 01 Oct 2024 00:00:01 +0100

Enterococcus hirae (E. hirae) infection is an uncommon pathogen in human infections. Bacteremia due to E. hirae associated with urinary tract infection is uncommon. We present a case of E. hirae bacteremia in a young woman with no underlying comorbidities. This case report emphasizes the importance of considering E. hirae as a potential pathogen in urinary tract infections.

Review of Antibody-Drug Conjugates

Tue, 01 Oct 2024 00:00:01 +0100

Strategic Policy Framework for Ensuring the Sustainability of Essential Healthcare in Korea

Sun, 01 Dec 2024 00:00:01 +0100

South Koreas rapid economic growth over the past 50 years has significantly improved healthcare outcomes, with life expectancy rising from 62.3 years in the 1970s to 82.7 years in 2022. However, the sustainability of its high-performing healthcare system is increasingly uncertain. Healthcare expenditure as a percentage of GDP reached 9.7% in 2022, surpassing the OECD average, while the fertility rate dropped to 0.72, undermining the systems demographic foundation. Challenges include freezing health insurance premiums despite rising costs, short-term fiscal injections without thorough evaluation, and expanding the physician workforce without accounting for demographic changes. These policies risk overburdening future generations and escalating systemic financial pressures. To ensure sustainability, a shift in healthcare policy is necessary; from expanding services to managing limited resources and controlling demand. South Korea must adopt a strategic, long-term framework that balances current needs with future sustainability, ensuring its healthcare system remains equitable and resilient.

Ischemia with Non-Obstructive Coronary Arteries

Sun, 01 Dec 2024 00:00:01 +0100

Many patients with angina or evidence of myocardial ischemia on noninvasive tests have no obstructive coronary artery disease. Ischemia with non-obstructive coronary arteries (INOCA) has been underrecognized despite its association with poor quality of life and effect on cardiovascular events. Two major mechanisms, coronary microvascular dysfunction (CMD) and coronary vasospasm, are keys to INOCA pathophysiology. Although noninvasive tests, such as stress echocardiography, cardiac positron emission tomography, and cardiac magnetic resonance imaging, offer evidence of CMD, the gold standard for diagnosing INOCA is coronary angiography with a comprehensive physiological assessment and provocation test of coronary vasospasm. Here, we provide the etiology and pathophysiology of INOCA and guide for the diagnostic approach and treatment of INOCA.

Prevention and Screening of Vitamin D Deficiency

Sun, 01 Dec 2024 00:00:01 +0100

Vitamin D is one of the important factors in skeletal muscle and bone health, and has recently been associated to various metabolic and cardiovascular diseases. There have been studied of an association with vitamin D deficiency and various metabolic disease. However, results of the studies are not concluded. There are no unified recommendations on criteria, measurement, and preventive supplementation for vitamin D deficiency. Recently, the US Preventive Services Task Force in 2021 and the Endocrine Society in 2024 addressed including evaluation, treatment, and prevention for vitamin D deficiency. This review examines the screening and prevention of vitamin D deficiency according to recent guidelines.

Endoscopic Management of Benign Pancreatic Stricture Associated with Chronic Pancreatitis

Sun, 01 Dec 2024 00:00:01 +0100

The most common symptom of chronic pancreatitis is abdominal pain. Potential causes include ductal hypertension due to pancreatic stricture, bile duct stricture, duodenal stricture, the presence of a pseudocyst, and increased nociception. In the management of main pancreatic ductal strictures associated with chronic pancreatitis, an endoscopic pancreatic sphincterotomy is typically performed, followed by stricture dilation and the insertion of a single plastic stent. If pancreatic stones are present, extracorporeal shockwave lithotripsy may also be necessary. After placing a plastic stent in the pancreatic duct, regular stent exchanges should be performed, maintaining stenting for approximately 1 year. For refractory pancreatic ductal stricture, the placement of multiple plastic stents or a fully covered metal stent may be considered. Although metal stents are effective, they are associated with a higher risk of adverse events, including stent migration, bile duct obstruction, and the formation of de novo pancreatic ductal strictures. This review discusses the endoscopic management of benign pancreatic ductal stricture associated with chronic pancreatitis.

Drug Allergy Delabeling

Sun, 01 Dec 2024 00:00:01 +0100

Drug allergy labels are critical for ensuring patient safety; however, unverified labels established without a rigorous diagnostic process can lead to suboptimal medication use, treatment failures, increased adverse drug reactions, and higher healthcare costs. In particular, unconfirmed penicillin allergy labels are strongly linked to the inappropriate use of broad-spectrum antibiotics, contributing to the rise of multidrug-resistant infections. The process of drug allergy delabeling enables many patients to safely use the medication in question, thereby facilitating the appropriate use of antibiotics and reducing unnecessary avoidance. Such delabeling is particularly vital as part of antimicrobial stewardship programs, as it enhances patient outcomes while decreasing healthcare expenses. Moving forward, the development of standardized procedures, enhanced awareness among patients and healthcare providers, and the implementation of validated risk-stratification methods is essential for more accurate and efficient drug allergy delabeling. These advancements will help mitigate the adverse effects of inaccurate labels and support optimal patient care.

Recurrent Submandibular Mass and Bilateral Periorbital Edema in IgG4-Related Disease: A Case Report

Sun, 01 Dec 2024 00:00:01 +0100

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated systemic disorder characterized by inflammatory, proliferative, and fibrotic lesions that can affect any body organ. The severity and extent of organ involvement vary significantly among individuals. Diagnosis of IgG4-RD necessitates a comprehensive assessment, including clinical presentation, radiological findings, laboratory tests, and histopathological examination. The 2019 American College of Rheumatology/European League Against Rheumatism classification criteria offer a valuable framework for diagnosing IgG4-RD. Although glucocorticoids and rituximab are the primary treatment options, the optimal long-term management strategy for IgG4-RD remains undetermined.

Bronchoalveolar Lavage and Its Interpretation

Sun, 01 Dec 2024 00:00:01 +0100

Bronchoalveolar lavage (BAL) is performed via bronchoscopy, typically under conscious sedation. It plays a crucial role in the differential diagnosis of lung disease, because it provides valuable information about the lung parenchyma, including cellular composition, the presence of microorganisms, and cytological features. Furthermore, BAL has therapeutic applications and is widely used in medical research. However, careful patient selection is required, because the diagnostic yield may vary and the procedure has inherent risks.

Percutaneous Kidney Biopsy: A Valuable Diagnostic Tool

Sun, 01 Dec 2024 00:00:01 +0100

Percutaneous kidney biopsy is a valuable diagnostic tool for the pathological evaluation of renal diseases, particularly glomerular disorders. It is crucial for guiding treatment decisions when clinical and laboratory findings are uncertain. Since its introduction in the mid-20th century, percutaneous kidney biopsy has evolved from an initial blind approach, associated with higher complication rates, to advanced methods using real-time ultrasound or computed tomography guidance and spring-loaded biopsy needles. These advancements have significantly improved tissue sampling accuracy and minimized complications, establishing percutaneous kidney biopsy as a relatively safe diagnostic procedure. Despite these improvements, the invasive nature of the procedure emphasizes the importance of careful patient selection and operator expertise. Nephrologists, as the primary operators and performers of kidney biopsy, play a pivotal role in ensuring timely and appropriate patient care.

Changes in the Work Patterns of Hospitalists in South Korea Following Medical School Expansion

Sun, 01 Dec 2024 00:00:01 +0100

Backgrounds/Aims: The recent increase in medical school admissions has potentially altered the working conditions of hospitalists in South Korea. This study investigated how these changes have affected the work patterns and responsibilities of hospitalists, particularly in light of the ongoing exodus of medical trainees that began on February 22, 2024. Methods: We surveyed members of the Korean Society of Hospital Medicine and the Korean Society of Surgery Hospital Medicine Study Group working as hospitalists from April 2 to 30, 2024. The survey was conducted via email and excluded personally identifiable information. Respondents characteristics, work types, hours, patient loads, support staff availability, and changes in job scope post-policy were analyzed. Results: Sixty-three hospitalists responded, with an equitable gender distribution and a median age of 39 years. A significant shift in work patterns was noted, with full-day shifts increasing from 22.2% to 39.7%, and a corresponding decrease in weekday daytime shifts. Work hours also significantly increased from a median of 40 to 45 hours per week. Changes in patient distribution were observed, with fewer hospitalists managing mid-range patient numbers and more handling smaller or larger loads. Despite the increased demands in the latter case, more than 50% of hospitalists reported a lack of support staff and a significant portion did not receive overtime compensation. Conclusions: The increase in medical school admissions and subsequent shifts in hospitalist workloads and hours indicate a strained healthcare system. Hospitalists are taking on more intensive and extended roles. The absence of adequate support staff and adjustments in compensation suggest that further systemic changes are necessary to sustain the efforts of hospitalists, thereby ensuring patient safety and care quality.

A Case of Concurrent Anti-Glomerular Basement Membrane Antibody Disease and Immunoglobulin A ...

Sun, 01 Dec 2024 00:00:01 +0100

Anti-glomerular basement membrane (GBM) antibody disease is a rare autoimmune disorder characterized by autoantibodies directed against antigens within the GBM, primarily affecting the kidneys and lungs. This severe form of glomerulonephritis has an incidence of less than two cases per million individuals with crescentic glomerulonephritis. The coexistence of immunoglobulin A (IgA) nephropathy and anti-GBM disease is rare. Here, we present a case of concurrent anti-GBM antibody disease and IgA nephropathy. A 49-year-old male presented with fever, azotemia, proteinuria, and hematuria. Biopsy of the kidney revealed crescentic glomerulonephritis with linear IgG deposition along the GBM and IgA deposition in the mesangium. Elevated serum levels of anti-GBM antibody (311 U/mL) confirmed the diagnosis of concurrent anti-GBM antibody disease and IgA nephropathy. Despite treatment with methylprednisolone, cyclophosphamide, and plasma exchange, renal function deteriorated, necessitating hemodialysis.

Non-face-to-face Treatment in Korea: Suggestions for Essential Conditions

Wed, 01 Feb 2023 00:00:01 +0100

Since February 24, 2020, non-face-to-face treatment has been temporarily allowed in Korea to protect patients and medical staff from COVID-19, and it has continued to be conducted until now. And on May 3, 2022, the Presidential Transition Committee announced the National Tasks to be focused on, including the institutionalization of non-face-to-face treatment centered on primary medical care. Concerns about non-face-to-face treatment in the medical community are increasing, but non-face-to-face treatment is currently being conducted without any restrictions. In this article, I would like to propose essential conditions for the safety of patients so that non-face-to-face treatment can be performed as a complementary means of face-to-face treatment.

Statin Use and the Risk of All-cause Mortality

Wed, 01 Feb 2023 00:00:01 +0100

Statins are the cornerstone in primary and secondary prevention of atherosclerotic cardiovascular disease. Most benefits of statin treatment mainly come from lowering low-density lipoprotein cholesterol levels. However, statins have pleiotropic effects on vascular dysfunction, inflammation, and immunomodulation beyond cholesterol-lowering, suggesting a positive impact on various health outcomes. All-cause mortality is a commonly chosen outcome in randomized controlled trials (RCTs) of statins. Nevertheless, the effect of statin treatment on the risk of all-cause mortality remains uncertain since it has usually been evaluated as a secondary outcome or a component of the primary composite outcome. A recent meta-analysis of RCTs also failed to draw a clear conclusion on this issue. Further studies investigating all-cause mortality as a primary endpoint are needed to determine the effect of statins on all-cause mortality from the perspective of evidence-based medicine.

Core Elements for Implementing Antimicrobial Stewardship Programs in Korean General Hospitals

Wed, 01 Feb 2023 00:00:01 +0100

Currently, antimicrobial resistance (AMR) is a major threat to global public health. To overcome this crisis, antimicrobial stewardship programs (ASPs) have been proposed. An ASP supports the optimal use of antimicrobials, including appropriate dosing decisions, as well as the duration and routes of administration. In South Korea, efforts are underway to overcome AMR through a national policy supporting ASPs. This study developed the core elements of an ASP for domestic medical facilities. Two Delphi surveys were conducted to select the core elements through expert consensus. The core elements for ASP implementation included leadership commitment, an operating system, action, tracking, reporting, and education. To ensure that these core elements are present in medical facilities, multiple departments must collaborate to support ASP operations. The establishment of a reimbursement system and workforce for ASPs are prerequisites for ASP implementation. The active implementation of core ASP elements in medical facilities requires the provision of financial support for the ASPs, cultivation of a healthcare workforce to perform ASPs, application of the core elements to healthcare accreditation, and provision of incentives to medical facilities via quality evaluation criteria.

A 71-Year-Old Man with Chronic Epigastric Pain

Wed, 01 Feb 2023 00:00:01 +0100

A 71-year-old man presented due to chronic epigastric pain. A computed tomography scan of the abdomen showed a lobulated multilocular cystic lesion in the pancreatic head. Considering the patients age and imaging findings, pancreaticoduodenectomy was performed. Pathological examination revealed an intraductal papillary mucinous neoplasm with high-grade dysplasia.

Interpretation of Estimated Glomerular Filtration Rate

Wed, 01 Feb 2023 00:00:01 +0100

Glomerular filtration rate (GFR) plays an important role in the clinical evaluation of renal function, classification, prognosis prediction, and drug dosing in patients with acute or chronic kidney disease . Estimated GFR (eGFR) is calculated based on endogenous filtration markers, such as creatinine and cystatin C. These are useful markers, but it is necessary to understand the clinical settings in which eGFR, calculated using creatinine or cystatin C, may be less accurate. Several equations, including the Cockcroft and Gault, modification of diet in renal disease, and chronic kidney disease-epidemiology collaboration (CKD-EPI) equations, are used to calculate eGFR. The latter is most common because it has high accuracy and can predict prognosis. Recently, a new race-omitting CKD-EPI equation has been developed but further studies are required to determine whether it can be applied in clinical practice and research. Furthermore, careful use of eGFR is needed in acute kidney injury, kidney transplantation, and dialysis patients. Drug dosing must be guided by accurate GFR assessment. In addition to medical care, GFR assessment is also important for public health and research. Therefore, further studies are needed to reevaluate and develop the equations for accurate eGFR calculations.

The First Step in Resolving Medical Disputes Involving Physicians of South Korea: Fair Medical ...

Sat, 01 Apr 2023 00:00:01 +0100

Physicians of South Korea are not guaranteed their safe health care environment amid the recent increase in medical disputes and changed medical disputes. There has been surprisingly high tendency of criminal punishment on physicians compared to foreign countries such as Japan, England and German. This criminal punishment has caused several problems such as avoidance treatment and defensive treatments, increasing medical costs, a phenomenon of avoiding applying to specialized department with a high risk of medical accidents. Considering the direct impact of medical appraisal on legal judgement, the medical communitys urgent task is to raise physicians who can conduct fair, objective and consistent medical appraisal of medical accidents.

SGLT2 Inhibitors: Emerging Drugs in Heart Failure

Sat, 01 Apr 2023 00:00:01 +0100

Sodium-glucose cotransporter 2 (SGLT2) inhibitors constitute a class of diabetes medications that have demonstrated the potential to improve outcomes for heart failure (HF) patients. Although they were originally developed to treat diabetes, clinical trials have demonstrated their ability to both reduce the risk and improve the prognosis of HF. SGLT2 inhibitors have unique mechanisms of action, including improvement of water retention and promotion of lipolysis, which contribute to their effectiveness in treating HF. They are considered essential primary treatment options for patients with HF, regardless of diabetes status and ejection fraction. Overall, the use of SGLT2 inhibitors in patients with HF is expected to increase in the future and may further improve treatment outcomes for HF patients.

New Guidelines for Idiopathic Pulmonary Fibrosis and Progressive Pulmonary Fibrosis

Sat, 01 Apr 2023 00:00:01 +0100

Idiopathic pulmonary fibrosis (IPF) is the most common and fatal idiopathic interstitial pneumonia and is characterized by chronic progressive pulmonary fibrosis of indeterminate etiology. In 2018, the American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Latin American Thoracic Society published joint clinical practice guidelines for IPF. The guidelines require exclusion of known causes of interstitial lung disease and identification of a radiological and/or pathologic pattern of usual interstitial pneumonia (UIP). The diagnosis of IPF is a multidisciplinary process, involving pulmonologists, radiologists, pathologists and, if necessary, experts in other medical fields. The 2022 guidelines for IPF revisit and clarify the radiological and pathological features of UIP. In addition, recommendations regarding transbronchial lung cryobiopsy, antacid medication, and antireflux surgery are revised or established based on up-to-date evidence in the 2022 guidelines. The new guidelines also encompass the definition and treatment of progressive pulmonary fibrosis (PPF). PPF comprises diverse fibrotic interstitial lung diseases other than IPF, which progress despite standard treatment. The diagnosis of PPF is based on symptoms, physiologic evidence, and radiologic evidence of progression. The use of nintedanib was suggested for patients with PPF other than IPF who are unresponsive to standard treatment. This review introduces and discusses the recommendations for the diagnosis and treatment of IPF and PPF in the new international guidelines.

Strategies to Reduce the Risk of Medical Malpractice Claims against Hospitalists

Sat, 01 Apr 2023 00:00:01 +0100

The hospitalist system has recently been implemented in Korea. Claims against hospitalists may become a new medicolegal issue, as the number of medical malpractice claims is increasing. Hospitalist medical malpractice cases frequently involve more severe patient injuries than those involving claims against other physicians, and these cases frequently involve errors in clinical judgment and communication. Doctor-patient relationship issues, poor communication skills, and physicians at high risk of malpractice claims are risk factors for medical malpractice claims against hospitalists. Strategies to lower the risk of medical malpractice claims against hospitalists include empathetic communication with patients, standardized handoffs or discharge summaries, direct and close communication with outpatient physicians, and timely referral and consultation. Hospitalists will soon have a significant impact on inpatient care in Korea.

A 22-year-old Woman with Chronic Back Pain

Sat, 01 Apr 2023 00:00:01 +0100

Low back pain, categorized as nociceptive, neuropathic, or nociplastic, is the leading cause of disability in terms of years lived among young people. The lumbar spine may produce specific or non-specific pain. Treatment depends on the underlying cause of low back pain. This review discusses the classification, prevalence, diagnosis, and treatment of low back pain in young adults.

Non-invasive Evaluation of Liver Fibrosis

Sat, 01 Apr 2023 00:00:01 +0100

An evaluation of liver fibrosis severity during the initial examination is essential for the determination of chronic liver disease prognosis. Although liver biopsy is the gold standard for evaluation of liver fibrosis, bleeding can occur. Therefore, several non-invasive approaches have been introduced, including an equation with clinical variables and assessments of liver stiffness (e.g., elastography). Most patients with chronic liver disease can undergo evaluation of liver fibrosis severity without a liver biopsy using these alternative methods.

Myasthenia Gravis Presenting as Sudden

Sat, 01 Apr 2023 00:00:01 +0100

Myasthenic crisis, which can be life-threatening due to severe respiratory failure, occurs in 15-20% of patients with myasthenia gravis. However, the crisis often develops within 1-2 years after diagnosis and is very rare as a first symptom of myasthenia gravis; isolated sudden-onset hypercapnic respiratory failure without other symptoms of myasthenia gravis is even rarer. A 63-year-old woman presented to the emergency department with fever and dizziness. Chest computed tomography showed multifocal peribronchial ground-glass opacities, and a diagnosis of pneumonia was made. Initially, the patient did not have dyspnea. However, she developed acute hypercapnic respiratory failure and was intubated. After mechanical ventilation, her hypercapnia improved initially, but worsened on initiation of weaning from the ventilator. As she had a high acetylcholine receptor antibody titer, myasthenia gravis was diagnosed. Her hypercapnia improved after treatment with pyridostigmine and methylprednisolone.

Immune-related Adverse Effect after BNT162b2 Vaccination with Parallel Immune Checkpoint ...

Sat, 01 Apr 2023 00:00:01 +0100

COVID-19 vaccination is essential in cancer patients. However, there is limited evidence of the prognosis of these patients, especially for those taking immune checkpoint inhibitors (ICIs). We present a patient on pembrolizumab for advanced endometrioid adenocarcinoma experiencing continuous diarrhea and subsequent episodes of fever with pain in multiple joints following a second dose of the BNT162b2 mRNA COVID-19 vaccine. An ICI-induced immune-related adverse effect (irAE) was the main diagnosis; cytokine release syndrome and rheumatoid arthritis were also considered. Notably, the novel irAE occurred after the 19th pembrolizumab trial, highlighting the potential effect of changes in systemic immunogenicity after BNT162b2 vaccination. Ultimately, the patient was treated with steroid, which alleviated her symptoms. Here, we report a rare adverse effect after COVID-19 vaccination in an endometrioid carcinoma patient on ICI therapy. This report shows that there is a need to consider and investigate vaccine-related adverse events.

In the Era of ChatGPT, Can Medical Artificial Intelligence Replace the Doctor?

Thu, 01 Jun 2023 00:00:01 +0100

Whether artificial intelligence (AI) can replace the role of doctors has seriously been discussed since the appearance of Chat Generative Pretrained Transformer (ChatGPT). Unlike past expectations that limit the role of AI in the medical field, doctors seem to both admire and be threatened by recent advances in AI models. Because previously developed and approved AI models have been managed and reviewed by medical experts during the preparation, refining, annotation, and verification of data, those systems can be considered to be based on evidence-based medicine. However, the current version of the ChatGPT model derives the most meaningful results from unverified open data. This approach enhances the accessibility to new information but is significantly different from the methodology of evidence-based medicine. Like all AI models developed to date, ChatGPT needs a system that can be rigorously verified and regulated by doctors to facilitate its use in the medical field.

Korean Guidelines for Postpolypectomy Colonoscopic Surveillance: 2022 Revision

Thu, 01 Jun 2023 00:00:01 +0100

The risk of developing metachronous advanced neoplasia is associated with the presence of polyps in index colonoscopy. Therefore, it is essential to establish the optimal colonoscopy surveillance period following polypectomy. In the 2020s, international guidelines published by the US Multi-Society Task Force, European Society of Gastrointestinal Endoscopy, and British Society of Gastroenterology were revised. In 2022, the Korean postpolypectomy colonoscopic surveillance guidelines were revised to recommend surveillance for adenoma size ? 10 mm, ? 3 adenomas, tubulovillous or villous adenoma, adenoma with high-grade dysplasia, traditional serrated adenoma, sessile serrated lesion (SSL) with dysplasia, serrated polyp with size ? 10 mm, and ? 3 SSLs.

Review of Antibody-Drug Conjugates

Thu, 01 Jun 2023 00:00:01 +0100

Antibody-drug conjugates (ADCs) are target-specific conjugates that consist of a monoclonal antibody connected to a cytotoxic payload using a stable linker. These conjugates combine the highly specific targeting ability and potent killing effect to accurately and efficiently eliminate cancer cells, which has ushered in a new era of targeted therapy. Since the first approval by the United States Food and Drug Administration in 2000, ADCs have experienced rapid development, with 14 of them receiving market approval. In this review, we examine the history, molecular structure, and pharmacological principles of ADCs, describing clinical trials and discussing the current challenges and future perspectives for the development of next-generation ADCs.

Endoscopic Features According to Helicobacter pylori Infection Status

Thu, 01 Jun 2023 00:00:01 +0100

It is important to evaluate Helicobacter pylori (H. pylori) infection based on endoscopic results because numerous studies have shown a link between H. pylori infection and upper gastrointestinal conditions, such as gastric cancer. The association between H. pylori infection and gastritis is fully described in the Kyoto classification of gastritis. Typical endoscopic findings in the absence of H. pylori infection are a regular arrangement of collecting venules, fundic gland polyps, red streaks, and other similar features. By contrast, typical endoscopic findings in individuals with active H. pylori infection include diffuse mucosal erythema, atrophy, intestinal metaplasia, inflated or tortuous folds, discharge of sticky mucus, mucosal nodularity, foveolar hyperplastic polyps, and/or xanthomas. Patchy mucosal redness and map-like mucosal redness are typical endoscopic findings in previously infected people. Because of its straightforward application in standard clinical practice, this categorization can reflect the risk of stomach cancer and be useful for both primary care physicians and experienced endoscopists.

Evaluation and Diagnosis of Acute Chest Pain

Thu, 01 Jun 2023 00:00:01 +0100

Acute chest pain is a frequent cause of visits to emergency departments. As the major etiologies of such pain include life-threatening acute myocardial infarction, aortic dissection, and pulmonary embolism, prompt diagnosis and management are essential. After exclusion of coronary artery disease, other cardiac causes must be considered. In this review, we discuss the diagnosis of acute chest pain with a focus on clinical symptoms and the initial examination.

Interpretation of Thyroid Autoantibodies in Hyperthyroidism

Thu, 01 Jun 2023 00:00:01 +0100

Thyrotoxicosis is a clinical state with a variety of various etiologies that results from excess thyroid hormones, including hyperthyroidism and thyroiditis. Graves' disease (GD) is a well-known autoimmune thyroid disease that causes hyperthyroidism, and its pathogenesis is mainly driven by the thyroid-stimulating hormone receptor antibody (TSHRAb), which is highly specific for GD. Measuring the TSHRAb is a fast and accurate diagnostic tool for GD and has been used to monitor disease activity and the treatment response. However, conventional TSH-binding inhibitory immunoglobulin (TBII) does not differentiate between stimulating, blocking, or neutral antibodies. In contrast, thyroid stimulatory immunoglobulin bioassays differentiate between stimulating and blocking antibodies and have comparably high sensitivity and specificity to TBII for GD. We also discuss the role of thyroid peroxidase antibody (TPOAb) and thyroglobulin antibody (TgAb) in thyrotoxicosis, although they are less specific than TSHRAb for GD. TPOAb is associated with autoimmune thyroiditis, while TgAb appears with TPOAb in patients with autoimmune thyroid disease. In addition, TPOAb or TgAb may be associated with a low recurrence of GD after discontinuing anti-thyroid drugs. Clinicians should interpret thyroid autoantibodies in the context of the patient's clinical presentation and consider their implications to manage and monitor thyrotoxicosis.

Missed Opportunities for Urate Lowering Therapy after Gout Flares in Frail Patients Living Alone

Thu, 01 Jun 2023 00:00:01 +0100

Background/Aims: Irrespective of socioeconomic status, urate lowering therapy (ULT) is crucial for all chronic gout patients. We investigated the presence of missed opportunities for ULT among underprivileged patients treated at a major public hospital in Korea after a severe gout flare. Methods: We first collected information on patients admitted under the diagnosis of gout (International Classification of Diseases 10th Revision code M10) at a major public hospital from March 2011 to February 2022. De-identified patient data, including sociodemographic status, uric acid levels, list of medications, and outpatient follow-up data, were extracted. The patients were grouped into frail patients, who were living alone and were admitted to the specialized ward (SPE), and those who were admitted to the general ward (GEN). Primary endpoints were the outpatient visit rate immediately after discharge and the rate of ULT maintenance after a year. Results: Acute gouty arthritis was the chief event during admission in 136 cases. The mean (

Improvement in Dasatinib-Induced Proteinuria after Switching to Nilotinib: A Case Report

Thu, 01 Jun 2023 00:00:01 +0100

Tyrosine kinase inhibitors (TKIs), such as imatinib, dasatinib, and nilotinib, have been used to treat chronic myelogenous leukemia (CML). The adverse effects of these TKIs vary according to the site of signaling pathway inhibition. Here, we report a case of dasatinib- induced proteinuria. A 56-year-old Korean woman was diagnosed with CML and treated with dasatinib. However, 3 years later, the patient developed hypertension and microalbuminuria. Losartan was ineffective, so a kidney biopsy was performed, which revealed dasatinib-associated glomerular changes. Subsequently, dasatinib was switched to nilotinib. After 1 month, the spot urine protein/creatinine ratio decreased from 2,985.0 mg/g to 237.8 mg/g. This case of heavy proteinuria developed after long-term TKI treatment and improved rapidly after switching to another TKI. The proposed strategy is important because it eliminates the need to discontinue the medication or use immunosuppressive drugs to treat proteinuria.

Antibiotic Stewardship: A Key Strategy to Combat Antibiotic Resistance

Tue, 01 Aug 2023 00:00:01 +0100

Antibiotic stewardship is a vital strategy to address antibiotic resistance by promoting responsible antibiotic use. It is aimed at improving patient outcomes, reducing resistance, minimizing adverse effects, and lowering healthcare costs. Collaborative efforts among healthcare professionals from various disciplines are crucial for its successful implementation. Recognizing value beyond immediate financial benefits is important. Committed leadership, designated pharmacists, action plans, tracking, reporting, and education are essential elements. Prioritizing and implementing comprehensive stewardship programs are necessary to combat antibiotic resistance and protect public health.

Shorter Oral Regimen for Multidrug Resistant Tuberculosis in South Korea

Tue, 01 Aug 2023 00:00:01 +0100

The treatment of multidrug- and rifampin-resistant tuberculosis (MDR/RR-TB) poses significant challenges, including frequent adverse drug reactions associated with complex treatment regimens involving multiple drugs administered over prolonged periods. However, recent clinical trials, such as Nix-TB, ZeNix, NExT, MDR-END, TB-PRACTECAL, and BEAT-India, have demonstrated that shorter oral regimens yield superior outcomes compared with conventional approaches. Furthermore, the World Health Organization guidelines for MDR/RR-TB treatment recommend a 6-month all-oral regimen that includes bedaquiline, pretomanid, linezolid, and moxifloxacin. However, the implementation of these shorter oral regimens in South Korea requires careful consideration. Health insurance coverage policies must be reviewed to include new TB drugs, such as pretomanid. The optimal dosage and treatment duration of linezolid should be determined to minimize side effects and prevent drug resistance; moreover, alternative regimens should be identified for patients who discontinue linezolid because of adverse drug reactions.

Epidemiology, Diagnosis, and Treatment of Portal Vein Thrombosis

Tue, 01 Aug 2023 00:00:01 +0100

In recent years, the incidence of portal vein thrombosis (PVT) in patients with cirrhosis has increased; the thrombosis ranges from asymptomatic partial to complete occlusion. Treatment is difficult. Anticoagulation therapy may be the optimal first-line treatment for patients with acute PVT who lack variceal bleeding or mesenteric ischemia. Minimally invasive treatment options include mechanical thrombectomy, chemical thrombolysis, and stent placement. However, the effectiveness and timing of anticoagulation and interventional therapies remain unclear.

Building a Sustainable Career in Hospital Medicine: Strategies for Research and Preventing Burnout

Tue, 01 Aug 2023 00:00:01 +0100

The hospital is the optimal setting for conducting research on healthcare quality improvement and patient safety, and hospital medicine is an auspicious field for career growth. Integrating clinical practice with non-clinical activities, including education and scholarly endeavors, has the potential to enhance job satisfaction and mitigate the risk of burnout. As a hospitalist, it is imperative to establish a professional growth plan, and to identify and prioritize core values. This review discusses strategies for engaging in research, fostering career progression, and preventing burnout among hospitalists.

A 78-Year-Old Man with Weakness and Loss of Appetite for 2 Months

Tue, 01 Aug 2023 00:00:01 +0100

The incidence rate of tuberculosis (TB) in Korea has been consistently decreasing, but the proportion of extrapulmonary tuberculosis (EPTB) remains relatively stable at around 20%. Diagnosing EPTB remains a challenge because clinical samples obtained from relatively inaccessible sites may be paucibacillary, thus reducing the sensitivity of diagnostic tests. Delayed diagnosis and treatment some form of EPTB, such as tuberculous meningitis, can lead to fatal outcomes. Therefore, it is crucial to have a high index of suspicion and perform appropriate testing early on. Obtaining a specimen from the lesion and conducting microbiological tests (acid-fast bacilli smear, mycobacterial culture, and nucleic acid amplification test) along with histopathological examination is essential. When the specimen is limited for all testing, mycobacterial culture test should be prioritized as it has the highest diagnostic yield and allows for drug susceptibility testing. All patients with presumed EPTB should be assessed for pulmonary TB to assess infectiousness and potentially assist with diagnosis.

Clinical Significance of Clonal Hematopoiesis

Tue, 01 Aug 2023 00:00:01 +0100

Clonal hematopoiesis (CH) is associated with somatic mutations of the hematopoietic stem cells responsible for red blood cell formation. The incidence of CH increases with age and negative environmental factors. It is particularly common in patients on chemotherapy, and is associated with a greater than 10-fold increased risk for hematological malignancy. It also increases the risk for cardiovascular disease. Despite recent advances in molecular and genetic research, the clinical and translational aspects of disease require more attention. However, as data accumulate, prevention of disease onset and progression will improve.

Prediction of Helicobacter pylori Infection by Endoscopic Severity of Erythematous Gastritis in ...

Tue, 01 Aug 2023 00:00:01 +0100

Background/Aims: Helicobacter pylori (H. pylori) infection is correlated with erythematous gastritis, which is one of the endoscopic findings of the Sydney classification system. The present study evaluated the association between the endoscopic severity of erythematous gastritis and H. pylori infection. Methods: We prospectively enrolled asymptomatic adults who were diagnosed with erythematous gastritis during screening esophagogastroduodenoscopy. A rapid urease test was performed in all participants to diagnose H. pylori infection. The severity of erythematous gastritis was determined based on the Sydney classification system. The primary endpoint was the H. pylori infection rate according to the severity of erythematous gastritis (mild to moderate vs. severe). Results: In total, 131 patients with erythematous gastritis were included. The rate of H. pylori infection was 45.8% across all patients. Of the 131 included patients, 45 had mild gastritis, 43 had moderate gastritis, and 43 had severe gastritis. The H. pylori infection rate was significantly different between patients with mild to moderate erythematous gastritis and those with severe erythematous gastritis (20.5% vs. 97.7%, respectively; p = 0.000). After adjustment for potential confounding variables, the severity of erythematous gastritis was associated with the H. pylori infection rate. The kappa value was 0.563, and interobserver variation was 14.43%. Conclusions: H. pylori infection is observed to a moderate degree in patients with erythematous gastritis. The severity of erythematous gastritis is associated with the H. pylori infection rate.

A Case of Aphasic Seizure as a Manifestation of Nonketotic Hyperglycemia in a Patient ...

Tue, 01 Aug 2023 00:00:01 +0100

Peritoneal glucose absorption in peritoneal dialysis causes hyperglycemia. Nonketotic hyperglycemia (NKH) includes hyperosmolar hyperglycemic state, which refers to a condition that includes hyperglycemia, hyperosmotic pressure, and dehydration without severe acidosis. NKH is associated with various types of epileptic seizures, but aphasic seizure as a neurological complication of NKH is very rare. Here we report a case of aphasic seizure in a patient with NKH who underwent peritoneal dialysis. A 57-year-old man who had been undergoing peritoneal dialysis visited our hospital with the chief complaint of aphasia. His magnetic resonance imaging scan was normal, but his electroencephalography showed frequent generalized delta slow activity as well as epileptiform discharges originating from the left frontotemporal lobe. His dialysis modality was switched to hemodialysis and he was started on insulin for glucose control. The latter resulted in the disappearance of his seizures and of his aphasia.

Perspective on Wearable Devices for Cardiac Arrhythmia Detection

Sun, 01 Oct 2023 00:00:01 +0100

In the field of arrhythmia, the significance of wearable devices is steadily increasing. These devices are becoming increasingly recognized not only among patients and physicians but also among the general population. Atrial fibrillation, in particular, benefits significantly from these devices in both diagnosis and treatment of this disease. However, there is a tendency to overlook various challenges associated with wearables. These include limitations in diagnostic accuracy, an inability to evaluate various types of cardiac arrhythmias, potential increases in patient anxiety, and the demands placed on expert physicians due to the vast amounts of data produced by wearable devices. This article emphasizes that while wearable devices play a pivotal role in cardiac arrhythmia diagnosis, areas for improvement remain.

Human Immunodeficiency Virus Infection and Gut Microbiota: A Review on Gut Microbiome ...

Sun, 01 Oct 2023 00:00:01 +0100

This review provides the complex interaction between human immunodeficiency virus (HIV) infection and gut microbiota. HIV infection exerts chronic effects by impairing the immune system, closely linked with alterations in gut microbiota. While advances in highly active antiretroviral therapy have achieved HIV undetectable in the bloodstream, persistent microbial translocation in the gut microbiota despite antiviral treatment leads to systemic immune activation and chronic inflammation in people living with HIV (PLHIV). There is the need for elucidating which specific microbes and their byproducts that contribute to immune activation and chronic inflammation in PLHIV. Furthermore, gaining a deeper understanding of the connection between HIV infection and metabolic disorders holds significant potential for addressing and managing conditions like premature aging and metabolic diseases. Monitoring alterations in gut microbiota composition shows promise in developing diagnostic markers and therapeutic potential for metabolic disorders in PLHIV.

Updated Guidelines for Acute Respiratory Distress Syndrome

Sun, 01 Oct 2023 00:00:01 +0100

Acute respiratory distress syndrome (ARDS) accounts for 10% of patients admitted to the intensive care unit and 23% of patients using mechanical ventilation, with a mortality rate of 45% in severe cases. The perception that patients with ARDS are vulnerable to ventilator-induced lung injury has led to lung-protective ventilation strategies. Accordingly, the American Thoracic Society, the European Society of Intensive Care Medicine (ESICM), and the Society of Critical Care Medicine announced ARDS mechanical ventilation guidelines in 2017. Since then, based on the results of newly reported research and data accumulated throughout the coronavirus disease 2019 pandemic, the ESICM announced an amendment to the previous guidelines in 2023. The revised ARDS guidelines discuss extending the ARDS definition and its phenotypes that were not mentioned in the previous guidelines. The new guidelines encompass ventilation strategies, including positive end-expiratory pressure and recruitment maneuvers in patients receiving mechanical ventilation. In addition, various oxygenation devices, such as high-flow nasal cannulated oxygen and continuous positive airway pressure in nonmechanically ventilated patients, are introduced. This review discusses new changes in the diagnosis and treatment of ARDS based on the new ESICM guidelines, providing a supportive background and rationale.

Advancements in the Management of Moderate-to-Severe Ulcerative Colitis: A Revised 2023 Korean ...

Sun, 01 Oct 2023 00:00:01 +0100

Biologics such as anti-tumor necrosis factor agents have been the cornerstone for the treatment of inflammatory bowel disease but face limitations, including loss of response and risk of opportunistic infections and malignancies. Newer biologics and small molecules like vedolizumab, ustekinumab, and tofacitinib offer favorable safety profiles and demonstrate efficacy in moderate-to-severe ulcerative colitis. The landscape of the pipeline of biologics and small molecules is rapidly evolving. Upcoming drugs such as upadacitinib, filgotinib, and ozanimod show promise in recently concluded clinical trials, expanding the therapeutic options for ulcerative colitis. This review aims to discuss the medical treatment options available for the management of moderate-to-severe ulcerative colitis, with a focus on biologics and small molecules recommended in revised 2023 Korean guidelines.

Recent Updates on Diagnosis and Treatment of Follicular Lymphoma

Sun, 01 Oct 2023 00:00:01 +0100

Follicular lymphoma (FL) is the third most common subtype of non-Hodgkin lymphoma in Korea. Patients with FL generally present with asymptomatic lymphadenopathy, which may wax and wane for years and have indolent disease course. Most patients with FL have advanced-stage disease at diagnosis and less than 20% of patients with FL have stage I/II disease. Radiation therapy is generally accepted with the treatment of choice for limited-stage FL and results in 60-80% of 10-year overall survival rates. Patients with advanced-stage FL do not require an immediate treatment unless they have symptomatic disease, compromised end organ function, B symptoms, or cytopenia. The initial treatment of advanced-stage FL recommends rituximab-containing immunochemotherapy followed by 2 years of maintenance with rituximab, or bendamustine plus rituximab is a preferred choice because of superior progression-free survival with less toxicity than other rituximab-containing immunochemotherapy. For patients with relapsed or refractory FL, there are many options ranging from anti-CD20 monoclonal antibody alone to a combination with lenalidomide and chemotherapy or autologous stem cell transplantation. In addition, the novel approaches for relapsed or refractory FL have been applied with phosphoinositide 3-kinase inhibitor, Brutons tyrosine kinase inhibitor, enhancer of zeste homolog 2 inhibitor, anti-CD19 chimeric antigen receptor T-cell therapy and bispecific antibodies.

A 43-Year-Old Man with Abdominal Pain and Diarrhea for 2 Months

Sun, 01 Oct 2023 00:00:01 +0100

Hypereosinophilic syndrome (HES) is a heterogeneous group of rare disorders characterized by blood and tissue eosinophilia accompanied by eosinophil-driven tissue damage and dysfunction. Clinical manifestations of HES are highly variable, as it is a multisystem disorder involving nearly all organs, but the skin, lungs, and gastrointestinal tract are the most common sites. Identifying and diagnosing HES is challenging because it requires the diagnostic elimination of many eosinophilic conditions, so a detailed stepwise approach should be considered.

The Laboratory Test for the Diagnosis of Idiopathic Inflammatory Myopathies

Sun, 01 Oct 2023 00:00:01 +0100

Idiopathic inflammatory myopathies (IIM) are a heterogeneous group of autoimmune muscle diseases with systemic involvement. Patients with IIM present with varying degrees of muscle disease, cutaneous manifestations, and internal organ involvement. The diagnosis of IIM is frequently delayed because of non-specific symptoms including weakness, easy fatigability, or myalgia. Laboratory tests can give clues for the diagnosis of myositis and other muscle diseases. Creatine kinase can be the screening tool for muscle diseases. About 40-60% of IIM had positive antinuclear antibody (ANA). Thus, positive ANA results increase the possibility of IIM diagnosis. In addition, the identification of myositis-related autoantibodies can help the diagnosis and classification. Myositis-specific autoantibodies (MSA) are found exclusively in IIMs and facilitate the identification of subsets of patients with relatively homogeneous clinical features. Myositis-associated antibodies are frequently found in association with other MSA; however, they may also be detected in various connective diseases.

A Case of Podocytic Infolding Glomerulopathy in an Allograft Kidney

Sun, 01 Oct 2023 00:00:01 +0100

Podocytic infolding glomerulopathy (PIG) is a rare disease diagnosed by its characteristic structure on electron microscopy. Histologically, there are microtubules and microspheres in the glomerular basement membrane (GBM). Most PIG has been reported in Japan, with a single case in South Korea; there are no previous reports of PIG in kidney transplant patients. Here, we report a 47-year-old Korean woman diagnosed with PIG after a kidney transplant. She was diagnosed with systemic lupus erythematosus. She was suspected of having lupus nephritis and subsequently underwent kidney transplantation. Routine testing showed increased proteinuria without renal functional impairment. A biopsy of the allograft kidney revealed mild interstitial fibrosis, tubular atrophy, and GBM thickening with intramembranous microspherules and microtubules on light microscopy. Electron microscopy showed GBM thickening with intramembranous microspherules and microtubules. These findings are consistent with PIG.

The Status of Cord Blood Banks and Their Management in Korea

Fri, 01 Dec 2023 00:00:01 +0100

Korean cord blood banks (CBBs) are stagnant, so we explore how to overcome this. For eligible CB units (CBUs), CBBs need to strengthen quality control and conduct innovative clinical trials to facilitate cord blood transplantation (CBT). For ineligible CBUs, it is necessary to promote domestic research and remove unnecessary regulations regarding foreign research. Establishing a Korean cord blood network will facilitate communication among related groups. Now cellular immunotherapy is the new horizon for CBBs. Thus, CBBs will shift the paradigm of our mission in diverse ways.

Cough in Severe Asthma

Fri, 01 Dec 2023 00:00:01 +0100

Asthma is a heterogeneous clinical syndrome that presents with variable symptoms, including cough, breathlessness, chest discomfort, and wheezing. Cough, a primary symptom of asthma, has distinct regulatory mechanisms and was associated with asthma severity, poor asthma control, diminished quality of life, and an increased risk of frequent future exacerbations. However, current tools for measuring asthma control do not include separate items for cough or other specific symptoms, and the true impact and clinical relevance of cough in asthma remains poorly understood. Consequently, current stepwise treatment algorithms based on asthma control may be overly simplistic and might not adequately address the heterogeneity of asthma or the mechanisms underlying its symptoms. Furthermore, this approach carries the risk of overestimating asthma severity and subsequent overtreatment. The concept of treatable traits is fundamental to precision medicine, wherein each symptom, especially cough, may serve as a treatable trait in its own right. In this paper, we aim to present evidence supporting the concept of cough as a treatable trait in asthma, addressing its three major components, which are clinical relevance, measurability, and treatability.

Synopsis of the Korean Society of Nephrology 2023 Practical Recommendations for the Management ...

Fri, 01 Dec 2023 00:00:01 +0100

Korea has one of the highest rates of end-stage kidney disease (ESKD) worldwide and nearly half of all new cases are attributed to diabetes. Diabetes represents a critical aspect of chronic kidney disease (CKD)-related mortality that entails substantial treatment costs. Given the profound impact of ESKD, it is imperative to initiate robust initiatives to formulate and implement effective preventive and therapeutic strategies. These strategies should target the prevention of CKD development in individuals with diabetes and decelerate the progression of diabetic kidney disease. Recognizing this challenge, the Korean Society of Nephrology (KSN) has introduced the kidney health plan 2033, a comprehensive endeavor designed to alleviate the burdens associated with CKD and ESKD in Korea. As part of this initiative, KSN has undertaken the development of the KSN 2023 practical recommendations for the management of diabetic kidney disease. The hope is that implementation of this guideline will delay the onset of kidney-related complications in diabetic patients throughout the country.

Hormone Treatment for Breast Cancer

Fri, 01 Dec 2023 00:00:01 +0100

Hormone receptor-positive breast cancer accounts for 60-70% of all breast cancers and has a better prognosis than human epidermal growth factor receptor-2 (HER2)-positive or triple-negative breast cancer. Hormone treatment for breast cancer is an important treatment method that is effective and has few side effects for hormone receptor-positive breast cancer. Hormone therapy is performed as adjuvant therapy in early breast cancer and as palliative therapy in metastatic breast cancer. In the past decade, molecularly targeted agents against intracellular targets such as mammalian target of rapamycin (everolimus), cyclin-dependent kinase 4 and 6 (palbociclib, ribociclib, abemaciclib), and phosphatidylinositol 3-kinase (alpelisib) has offered patients effective therapeutic options, and combination of hormone treatment with the molecular agents have continued to improve the outcome of breast cancer.

A 33-Year-Old Man Presented with Abdominal Pain and Vomiting Starting a Day Ago

Fri, 01 Dec 2023 00:00:01 +0100

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are expanding their role beyond the glucose-lowering effects to include reducing body weight and managing the risk of cardiovascular and renal diseases. Accordingly, the number of people with type 2 diabetes using these medications is rapidly increasing. To minimize the potential side effects and ensure safer use, its essential to time prescriptions correctly and educate patients thoroughly. Special caution is required when prescribing to patients with symptomatic and severe hyperglycemia who require insulin. Patients should be instructed to discontinue the medication immediately if they experience symptoms like abdominal pain, nausea, or vomiting. Moreover, if a patient taking SGLT-2 inhibitors is in poor general condition, diagnostic tests for euglycemic diabetic ketoacidosis should be performed, even if the blood glucose levels are not elevated. In such cases, prompt fluid resuscitation and intravenous insulin treatment should be initiated. Additionally, the risk of diabetic ketoacidosis may increase under acute stress conditions such as severe infections, trauma, or major surgery. Therefore, it may be necessary to discontinue SGLT-2 inhibitors and switch to other medications for blood glucose management in these situations.

Application and Interpretation of High-Resolution Computed Tomography for the Diagnosis of ...

Fri, 01 Dec 2023 00:00:01 +0100

Interstitial lung disease (ILD) encompasses a heterogeneous group of over 200 diffuse parenchymal lung diseases. Accurate diagnosis of ILD is essential for appropriate treatment but can be challenging to achieve. For patients with suspected ILD, high-resolution computed tomography (HRCT) is a minimally invasive approach that allows for convenient repeat imaging. Compared to a conventional computed tomography (CT) protocol, the HRCT protocol for ILD patients involves two additional series with different technical requirements: a prone inspiration scan, and a supine expiration scan. The prone scan is useful when dependent opacification is observed on a supine chest CT scan. It facilitates the diagnosis of honeycombing, reducing observer variation in diagnosing idiopathic pulmonary fibrosis. The expiratory scan is useful for identifying air trapping, which is essential for the diagnosis of hypersensitivity pneumonitis. It is used to assess the three-density sign, which is specific for hypersensitivity pneumonitis and characterized by patchy distribution of normal-appearing lobules, ground glass opacities, and lobules with reduced lung density and vessel size. The HRCT ILD protocol should be performed regularly to assess changes in the extent of fibrosis and to diagnose lung cancer or acute exacerbation when clinically indicated.

Bloodless Treatment of Jehovah

Fri, 01 Dec 2023 00:00:01 +0100

Background/Aims: Jehovahs Witnesses refuse blood transfusions for religious reasons. Soonchunhyang University Hospital Seoul has operated a bloodless treatment center since 2000, and a database of bloodless treatment patients has been created. This study aimed to analyze the bloodless treatment outcomes of lymphoma and multiple myeloma patients. Methods: We retrospectively analyzed data of patients diagnosed with lymphoma (22 patients) or multiple myeloma (seven patients) who were treated bloodlessly at Soonchunhyang University Hospital Seoul from 2006 to 2021. Results: The 2-year survival rate for lymphoma patients was 66.6%, with 22.7% dying within 6 months of diagnosis. Those who died early (within 6 months) had a median hemoglobin level of 5.5 g/dL and a median platelet count of 50,142/

Metformin-Associated Lactic Acidosis Precipitated by an Acute Obstructing Ureteral Stone in a ...

Fri, 01 Dec 2023 00:00:01 +0100

A 35-year-old male with type-2 diabetes mellitus and a history of insulin and metformin (2,000 mg/day) use presented to the emergency department (ED) with generalized weakness. Abdominal computed tomography (CT) performed 3 months prior to presentation showed a severely atrophic right kidney and a few tiny stones in the left kidney, with a serum level of creatinine of 1.14 mg/dL. At the ED, the patients blood pressure was 153/89 mmHg. Workup revealed acute kidney injury (creatinine, 11.97 mg/dL), high-anion-gap metabolic acidosis (pH, 6.93), and a blood lactic acid level > 15 mmol/L. Based on the medication history, the patient was diagnosed with metformin-associated lactic acidosis. CT showed a left distal ureteral stone, measuring 6 mm in size, which resulted in hydroureteronephrosis. The patient was initially treated with continuous renal replacement therapy. Subsequently, left percutaneous nephrostomy was performed, which led to the return of the creatinine level to baseline, with complete resolution of lactic acidosis.

Arbitrary Uninsured Benefits are Insured Benefits

Tue, 01 Feb 2022 00:00:01 +0100

2021 Korean Heart Rhythm Society Guidelines for Catheter or Surgical Ablation of Atrial Fibrillation

Tue, 01 Feb 2022 00:00:01 +0100

Rhythm control therapy is used in atrial fibrillation (AF) management to improve AF-related symptoms along with rate control. AF catheter ablation is effective in maintaining sinus rhythm and has an acceptable complication rate. Compared with antiarrhythmic drugs, AF catheter ablation is superior with respect to arrhythmia-free survival and improvement in the quality of life. Therefore, AF ablation is recommended for rhythm control after the failure of antiarrhythmic drugs and is sometimes considered a first-line therapy for AF patients. Radiofrequency and cryoballoon ablation show similar efficacy, with slightly different complication profiles. Surgery for AF is also an effective rhythm control therapy and should be considered in patients undergoing cardiac surgery or in those with failed catheter ablation. For patients undergoing AF catheter ablation, performing ablation under uninterrupted warfarin or non-vitamin K oral anticoagulant treatment is recommended for periprocedural stroke risk management. Here, we review existing data and discuss the general principles of AF catheter and surgical ablation in patients with AF.

COVID-19 and Long-Term Sequelae

Tue, 01 Feb 2022 00:00:01 +0100

After acute corona virus disease 2019 (COVID-19), there have been increasing reports of persistent and long-term symptoms similar to the post- viral syndromes described in survivors of severe acute respiratory syndrome (SARS) or middle east respiratory syndrome (MERS). Here, we provide a comprehensive review of the current literature on long-term COVID-19 focusing on organ-specific sequelae. Many of the recovered COVID-19 patients may be affected by long-term health. The future for COVID-19 survivors remains uncertain, and well conducted long term research will be needed.

The Value of Hospital Medicine

Tue, 01 Feb 2022 00:00:01 +0100

In healthcare, value is defined as the measured improvement in a person's health outcomes for the cost of achieving that improvement. In the era of value in healthcare, hospital medicine successfully embraced strategies to improve hospital safety and to reduce medical error, length of stay and medical cost. As a specialist in general care and hospital system, hospitalists should learn topics of hospital medicine including safety, quality improvement, co-management, professionalism and leadership.

Diagnostic Approach to Autoimmune Hepatitis

Tue, 01 Feb 2022 00:00:01 +0100

Autoimmune hepatitis (AIH) is a chronic liver disease caused by unknown etiology, characterized by elevated liver enzyme, hypergammaglobulinemia, circulating autoantibodies, and histological interface hepatitis. As untreated AIH often leads to decompensated cirrhosis and even death, prompt and timely diagnosis is essential. However, about 1/3 of patients with AIH have cirrhosis at diagnosis. On the other hand, new onset acute or acute exacerbation of previous undiagnosed AIH can be presented as acute hepatitis. Thus, any patients with acute or chronic liver disease with hypergammagloblinemia without other cause should be considered to evaluate circulating non-organ specific autoantibodies for diagnosis of AIH. In case of suspected AIH, liver biopsy should be considered to evaluate its histological characteristics including interface hepatitis, plasma cell infiltration, emperipolesis, and rosettes. When the diagnosis is made, prompt treatment with prednisolone followed by combined azathioprine should be considered to improve its prognosis.

Lung Cancer Screening with Low-Dose Chest Computed Tomography

Tue, 01 Feb 2022 00:00:01 +0100

Early detection and treatment is important to reduce mortality from lung cancer. Based on the positive results of lung cancer-related mortality reduction from large randomized trials of low-dose chest computed tomography (LDCT)-based screening in high-risk populations, LDCT-based screening programs have been implemented in several countries including Republic of Korea. This review focus on the current evidence and state of the art of LDCT-based lung cancer screening, and further discuss the ongoing efforts to develop more efficient screening programs worldwide. This article includes recent updates on the identification of high-risk population eligible for screening and management for screen-detected nodules. Additionally, aspects on future research direction would be addressed.

Factors Related to Successful Tuberculosis Treatment in Vulnerable Groups

Tue, 01 Feb 2022 00:00:01 +0100

Background/Aims: Although the incidence and mortality of tuberculosis are decreasing in South Korea, the number of applications for financial assistance with the cost of tuberculosis treatment made by individuals from vulnerable groups was 3.8 times higher in 2019 compared to 2017 (Tuberculosis Relief Belt Project, 2019). Methods: We analyzed the data of patients who received financial aid for tuberculosis treatment (in the period 2014-2018) from the Tuberculosis Relief Belt Project, which was designed to assist vulnerable groups. This study analyzed 137 subjects, and the independent variables included patient factors (age, gender, nationality, tuberculosis type, number of comorbidities, and place of residence) and treatment type (outpatient or inpatient). The dependent variable was the treatment outcome. Results: The likelihood of treatment success was significantly lower for patients with one (odds ratio [OR] 0.202), two (OR 0.147), or three or more (OR 0.070) comorbidities compared to those with no comorbidities. This was also the case for patients living alone (OR 0.097), and for those classified as homeless (OR 0.053). Korean patients (OR 8.512) had a significantly higher probability of a successful treatment outcome than foreigners. Conclusions: Appropriate community-based management of individuals with tuberculosis from vulnerable groups, including foreigners, people with comorbidities, people living alone, and people with an unstable residential situation or homeless status, is important.

Treatment of CD19-Positive Mixed Phenotype Acute Leukemia with Blinatumomab

Tue, 01 Feb 2022 00:00:01 +0100

Mixed phenotype acute leukemia (MPAL) encompasses a rare group of acute leukemia with blasts expressing markers specific to several lineages, which accounts for 2-5% of all newly diagnosed cases of acute leukemia. At present, patients with MPAL are treated with acute lymphoblastic leukemia (ALL)-directed chemotherapy. However, the prognosis of MPAL, especially in cases of relapsed/refractory (R/R) disease, remains poor. Blinatumomab, a bispecific T cell-engaging antibody, has shown encouraging outcomes in R/R B cell ALL positive for CD19. Here, we report a patient with CD19⁺ MPAL who achieved complete remission after treatment with blinatumomab, which may be a therapeutic option for patients with relapsed CD19⁺ MPAL. To our knowledge, this is the first case report of MPAL treated with blinatumomab in Korea.

New Health Technology before nHTA is also Uninsured Benefit

Fri, 01 Apr 2022 00:00:01 +0100

There has been a misunderstanding that new health technology before new health technology assessment is neither insured benefit nor uninsured benefit. But medical treatment is either insured benefit or uninsured benefit. New health technology is medical treatment. Therefore it shall be either insured benefit or uninsured benefit. It is nothing else. Subparagraph 4 (n) of (attached) Table 2 of ?Rule for Standard of insured Benefits of National Health Insurance? determines whether new health technology is insured benefit or uninsured benefit, which was introduced on Jannuary 1, 2002. Main sentence of the subparagraph 4 (n) states that new health technology is in principle uninsured benefit. The latter part of the subparagraph 4 (n) states that new health technology is exceptionally insured benefit. In a word, the subparagraph 4 (n) state that new health technology is uninsured benefit of main sentence or uninsured benefit of the latter part. In case where the subparagraph 4 (n) does not apply to new health technology, article 41 (2) 2 of the Act applies. this paper calls this overdetermination. Overdetermination is three-layered, but only two-layered overdetermination was discussed in this paper.

2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease

Fri, 01 Apr 2022 00:00:01 +0100

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the proven GERD with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barretts mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis. Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.

Treatment Guidelines for Rheumatoid Arthritis

Fri, 01 Apr 2022 00:00:01 +0100

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease with synovitis and extra-articular systemic involvement. Chronic RA treatment is challenging and represents a major health burden worldwide. Recent insights regarding RA pathogenesis have led to novel therapeutic agents, especially biologics. Furthermore, accumulating experience and new clinical studies have helped to inform updated recommendations for treatment of RA. Recently, treatment guidelines from the American College of Rheumatology were released. Here, we review these guidelines and their application to daily practice.

Critical Decision Making at the Point of Care

Fri, 01 Apr 2022 00:00:01 +0100

Optimal decision-making requires an understanding of the principles of evidence-based medicine to judge the quality of the evidence. Numerous pitfalls exist in diagnostic reasoning and decision-making. There are also many considerations with regard to evidence-based prescription. Increasingly, hospitalists have to work in wards organized as Accountable Care Units (ACUs). Practice guidelines and systematic reviews represent the highest quality of evidence available. There is great clinical importance in rapid access to precise answers, especially those based on summary literatures, to various challenging questions. In practice, a culture of education, updates to support hospitalists, and integration of evidence-based medicine into clinical practice, using diverse digital medical resources and cloud storage, are necessary.

Early Diagnosis and Management of Non ST-Segment Elevation Acute Myocardial Infarction

Fri, 01 Apr 2022 00:00:01 +0100

Acute myocardial infarction (MI) is a cardiovascular disease with high mortality. Acute MI is usually divided into ST-segment elevation MI (STEMI) and non ST-segment elevation MI (NSTEMI) based on the electrocardiogram (ECG). NSTEMI is often misdiagnosed in patients presenting to emergency departments with acute chest pain because its clinical course varies and is atypical compared to STEMI. The symptoms can be vague and the ECG is often not diagnostic. In this setting, an early accurate diagnosis and risk stratification could improve the mortality of patients with NSTEMI. Cardiac biomarkers such as high-sensitivity cardiac troponin (hs-cTn) help to diagnose NSTEMI. Serial hs-cTn assays should be considered to differentiate other conditions, especially in an ambiguous clinical situation. If acute MI is strongly suspected based on the symptoms, ECG, and cardiac biomarkers, catheterization laboratory activation should be timely considered to evaluate the coronary arteries and possible revascularization with percutaneous or surgical strategies depending on risk factors. After successful revascularization, antianginal medications, risk factor control, and early recognition of heart failure are essential to improve the cardiovascular prognosis.

Novel Diagnostic Criteria for Functional Esophageal Disorders

Fri, 01 Apr 2022 00:00:01 +0100

The diagnosis of functional esophageal disorders has evolved from conventional manometry in 1970s to high-resolution manometry in 2010s. The conventional manometry was based on linear plot, whereas newly developed high-resolution manometry is based on spatiotemporal plots. Additionally, novel parameters including integrated relaxation pressure, distal contractile integral, and distal latency have expanded our understanding of pathophysiology of functional esophageal disorders including esophageal achalasia. Following three rounds of revision, the fourth version of Chicago classification of esophageal motility disorders was developed, which is more closely related to clinical situations compared with the previous versions. Moreover, functional lumen imaging probe (FLIP), based on the distensibility of esophageal lumen and sphincter, has also strengthened our understanding of functional esophageal disorders.

Single-Center Real-World Experience of Multiple Myeloma in the 21st Century

Fri, 01 Apr 2022 00:00:01 +0100

Background/Aims: The incidence of multiple myeloma (MM) in Korea is rapidly increasing. The diagnostic criteria of MM have been updated and novel therapeutic agents are available. This study explored the features of MM patients registered at Asan Medical Center (AMC) and the outcomes over the past 15 years. Methods: Data were obtained from the AMC MM registry, which has been collecting the data of MM patients prospectively. The 774 MM patients included in our analysis were diagnosed from 2003, when thalidomide became available as a novel therapeutic agent, until April 2019. The 2-year survival rate of these patients was assessed. Patients were divided into two groups based on whether they were older or younger than 65 years, which is the cutoff age for the indication of autologous stem cell transplantation. Patients were also grouped according to the year of diagnosis: up to 2006, when bortezomib became available, and up to 2010, when the cost of lenalidomide was reimbursed. Results: Patients < 65 years of age had better prognostic features, including a better performance, less advanced disease stage, and fewer abnormalities in their fluorescent in-situ hybridization (FISH) analysis results. A comparison of our Korean patients with patients registered in the Myeloma Related Disorder Registry data of Australia and New Zealand, showed ethnic discrepancies. The median overall survival of all patients was 3.7 years, with a 5-year survival rate of 41.8% and a 10-year survival rate of 23.4%. Survival progressively improved in patients diagnosed later. Age, performance status, renal function, C-reactive protein level, lactate dehydrogenase level, and cytogenetic findings were identified as significant prognostic factors. Conclusions: This real-world survey revealed the clinical features and survival rates of patients at a tertiary Korean Hospital who were diagnosed with MM at the beginning of 21st century.

Nutcracker Syndrome with Thin Basement Membrane Disease: A Case Report

Fri, 01 Apr 2022 00:00:01 +0100

Nutcracker syndrome is caused by external compression of the left renal vein and is characterized by various symptoms, such as hematuria and left flank pain. However, long-standing gross hematuria is uncommon. We report the case of a 23-year-old woman who had had painless gross hematuria for several months. Kidney biopsy revealed thin basement membrane disease, but this did not explain the gross hematuria with proteinuria. Renal venography and Doppler ultrasonography showed increased diameter and velocity ratios between the left renal vein and inferior vena cava. Cystoscopy revealed that the hematuria originated from the left ureteral orifice. These results indicate coexisting Nutcracker syndrome. Nutcracker syndrome with thin basement membrane disease should be considered in the differential diagnosis of a patient who has long-standing gross hematuria.

Long-Term Care Insurance and Medical Services for the Elderly: The Role of the Healthcare Industry

Wed, 01 Jun 2022 00:00:01 +0100

The long-term care insurance for the elderly system was officially implemented in July 2008, following a 3-year pilot program starting in 2005. The purpose of this system was to improve the quality of life of seniors and reduce the burden of care among family members, given the growing elderly population. By 2021, the scale of the system had increased by two to four times, with 860,000 beneficiaries and 9,824,800,000,000 KRW worth of insurance benefits. In line with this increase, it is necessary to efficiently establish and improve the system so that it can directly meet the medical needs of the beneficiaries. This may serve to reduce the rapidly increasing expenditure related to the elderly medical expenses, which in turn leads to a decrease in societal costs. In conclusion, senior care needs to be properly established and implemented in order to create organic intra- and inter-field connections between medicine, healthcare, and welfare.

Consensus Document on Perioperative Antithrombotic Management: Part 1. A Review

Wed, 01 Jun 2022 00:00:01 +0100

The prevalence of ischemic heart disease is steadily growing as populations age. Antithrombotic treatment is a key therapeutic modality for the prevention of secondary cerebro-cardiovascular disease. Patients with acute coronary syndrome or who are undergoing percutaneous coronary intervention must be treated with dual antiplatelet therapy for a mandatory period. The optimal perioperative antithrombotic regimen remains debatable; antithrombotics can cause bleeding. Inadequate antithrombotic regimens are associated with perioperative ischemic events, but continuation of therapy may increase the risks of perioperative hemorrhagic complications (including mortality). Many guidelines on the perioperative management of antithrombotic agents have been established by academic societies. However, the existing guidelines do not cover all specialties, nor do they describe the thrombotic and hemorrhagic risks associated with various surgical interventions. Moreover, few practical recommendations on the modification of antithrombotic regimens in patients who require non-deferrable interventions/surgeries or procedures associated with a high risk of hemorrhage have appeared. Therefore, cardiologists, specialists performing invasive procedures, surgeons, dentists, and anesthesiologists have not come to a consensus on optimal perioperative antithrombotic regimens. The Korean Platelet-Thrombosis Research Group presented a positioning paper on perioperative antithrombotic management. We here discuss commonly encountered clinical scenarios and engage in evidence-based discussion to assist individualized, perioperative antithrombotic management in clinical practice.

Intraductal Radiofrequency Ablation as a Palliative Treatment for Advanced Malignant Hilar ...

Wed, 01 Jun 2022 00:00:01 +0100

Malignant hilar biliary obstruction (MHBO) frequently accompanies cholestasis and cholangitis, and requires biliary stent placement. To prevent stent occlusion and prolong survival, local ablation therapy can be considered adjunctive to stent placement. Intraductal radiofrequency ablation (ID-RFA) is a recently developed local therapy for malignant biliary obstruction that can be easily performed employing endoscopic retrograde cholangiography. The use of ID-RFA to treat MHBO (as distinct from distal biliary obstruction) was suggested to be associated with severe adverse events. However, recent comparative studies have shown that ID-RFA is feasible and safe, and acceptably efficacious, in patients with advanced MHBO; newer temperature-controlled ID-RFA devices may enhance safety further. Regularly repeated ID-RFA with stent exchange affords better survival than stenting alone. However, the optimal ID-RFA strategy for MHBO remains inconclusive given the lack of data. Further large-scale clinical trials are needed.

Diagnosis and Treatment of Secondary Hypertension

Wed, 01 Jun 2022 00:00:01 +0100

Secondary hypertension, which refers to arterial hypertension caused by an identifiable medical condition, accounts for 5-10% of all hypertensive diagnoses; however, this is thought to be an underestimate. If diagnosed promptly, secondary hypertension can be treated, and proper blood pressure restored. This review focuses on the screening, diagnosis, and management of the most common forms of secondary hypertension, including primary aldosteronism, renovascular hypertension, pheochromocytoma, Cushings syndrome, and renal parenchymal disease.

Measurement and Interpretation of Fractional Exhaled Nitric Oxide

Wed, 01 Jun 2022 00:00:01 +0100

Nitric oxide is produced by the human lungs and increases in response to type 2 inflammation. The level of fractional exhaled nitric oxide (FeNO) may reflect type 2 inflammation in the airways, which is related to eosinophilic inflammation and treatment responsiveness to corticosteroids. The FeNO test is a non-invasive, simple, and safe point-of-care test to evaluate airway inflammation. It has been standardized for clinical use and has been widely utilized in daily medical practice. However, various intrinsic and extrinsic factors can affect FeNO levels, and understanding and controlling such factors will improve the utility of this measure. The FeNO test can be used to confirm an asthma diagnosis, predict treatment responses to corticosteroids, and guide inhaled corticosteroid therapy for asthma treatment.

Crohn

Wed, 01 Jun 2022 00:00:01 +0100

Crohns disease is usually diagnosed according to intestinal symptoms, but extra-intestinal manifestations are important in approximately one-third of cases. Although several extra-intestinal symptoms associated with various organs have been reported, renal involvement is uncommon in patients with Crohns disease. Tubulointerstitial nephritis in a patient with Crohns disease is usually caused by infection, sarcoidosis, or medications. However, primary tubulointerstitial nephritis caused by Crohns disease alone is extremely rare. A 19-year-old male patient was referred to our hospital because of an increase in serum creatinine level. He underwent a kidney biopsy with renal insufficiency. Renal histological findings revealed granulomatous tubulointerstitial nephritis. Thereafter, a colonoscopy was performed with suspicion of Crohns disease. Ultimately, he was diagnosed with granulomatous tubulointerstitial nephritis based on Crohns disease. The patient had improved gastrointestinal symptoms after the last treatment. This case report presents a rare case of primary tubulointerstitial nephritis caused by Crohns disease.

The Use of Palliative Endoscopic Ultrasound-guided Enterostomy to Treat Small Bowel Obstruction ...

Wed, 01 Jun 2022 00:00:01 +0100

Recurrent or refractory small bowel obstruction in postsurgical patients with advanced malignancies poses therapeutic dilemmas. Although some promising results have been achieved as small bowel endoscopic techniques advanced, palliative stent placement is both challenging and complex. Endoscopic ultrasound (EUS)-guided anastomosis using a lumen-apposing metal stent has been recently used during gastroenterostomy to treat benign or malignant gastric outlet obstruction. Data on the outcomes of EUS-guided enterostomy in patients with recurrent small bowel obstruction are lacking, although the technique is applicable throughout the entire gastrointestinal tract. We recently encountered recurrent or refractory small bowel obstruction in two poor surgical candidates. For the first case, we performed EUS-guided enterostomy to treat a recurrent obstruction after conventional stent insertion. The second case underwent EUS-guided transenteric stent placement to treat refractory small bowel obstruction associated with diffuse peritoneal carcinomatosis after failure of a conventional push endoscopic procedure.

What is the Fee for Infection Prevention and Control? Current Status and Prospect

Mon, 01 Aug 2022 00:00:01 +0100

Infection control is an essential factor for improving the quality of acute and long-term care facilities, including patient safety. Infection control should be implemented in all medical facility sectors, and participation of all healthcare workers is required. For efficient infection control, securing and maintaining professionals with sufficient experience and training to establish and implement infection control plans focusing the infection control unit is imperative. Moreover, there should be no shortage of infection control supplies, including consumables and disposables necessary for hand hygiene, personal protective equipment, and isolation. The fee for infection prevention and control should be resourced as necessary funding to establish such infection control infrastructure. Moreover, re-evaluating whether the standard for the fee for infection prevention and control is appropriate, improving the current payment mode, and monitoring whether the fee used is executed as infection control costs are necessary.

Consensus Document on Perioperative Antithrombotic Management: Part 2. Case Study

Mon, 01 Aug 2022 00:00:01 +0100

Given the progressive improvements in antithrombotic strategies, management of cardiovascular disease has become sophisticated/refined. However, the optimal perioperative management of antithrombotic therapy in patients with acute coronary syndrome or who are scheduled for percutaneous coronary intervention remains unclear. Assessments of the thrombotic and hemorrhagic risks are essential to reduce the rates of mortality and major cardiac events. However, the existing guidelines do not mention these topics. This case-based consensus document deals with common clinical scenarios and offers evidence-based guidelines for individualized perioperative management of antithrombotic therapy in the real world.

Chimeric Antigen Receptor-T Cell Therapy

Mon, 01 Aug 2022 00:00:01 +0100

Chimeric antigen receptor (CAR) T-cell therapy constitutes a revolutionary advancement in personalized cancer treatment. During this treatment, a patient's own T cells are genetically engineered to express a synthetic receptor that binds a tumor antigen. CAR-T cells are then expanded for clinical use and infused back into the patient's body to attack cancer. CAR-T cells have produced remarkable clinical responses with B-cell malignancies. However, CAR-T cells therapy is not without problems. Barriers to effective CAR-T cells therapy include severe life-threatening toxicities and modest anti-tumor activity. In this review, we introduce the concept of CAR-T cells therapy, currently available CAR-T cells therapy options, and how to deal with adverse events.

Patient Safety and Quality Improvement in Hospital Medicine

Mon, 01 Aug 2022 00:00:01 +0100

Hospitalists are specialists in inpatient care who aim to improve patient safety and quality of care. Accordingly, hospitalist research focuses on patient safety and quality improvement (QI). Major hospital medicine journals publish studies on patient safety and QI. This review introduces the latest research related to patient safety and QI research in the field of hospital medicine.

Diagnosis and Management of Comorbidities Associated with Bronchiectasis

Mon, 01 Aug 2022 00:00:01 +0100

Patients with non-cystic fibrosis bronchiectasis (hereafter referred to as bronchiectasis) often present with comorbidities. These comorbidities significantly impact symptoms, acute exacerbation, hospitalization, disease progression, and mortality in patients with bronchiectasis. Thus, accurate diagnosis and management of comorbidities associated with bronchiectasis are essential to reduce the disease burden of bronchiectasis. This review provides a state-of-the-art summary of key pulmonary and extra-pulmonary comorbidities associated with bronchiectasis, outlines clinical tools to quantify the prognosis of bronchiectasis, and suggests a workflow to diagnose and manage comorbidities associated with bronchiectasis.

Diagnosis of Small Intestinal Bacterial Overgrowth

Mon, 01 Aug 2022 00:00:01 +0100

Small intestinal bacterial overgrowth (SIBO) occurs when the small bowel is colonized by high numbers of abnormal microorganisms. There is no gold standard diagnostic test for SIBO. Both small bowel aspiration and breath testing have limitations as diagnostic tests. However, breath testing has the practical advantages of being readily available, inexpensive, and noninvasive.

The Impact of Pulmonary Hypertension on the Clinical Outcomes of Acute Myocardial Infarction ...

Mon, 01 Aug 2022 00:00:01 +0100

Background/Aims: Pulmonary hypertension (PH) in patients with heart failure contributes to a poor prognosis. However, the role of PH in the long-term clinical outcome is unclear in those with acute myocardial infarction (AMI). The clinical significance of elevated right ventricular systolic pressure (RVSP) on routine echocardiography is underestimated. Methods: This study enrolled 2,526 AMI patients (65.1

Renal Infarction in Vascular Ehlers-Danlos Syndrome

Mon, 01 Aug 2022 00:00:01 +0100

Renal infarction is a condition caused by sudden disturbance of renal arterial blood flow, which occurs frequently in cardioembolic disease, renal artery injury (trauma, Marfan syndrome, rarely Ehlers-Danlos syndrome), and in association with a hypercoagulable state. Ehlers-Danlos syndrome is a rare hereditary connective tissue disease characterized by skin fragility, hyperelasticity, hypermobility of small joints, and easy bruising. Among the subtypes, vascular Ehlers-Danlos syndrome is a very rare genetic disease caused by a mutation in the COL3A1 gene. As blood vessels are fragile due dysfunctional collagen synthesis, complications of bleeding due to arterial dissection or rupture are common in patients with this disease. Here, we report a case of vascular Ehlers-Danlos syndrome diagnosed based on a renal infarction caused by thrombus and renal artery injury; we also present a review of the relevant literature.

Post COVID-19 Emerging Infectious Diseases: What is the Next Pandemic Agent?

Sat, 01 Oct 2022 00:00:01 +0100

Emerging infectious diseases are increasing recently and globally. We have a long list of infectious disease epidemic in the 21th century followed by SARS, MERS, Ebola virus disease, and Zika virus infection. COVID-19 is a still ongoing pandemic. What will be the next pandemic agent? The World Health Organization proposed a research and development blueprint regarding global pandemic in 2016. The United Kingdom maintains a list of high consequence infectious diseases and is monitoring them. The Republic of Korea designates Class 1 infectious diseases capable of causing outbreak or epidemic. This article briefly describes several infectious diseases and its causative pathogen that should receive special attention.

Post-COVID-19 Syndrome

Sat, 01 Oct 2022 00:00:01 +0100

Although acute COVID-19 usually lasts for 12 weeks from the onset of symptoms, some patients experience variable persistent symptoms. Post-COVID-19 syndrome is defined as persistent symptoms and/or long-term complications that appear during or after COVID-19, persist for more than 12 weeks, and cannot be explained by an alternative diagnosis. The common symptoms of post-COVID-19 syndrome include general, pulmonary, hematological, cardiovascular, neuropsychiatric, renal, endocrine, gastroenterological, and dermatological symptoms. As the natural course and pathophysiology of COVID-19 are not yet clear, close monitoring is needed for various sequelae in multiple organs that occur in post-COVID-19 syndrome. In particular, patients who have been hospitalized in the intensive care unit or who have recovered from severe COVID-19 require close monitoring for the development of post-COVID-19 syndrome. Multidisciplinary collaboration is essential to provide integrated outpatient care for patients with post-COVID-19 syndrome.

2021 Korean Thyroid Imaging Reporting and Data System (2021-K-TIRADS) and Imaging-Based ...

Sat, 01 Oct 2022 00:00:01 +0100

The rate of detection of thyroid nodules and carcinomas has increased with the widespread use of ultrasonography (US), which is the primary imaging modality for the detection and risk stratification of thyroid nodules. The appropriate diagnosis and management of these patients is based on the risk factors related to the patients as well as the thyroid nodules. The Korean Society of Thyroid Radiology (KSThR) published consensus recommendations for US-based management of thyroid nodules in 2011 and revised them in 2016. These guidelines have been used as the standard guidelines in Korea. However, recent advances in the diagnosis and management of thyroid nodules have necessitated the revision of the original recommendations. The task force of the KSThR has revised the Korean Thyroid Imaging Reporting and Data System and recommendations for US lexicon, biopsy criteria, US criteria of extrathyroidal extension, optimal thyroid computed tomography protocol, and US follow-up of thyroid nodules before and after biopsy. The biopsy criteria were revised to reduce unnecessary biopsies for benign nodules while maintaining an appropriate sensitivity for the detection of malignant tumors. The goal of these recommendations is to provide the optimal scientific evidence and expert opinion consensus regarding US-based diagnosis and management of thyroid nodules.

Management Strategies for the Successful Establishment and Growth of the Hospitalist System

Sat, 01 Oct 2022 00:00:01 +0100

Appropriate management strategies are required to establish, maintain, and promote the growth the hospitalist system. Herein, we discuss strategies for the successful operation of the hospitalist system from the business point of view, particularly in terms of human resources and organizational management. Hospital executives should establish the vision, mission, value, and key value drivers of the hospitalist system from its inception, as well as decide its size and operation pattern according to the situation of each medical institution. Hospitalists are employed through the process of recruitment to increase the number of applicants and allow the selection of suitable candidates. Once the hospitalist system is constructed and operational, the focus must shift toward its growth. The goals and strategies for growth should be decided, leaders must be selected, and assistants must be employed. In the future, the hospitalist system is expected to play an essential role in improving the quality of medical care. Therefore, medical institutions should strategically introduce, maintain, and promote the growth of the hospitalist system.

Diagnostic Approach for Acute Myeloid Leukemia Based on the World Health Organization ...

Sat, 01 Oct 2022 00:00:01 +0100

Acute myeloid leukemias (AMLs) are heterogeneous hematologic neoplasms characterized by myeloblast or promyelocyte proliferation without normal differentiation. The World Health Organization (WHO) classifies AMLs on the basis of chromosomal and genetic aberrations, with different prognoses for each subtype. Therefore, accurate diagnosis and classification of AMLs is critical for timely and appropriate treatment. Initial diagnostic workup includes morphologic assessment of the bone marrow aspirate and trephine biopsies, immunophenotyping using flow cytometry or immunohistochemistry stains, chromosomal analysis using the G-banding technique or fluorescence in situ hybridization, and mutation analysis using polymerase chain reaction, direct sequencing, or next-generation sequencing. The present study provides an algorithm for AML diagnosis and classification based on the WHO criteria and describes different clinicopathological stages of the workup.

Clinical Implication of Molecular Tumor Board

Sat, 01 Oct 2022 00:00:01 +0100

Due to rapid technical advances, steeply declining sequencing costs, and the ever-increasing number of targeted therapies, it is expected that extensive tumor DNA or RNA sequencing will be applied in standard of care. Clinicians will thus be confronted with increasingly complex genetic information and multiple test-platforms to choose from. General medical training, meanwhile, can hardly keep up with the pace of innovation. Consequently, there is a rapidly growing gap between clinical knowledge and genetic potential in cancer care. Multidisciplinary Molecular Tumor Boards (MTBs) have been suggested as a means to address this disparity, as a multidisciplinary approach to keep pace with the growing knowledge of complex molecular alterations in patients with advanced solid cancer. MTBs are designated to interpret these data and provide clinical recommendations. Not all patients with cancer have access to advice of an MTB. We aimed to determine the current status, opportunities, and challenges of the organization of MTBs in the Korea.

Percutaneous Treatment of Recurrent Stroke Caused by a Cardiac Foreign Body: A Case Report

Sat, 01 Oct 2022 00:00:01 +0100

We present a case of recurrent ischemic stroke in a 68-year-old man with a linear foreign body in the right atrium and ventricle and a patent foramen ovale (PFO). The patient developed atrial fibrillation despite taking warfarin at a therapeutic dose and had a third acute stroke. We planned left atrial appendage (LAA) occlusion via the PFO, followed by PFO closure and foreign body removal. The percutaneous LAA occlusion and PFO closure were successful. However, it was difficult to remove the radiolucent foreign body. We inserted an Omni catheter via the right jugular vein to contact the foreign body in the right atrium directly, grasped its distal end with a snare, and successfully extracted it. The patient was followed-up in the outpatient clinic and had no recurrent stroke.

Successful Living Donor Kidney Transplantation in a Patient with MTHFR Deficiency and ...

Sat, 01 Oct 2022 00:00:01 +0100

Perioperative anticoagulation in a kidney transplant recipient with heparin-induced thrombocytopenia is challenging due to paradoxical hypercoagulability. A 49-year-old man with end-stage kidney disease and a previous stroke history was referred for living donor kidney transplantation. After the fifth dialysis session, the platelet count decreased to 10,000/?L, and heparin was immediately discontinued. Five days later, pulmonary thromboembolism with deep vein thrombosis was identified. Anti-heparin PF4 antibody, elevated serum homocysteine, and methylenetetrahydrofolate reductase gene mutations were discovered. Subsequent coronary angiography revealed three-vessel disease. Apixaban, folate, aspirin, and clopidogrel were administered and an inferior vena cava filter was implanted. Thereafter, coronary artery bypass graft surgery was performed using argatroban-bridging without complications. Kidney transplantation was performed 3 months later using the argatroban protocol. The graft kidney functioned well without any complications. In conclusion, we successfully conducted kidney transplantation in a thrombophilic patient with a methylenetetrahydrofolate reductase deficiency and heparin-induced thrombocytopenia by establishing an individualized perioperative anticoagulation protocol.

Current Challenges for the Korean Association of Internal Medicine

Thu, 01 Dec 2022 00:00:01 +0100

Since its establishment in 1945, the Korean Association of Internal Medicine (KAIM) has had a proud history of overcoming challenges with the combined and harmonized endeavors of all KAIM members. KAIM is now facing several issues related to marked social changes in Korea as well as revolutions in medical science and scientific and communications technologies. Furthermore, KAIM shortened the resident training program in 2017. Internal medicine (IM) is an essential discipline for maintaining and improving the health of Korean citizens. However, the Korean Ministry of Health and Welfare lacks initiatives for supporting IM, and the Korean Health Insurance reimbursement policy does not reflect the essential role of IM in health care. This is aggravated by imbalances in hospital resources and skewed notions in patients preferences with regard to metropolitan and non-metropolitan areas. Limited preferences in application to subspecialties may be an obstacle for coordinated development of IM. The current generations of students and residents are familiar with online educational lectures and have different needs for educational materials, which are not met by conventional educational materials. Recent experiences in the COVID-19 pandemic have exacerbated or accelerated these changes and problems. From this perspective, I will summarize the challenges that KAIM is now facing, and outline some possible solutions.

2022 Consensus Statement on the Management of Familial Hypercholesterolemia in Korea

Thu, 01 Dec 2022 00:00:01 +0100

Familial hypercholesterolemia (FH) is the most common monogenic disorder. Due to the marked elevation of cardiovascular risk, the early detection, diagnosis, and proper management of this disorder are critical. Herein, the 2022 Korean guidance on this disease is presented. Clinical features include severely elevated low-density lipoprotein cholesterol (LDL-C) levels, tendon xanthomas, and premature coronary artery disease. Clinical diagnostic criteria include clinical findings, family history, or pathogenic mutations in the LDLR, APOB, or PCSK9. Proper suspicion of individuals with typical characteristics is essential for screening. Cascade screening is known to be the most efficient diagnostic approach. Early initiation of lipid-lowering therapy and the control of other risk factors are important. The first-line pharmacological treatment is statins, followed by ezetimibe, and PCSK9 inhibitors as required. The ideal treatment targets are 50% reduction and < 70 or < 55 mg/dL (in the presence of vascular disease) of LDL-C, although less strict targets are frequently used. Homozygous FH is characterized by untreated LDL-C > 500 mg/dL, xanthoma since childhood, and family history. In children, the diagnosis is made with criteria, including items largely similar to those of adults. In women, lipid-lowering agents need to be discontinued before conception.

Updated Treatment Guidelines for Chronic Hepatitis B

Thu, 01 Dec 2022 00:00:01 +0100

Chronic hepatitis B virus (HBV) infection is a major cause of liver cirrhosis and hepatocellular carcinoma in Korea. While the prevalence of HBV infection is gradually declining in Korea, 3 of the population still suffers from HBV-related chronic liver diseases. In this review, we summarize the updated clinical guidelines for management of chronic HBV, as revised by the Korean Association for the Study of the Liver in 2022.

Abdominal Pain over 6 Months

Thu, 01 Dec 2022 00:00:01 +0100

Inflammatory bowel disease includes two major types of disease: Crohns disease and ulcerative colitis. The incidence of inflammatory bowel disease is increasing worldwide, including in Korea. This chronic disease progresses gradually, with cycles of improvement and exacerbation. Therefore, a quick diagnosis and appropriate treatment are necessary. In this review, we discuss the clinical symptoms of inflammatory bowel disease, as well as diagnostic methods.

Evaluation of Diastolic Dysfunction and the Role Thereof in Heart Failure with Preserved ...

Thu, 01 Dec 2022 00:00:01 +0100

Evaluation of left ventricular diastolic function is essential, especially in patients with heart failure with preserved ejection fraction. The American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines were released in 2016. Four principal parameters were used to assess left ventricular diastolic function. However, there are grey areas; the situation is complex. Recently, various other indicators have been employed to explore left ventricular diastolic function.

Endobronchial Involvement of Mycobacterium intracellulare in a Patient with Previously Treated ...

Thu, 01 Dec 2022 00:00:01 +0100

The incidence of nontuberculous mycobacterial pulmonary disease is increasing, and Mycobacterium avium complex (MAC) is the most common causal species. Patients with underlying structural lung disease or an immunosuppressive condition are at increased risk for MAC infections. Endobronchial lesions caused by MAC infection are extremely rare, especially in immunocompetent hosts. Here, we describe a case of a 58-year-old woman with pulmonary infiltration and endobronchial involvement caused by MAC. The patient had shortness of breath and a productive cough. She had undergone surgery and chemoradiotherapy for lung cancer 10 years prior. Radiological findings revealed small centrilobular nodules with consolidation in the right lung and mild stenosis at the right main bronchus. Bronchoscopy revealed yellowish-white caseous necrosis in the right main bronchus. Mycobacterium intracellulare was identified in bronchial washing fluid. She was treated with antimicrobial medications. After 6 months of treatment, bronchial lesions, radiological findings, and symptoms had improved remarkably and she showed culture conversion.

The Vision of Hospitalist System in Korea

Mon, 01 Feb 2021 00:00:01 +0100

Impact of a Primary Health Care Chronic Diseases Management Pilot Program

Mon, 01 Feb 2021 00:00:01 +0100

Considerable efforts have been made to prevent and manage hypertension and diabetes, but the prevalence of these diseases has not changed significantly over the past 10 years. Hypertension and diabetes are chronic conditions requiring continuous treatment and management. Controlling blood pressure and blood sugar levels can prevent life-threatening complications and a deterioration in the quality of life. Community-centered primary health care is characterized by inclusiveness and continuous contact. Well-established primary health care services can reduce the number of unnecessary emergency room visits, hospitalizations, and medical tests, and therefore minimize unnecessary medical expenses. However, the number of patients treated for mild chronic diseases at large hospitals has increased, with a concomitant decrease in the proportion of outpatient clinic visits (41.6% in 2007 vs. 37.8% in 2016). Thus, there is a clear need to strengthen primary health care, including for the treatment of chronic diseases. To establish a chronic diseases management system based on local clinics, the Ministry of Health and Welfare of Korea launched a pilot chronic diseases management program aimed at increasing patient acceptance of local primary health care. The program was implemented in 2014, 2016, and 2019. This review examines the short-term impact of the pilot program with respect to the prevention and management of hypertension and diabetes.

The Current Strategy of Helicobacter pylori Eradication

Mon, 01 Feb 2021 00:00:01 +0100

Helicobacter pylori (H. pylori) is the main cause of most gastroduodenal diseases. Triple therapy including two antibiotics, amoxicillin and clarithromycin, and a proton pump inhibitor given for a week has been recommended as the treatment of choice since the revision of the Korean H. pylori Clinical Practice Guidelines in 2013. However, antimicrobial resistance significantly decreased the cure rate of H. pylori eradication to 63.9%. Thus, the new H. pylori treatment regimen would be needed to increase the eradication rate in Korea. Recently, the update of clinical practice guideline for treatment of H. pylori was developed by conducting a meta-analysis. In this review, the recommended H. pylori eradication regimen in current 2020 guideline will be discussed.

Treatment of Critically Ill Patients with Coronavirus Disease 2019

Mon, 01 Feb 2021 00:00:01 +0100

Clinical manifestations of coronavirus disease 2019 (COVID-19) is diverse ranging from asymptomatic or mild respiratory symptoms to severe acute respiratory distress syndrome (ARDS) and respiratory failure. As the pandemic progresses, the number of critically ill COVID-19 patients continues to increase. Whether or not COVID-19 ARDS patients are distinct from conventional ARDS is not settled, and there is no definite evidence that they should be treated differently from ARDS of other origins. The use of oxygen treatment with high flow nasal cannula has been increased. Invasive mechanical ventilation should be applied with lung protective strategy in mind. Prone positioning should be actively considered. Since the primary cause of death of COVID-19 patients is respiratory failure, understanding the characteristics of COVID-19 ARDS and its treatment is necessary for optimal outcome.

Diagnosis and Treatment of Adult-Onset Still

Mon, 01 Feb 2021 00:00:01 +0100

Adult-onset Stills disease (AOSD) is an obscure disease that is usually diagnosed after the exclusion of other febrile diseases, including other autoimmune, infectious, and malignant diseases. Although definitive diagnostic criteria and treatment guidelines for AOSD are thus far lacking, the typical manifestations of AOSD have been identified and effective medications for remission and maintenance have been proposed. The pathophysiology of the AOSD is unclear, but diagnostic criteria and treatment guidelines for AOSD can be established by determining its core etiology and conducting clinical trials of previously tested immunosuppressants and biologics.

Urinary Extracellular Vesicles as Biomarkers of Kidney Disease

Mon, 01 Feb 2021 00:00:01 +0100

Extracellular vesicles (EVs) are membrane-bound vesicles produced and released into the extracellular fluid by cells under physiological and stressful conditions. They play a role as intracellular communicators by carrying and delivering biomolecules, such as proteins, lipids, or nucleic acids. Urinary EVs have gained important recognition as potential diagnostic biomarkers in renal disease, as they can originate from diverse cell types, including glomerular podocytes, tubular epithelial cells, or endothelial cells. Accumulating evidence has emphasized the feasibility of using EVs as biomarkers for diagnostic, prognostic, and therapeutic purposes in several forms of renal disease, such as acute kidney injury, glomerulonephritis, and renal transplantation. In this review, we introduce recent studies that attempt to identify urinary EVs as candidate biomarkers for human kidney diseases and consider their potential implications as a therapeutic option in significant kidney diseases.

Beta-Lactam Allergy: Real Practice in a Regional Hospital

Mon, 01 Feb 2021 00:00:01 +0100

Background/Aims: Beta-lactam (BL) antibiotics are widely prescribed for controlling bacterial infections and relevant culprits of adverse drug reactions (ADRs). BL allergy may vary according to prescription patterns within a given period of time. However, BL allergy in contemporary clinical practice has rarely been a focus of research. Methods: To investigate the clinical characteristics of BL allergy, subjects with ADRs to medicines, including BL antibiotics, were retrospectively reviewed. Results: Among the 175 enrolled subjects, BL antibiotics as culprits were confirmed in 79 (45.1%, female 53.2%, age 49

Immunoglobulin G4-Related Kidney Disease with Membranous Proliferative Glomerulonephritis ...

Mon, 01 Feb 2021 00:00:01 +0100

Immunoglobulin G4 (IgG4)-related kidney disease is a chronic immune-mediated fibro-inflammatory disorder characterized by multiple organ infiltration with IgG4-positive plasma cells, storiform fibrosis, and obliterative phlebitis or tumefactive lesions. Previous studies have explored IgG4-related kidney disease, increasing our understanding of its clinical manifestations, and pathological and radiologic findings. However, IgG4-related kidney disease can be misdiagnosed since it mimics malignancies. We report a case of a 77-year-old Korean man diagnosed with IgG4-related kidney disease with membranous proliferative glomerulonephritis, presenting with a renal pelvic mass suspected of being malignant.

Removal of a Small Bowel Bezoar Causing Bowel Obstruction via Mechanical Compression after ...

Mon, 01 Feb 2021 00:00:01 +0100

Small bowel obstructions (SBOs) that develop for various reasons often require prompt medical treatment. Migration of a gastric bezoar (indigestible foreign material that has accumulated in the stomach) is a rare cause of SBO. Treatment of a symptomatic SBO caused by a bezoar requires a multidisciplinary approach that considers the patients physical status and comorbidities and the bezoar volume, location, and pathology. Although surgery is the treatment of choice, endoscopic treatments such as fragmentation and retrieval may serve as alternatives. We present the first case of resolution of a large phytobezoar via mechanical compression after covered metal stent insertion, followed by stent retrieval, in a patient with a symptomatic SBO that persisted even after two sessions of push-endoscopic fragmentation.

Pyoderma Gangrenosum of the Chest Wall in a Male Patient with Ulcerative Colitis

Mon, 01 Feb 2021 00:00:01 +0100

Ulcerative colitis, an inflammatory bowel disease, often exhibits extra-intestinal manifestations including various dermatological problems. Pyoderma gangrenosum (PG) is a painful ulcerative cutaneous disorder characterized by the development of rapidly enlarging nodules. The lesion may become aggravated when ulcerative colitis is active, and it commonly affects the extensor surfaces of the lower extremities but rarely the upper extremities, face, periauricular area, anterior chest, back, or buttocks. We encountered a rare case of PG of the chest wall near the left breast, on the face and pretibial area of a male patient with ulcerative colitis. He had not undergone breast surgery and had no history of trauma. The lesion and symptoms were successfully treated by steroid and mesalazine; there was no need for surgery or more potent drugs.

The Prospect of Geriatric Medicine

Thu, 01 Apr 2021 00:00:01 +0100

2021 Korean Heart Rhythm Society Guidelines for Screening and Management of Subclinical Atrial ...

Thu, 01 Apr 2021 00:00:01 +0100

Atrial fibrillation (AF) is a strong risk factor for embolic stroke. In patients with AF, optimal anticoagulation therapy, administered according to the stroke risk scoring system, can effectively reduce the stroke risk. However, AF episodes are frequently asymptomatic, with a significant number of them detected after a stroke event. Therefore, the early detection of subclinical AF and the subsequent administration of optimal oral anticoagulation therapy is expected to reduce the risk of stroke. However, this strategy requires more effective screening for the detection of AF in the asymptomatic stage, which accounts for the recent research interest in silent/subclinical AF. Today, the widespread use of cardiac implantable electronic devices and wearable rhythm monitors has enabled the detection of atrial high-rate episodes/subclinical AF in a substantial number of patients. The risk of stroke appears to be related to the duration of this phenomenon. Subclinical AF increases the risk of stroke, but generally not as much as clinical AF, but whether long-term anticoagulation therapy is required in patients with subclinical AF is unclear. Here we review existing data on the epidemiology, clinical significance, and suggest guidelines on management of subclinical AF and the optimal screening strategies aimed at its detection.

Anti-Diabetic Drugs in Cardiovascular Disease

Thu, 01 Apr 2021 00:00:01 +0100

Diabetes is one of the important risk factors in cardiovascular disease associated with atherosclerosis, and cardiovascular disease is the leading cause of death in patients with diabetes mellitus. Recent randomized placebo-controlled cardiovascular outcome trials of all new antidiabetic drugs have linked SGLT-2 inhibitors and GLP1-agonists to not only increased cardiovascular stability but significant reduction of cardiovascular disease. These results have led to preferential selection of the most effective and beneficial antidiabetic drugs with the evidence of cardiovascular safety and efficacy. Herein, we address cardiovascular stability and the effectiveness of antidiabetic drugs, focusing on recently developed ones.

Nonalcoholic Fatty Liver Disease and Endoplasmic Reticulum Stress

Thu, 01 Apr 2021 00:00:01 +0100

Nonalcoholic fatty liver disease (NAFLD) is a major public health problem with comorbidities including obesity and dyslipidemia. Although the manifestations of NAFLD range from simple steatosis to non-alcoholic steatohepatitis, these may potentially give rise to liver cirrhosis and hepatocellular carcinoma. However, the mechanisms underlying NAFLD, and the factors that determine the individual risk of disease progression, remain poorly known. The most obvious clinicopathological characteristic of NAFLD is hepatic lipid accumulation and subsequent inflammation. In hepatocytes, the endoplasmic reticulum (ER) is a critical site of protein synthesis, detoxification, lipid and glucose metabolism, and Ca²⁺ homeostasis; the ER is involved in NAFLD pathogenesis. Hepatic accumulation of lipids stresses the ER; this activates the unfolded protein response (UPR), which is classically viewed as an adaptive pathway that maintains ER homeostasis. Recent studies have revealed that UPR sensors regulate hepatic steatosis and the cellular response to lipotoxic stress. Therefore, the basic mechanisms of ER stress and UPR induction are of great interest for understanding the pathogenesis of NAFLD. The present review focuses on the roles played by ER stress and the UPR in NAFLD pathogenesis.

Fever of Unknown Origin: An Overview of the Diagnostic Approach

Thu, 01 Apr 2021 00:00:01 +0100

Although fever of unknown origin (FUO) was first defined in 1961, it remains a diagnostic challenge. The revised 1991 definition categorized FUO into classic FUO, nosocomial FUO, neutropenic FUO, and human immunodeficiency virus-related FUO, each requiring at least three outpatient visits or 3 days of in-hospital stay. The causes of classic FUO differ greatly geographically and temporally, and are divided into infections, noninfectious inflammatory diseases, neoplasms, and miscellaneous diseases. A systematic, comprehensive and rational approach is required for appropriate diagnosis. A medical history and physical examination are very important; they may reveal diagnostic clues. Here, we review the literature on the causes and diagnostic approaches of classical FUO.

Screening of Pancreatic Cancer for Early Diagnosis

Thu, 01 Apr 2021 00:00:01 +0100

Over 80% of patients with pancreatic ductal adenocarcinomas (PDAs) present with symptomatic, surgically unresectable disease. If a stage shift from the current 20% proportion of resectability to early detection could be achieved, this would greatly improve the survival of patients with this generally dismal disease. Although the goal of early detection is laudable, the relatively low prevalence of PDA renders general population screening unfeasible. To avoid the perils of overdiagnosis and to focus early detection efforts on individuals deemed to be at higher-than-average risk, we need to define such subsets of individuals, such as kindred of existing patients and those with precursor cystic lesions, chronic pancreatitis, and new-onset diabetes. The next step is to determine when and how often to monitor at-risk individuals and the diagnostic modalities that will be employed in the surveillance. Enormous challenges remain in terms of validated blood-based biomarkers, imaging modalities, and when and how often surveillance.

Clinical Practice Guidelines for the Treatment of Functional Dyspepsia in Korea

Thu, 01 Apr 2021 00:00:01 +0100

Background/Aims: Functional dyspepsia (FD) is a chronic upper gastrointestinal symptom complex that routine diagnostic work-up, such as endoscopy, blood laboratory analysis, or radiological examination, fails to identify a cause for. It is highly prevalent in the Korean population, and its response to the various available therapeutic strategies is only modest because of the heterogeneous nature of its pathogenesis. We constituted a guidelines development committee to review the existing guidelines on the management of FD. Methods: This committee drafted statements and conducted a systematic review and meta-analysis of various studies, guidelines, and randomized control trials. External review was also conducted by selected experts. These clinical practice guidelines for FD were developed based on evidence recently accumulated with the revised version of FD guidelines released in 2011 by the Korean Society of Neurogastroenterology and Motility. Results: These guidelines apply to adults with chronic symptoms of FD and include the diagnostic role of endoscopy, Helicobacter pylori screening, and systematic review and meta-analyses of the various treatment options for FD (proton pump inhibitors, Helicobacter pylori eradication, and tricyclic antidepressants), especially according to the FD subtype. Conclusions: The purpose of these new guidelines is to aid understanding, diagnosis, and treatment of FD, and the targets of the guidelines are clinicians, healthcare workers at the forefront of patient care, patients, and medical students. The guidelines will continue to be revised and updated periodically.

Nafcillin-Associated Hypokalemia

Thu, 01 Apr 2021 00:00:01 +0100

Hypokalemia is a common finding in various clinical settings; it is associated with diuretic use and loss of potassium via the gastrointestinal tract. Less common causes are renal tubular acidosis, diabetic ketoacidosis, excess insulin, primary hyperaldosteronism, and medications, such as amphotericin B. Nafcillin, a narrow-spectrum penicillin class antibiotic, which is selectively prescribed for methicillin-susceptible Staphylococcal aureus infections, and is commonly associated with gastrointestinal side effects, such as nausea, vomiting, and abdominal pain. However, in rare cases it can cause hypokalemia, which is usually overlooked. Severe hypokalemia was detected in a 59-year-old male patient hospitalized due to traumatic cerebral hemorrhage who received 12 g of nafcillin per day for more than 2 weeks for sepsis caused by methicillin-sensitive Staphylococcus epidermidis. We confirmed the association between nafcillin and hypokalemia through further evaluation and a review of the relevant literature. Clinicians should be aware of hypokalemia as a complication when using high doses of nafcillin.

COVID-19 Mimicking Acute Colitis

Thu, 01 Apr 2021 00:00:01 +0100

On 11 February, 2020, the World Health Organization announced that COVID-19 was a novel coronavirus disease first detected in Wuhan, Hubei Province, China. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The complete clinical picture is not fully known. Illness ranges from mild to fatal. The common symptoms include fever, cough, and dyspnea usually developing 2-14 days after exposure. However, diarrhea was present in a few patients with COVID-19. We report a case of COVID-19 mimicking acute colitis.

Systemic Lupus Erythematosus Manifested as Pancytopenia during Tuberculosis Treatment

Thu, 01 Apr 2021 00:00:01 +0100

A 49-year-old Chinese woman presented to Ilsan Paik Hospital emergency department with fever and general weakness. Chest computed tomography revealed cavity and peribronchial nodules and consolidation in the right upper lobe. A diagnosis of suspected active tuberculosis was made. A review of the patients medication prescribed at another hospital indicated that she had been taking antituberculosis medication for several months. Initially, the patient had anemia and mild thrombocytopenia. In addition, she developed leukopenia and her thrombocytopenia worsened. After discontinuing the antituberculosis medication, her pancytopenia initially improved, but was aggravated again after starting on antituberculosis drugs. Despite discontinuing the antituberculosis medication again, her pancytopenia progressed. As she had a high anti-nuclear antibody titer, another systemic disease was suspected. She was diagnosed with systemic lupus erythematosus and her leukopenia and thrombocytopenia improved after initiation of treatment with systemic steroids and antimalarial drugs.

Blood Tests for the Diagnosis of Adrenal Diseases

Thu, 01 Apr 2021 00:00:01 +0100

Comprehensive Understanding and Field Application of COVID-19 Vaccine

Tue, 01 Jun 2021 00:00:01 +0100

Evidence-Based Guidelines for the Treatment of Helicobacter pylori Infection in Korea: 2020 ...

Tue, 01 Jun 2021 00:00:01 +0100

Helicobacter pylori (H. pylori) infection is one of the most common infectious diseases worldwide. Although its incidence is gradually decreasing, about half of the world's population still get infected. H. pylori infection is responsible for substantial gastrointestinal morbidity worldwide. It is the most common cause of gastric and duodenal ulcers as well as gastric cancer. Since the revision of the H. pylori Clinical Practice Guidelines in 2013, the eradication rate of H. pylori has gradually decreased with the use of classical triple therapy, wherein amoxicillin, clarithromycin, and proton pump inhibitors are administered, for 7 days. According to a nationwide randomized controlled study conducted by the Korean College of Helicobacter and Upper Gastrointestinal Research released in 2018, the intention-to-treat eradication rate was only 63.9%, which was due to increased antimicrobial resistance induced by the use of antibiotics, especially clarithromycin. The update of clinical practice guideline for treatment of H. pylori was developed based on evidence-based medicine by conducting a meta-analysis. The draft recommendations were finalized after expert consensus on three recommendations regarding the indication for treatment and eight recommendations on the treatment itself. These guidelines are designed to provide patients, nurses, medical school students, policymakers, and clinicians with clinical evidence to guide primary care and treatment of H. pylori infection. These may differ from current medical insurance standards and will be revised further, if necessary, based on research-based evidence.

Improved Capsule Endoscopy Using New Computer Vision Technologies

Tue, 01 Jun 2021 00:00:01 +0100

Advanced computer vision technologies can be used to improve the performance of capsule endoscopy. Specifically, new technologies can be used to enhance the image quality of capsule endoscopes, which has previously been limited by mechanical constraints. The trajectory of a capsule endoscope, which can be estimated by reconstructing the captured images, helps to predict the location of lesions. Computer vision technology is utilized in a more practical way in a recently developed capsule endoscope comprising a stereo camera. Using this device, images can be interpreted in three dimensions, enabling more accurate measurements of size. The use of deep learning for image recognition is associated with an improved lesion detection rate and reduced reading time in clinicians. This evolving technology requires close cooperation between medical and IT professionals for optimized clinical use.

An Updated Review of Chronic Lymphocytic Leukemia

Tue, 01 Jun 2021 00:00:01 +0100

Chronic lymphocytic leukemia (CLL), characterized by monoclonal B-cell accumulation and highly variable clinical manifestations that range from an indolent to an aggressive course, is rare in Korea. Asymptomatic patients with early stage CLL can be followed up without treatment; however, those with active or advanced disease require treatment immediately after diagnosis, for symptom alleviation and prolonging survival. Previously, chemotherapy using cytotoxic agents was the only therapeutic option available for patients with CLL. Research has provided a deeper understanding of the pathophysiology of the disease, and novel agents such as monoclonal antibodies and small-molecule inhibitors that target specific sites on leukemic cells have been introduced. The advent of these new drugs has led to improved clinical outcomes in patients with CLL. Currently, Brutons tyrosine kinase inhibitors or B-cell lymphoma-2 inhibitors are recommended as frontline therapy, prior to the administration of cytotoxic agents or combination therapy with monoclonal antibodies. In this article, we review the diagnosis and prognosis of CLL, in addition to the clinical implications of the various therapeutic options.

Interpretation of Pulmonary Function Tests and Optimization of Inhalation Therapy

Tue, 01 Jun 2021 00:00:01 +0100

Spirometry, also called office-based pulmonary function testing, is a useful tool for diagnosis and classification of lung disease. Here, we outline a simple stepwise approach for interpretation of spirometry results. The first step is to determine the forced expiratory volume in a one second/forced vital capacity (FEV1/FVC) ratio. If airflow is limited, a bronchodilator is administered followed by reassessment. The next step is to determine whether FVC is low; an observed decrease in FVC indicates a restrictive patten. For patients with obstructive disease, inhalation medication is needed. Therefore, this review also describes the most appropriate inhalation device for each patient and the correct use of the device to maximize inhalation therapy benefits.

Diagnostic Approach to Angina Pectoris

Tue, 01 Jun 2021 00:00:01 +0100

Stable angina is a chronic, systemic disease with a wide range of associated symptoms and clinical outcomes. Prompt diagnosis can be challenging for clinicians. Typical chest pain caused by stable angina occurs when the myocardium receives inadequate oxygen, resulting in myocardial ischemia. Various diagnostic tools including non-invasive tests such as coronary computed tomographic angiography and image-based stress tests have evolved over the last decade. An important factor in the selection of the proper diagnostic test for stable angina is assessment of the pre-test probability in the event of possible coronary arterial stenosis.

Guidelines for Safe Drug Use

Tue, 01 Jun 2021 00:00:01 +0100

Background/Aims: In Korea, medications are available by prescription from a physician, or can be purchased over-the-counter (OTC) without a prescription. Education regarding both prescribed and OTC drugs is important to minimize side effects and avoid drug abuse. The risk of side effects due to polypharmacy is increasing due to the growing number of elderly patients with comorbidities. Methods: There are various clinical guidelines for physicians, but it is difficult for patients and their caregivers to find published guidelines regarding drug use. In this regard, experts from nine subspecialties of internal medicine, geriatric medicine, and guideline development methodology formed a working group to develop guidelines for safe drug use under the Clinical Practice Guidelines Committee of the Korean Association of Internal Medicine. Results: The main contents of this guideline are 1) safe and effective drug administration, 2) the proper use of analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs), 3) the proper use of tranquilizers and sleeping pills to prevent drug abuse, 4) points to be aware of when taking multiple medications. Conclusions: The guidelines were developed for patients and their caregivers to understand the general principles and precautions for drug use, including commonly used painkillers, mood stabilizers, sleeping pills, and polypharmacy. These guidelines could also be used as educational materials for physicians, nurses, and healthcare workers to educate patients and their caregivers.

Hepatopulmonary Syndrome with Finger Clubbing

Tue, 01 Jun 2021 00:00:01 +0100

Hepatopulmonary syndrome is a rare lung complication of liver cirrhosis, caused by pulmonary microvascular vasodilation that induces abnormal arterial oxygenation. Typical findings on physical examination are finger clubbing and cyanosis. Dyspnea is a common symptom and is worse in the upright position. Contrast echocardiography is a useful diagnostic test. Currently, the only effective treatment is liver transplantation. We report the case of a woman with cirrhosis who has hepatopulmonary syndrome with finger clubbing, confirmed by contrast echocardiography. The patient is waiting for a liver transplant.

Large Hypothyroidism-Induced Pericardial Effusion with Increased Serum Tumor Markers

Tue, 01 Jun 2021 00:00:01 +0100

Pericardial effusion is a common disease seen by echocardiography, and it is found in 39% of annual echocardiograms. Although moderate pericardial effusion has been reported in some cases, it is usually asymptomatic and is rarely accompanied by cardiac tamponade. A large pericardial effusion may be due to various causes, including idiopathic causes, tuberculosis, cancer, connective tissue disease, infection, and hypothyroidism. Recent advances in analytic and imaging techniques have increased our ability to diagnose the cause of pericardial effusion accurately. This information is important for determining the proper treatment based on each cases clinical characteristics. We report a case of large, recurrent pericardial effusion accompanied by hypothyroidism with initial increased levels of tumor markers, including cancer antigen 125, carcinoembryonic antigen, and alpha-fetoprotein. The patient was treated with thyroid hormone only. In follow-up images, the pericardial effusion was resolved and all of the tumor markers were normalized.

A Rare Case of Pulmonary Arteriovenous Malformation Caused by Hereditary Hemorrhagic ...

Tue, 01 Jun 2021 00:00:01 +0100

Hereditary hemorrhagic telangiectasia (HHT) is an uncommon autosomal dominant disorder resulting in vascular malformation, such as pulmonary arteriovenous malformation (PAVM). Here, we report a rare case of pulmonary arteriovenous malformation caused by HHT in a hemodialysis (HD) patient. A 34-year-old man receiving maintenance HD via radiocephalic arteriovenous fistula developed progressive dyspnea without definite pulmonary edema. His mother had been diagnosed with HHT. He had experienced multiple episodes of epistaxis and had been intermittently treated with blood transfusions because of severe anemia. Blood gas analysis showed hypoxia. Chest computed tomography revealed multiple dilated vessels of variable sizes, continuous with the pulmonary artery throughout both lung fields, consistent with PAVM. After treating pulmonary artery embolization at the largest PAVM, he recovered from his dyspnea symptoms and hypoxia.

2021 Korean Heart Rhythm Society Guidelines for Screening and Management of Subclinical Atrial ...

Tue, 01 Jun 2021 00:00:01 +0100

Untact Management of Patients with Chronic Kidney Diseases

Sun, 01 Aug 2021 00:00:01 +0100

2021 Korean Heart Rhythm Society Guidelines: Management of Atrial Fibrillation in Specific ...

Sun, 01 Aug 2021 00:00:01 +0100

Optimized management of atrial fibrillation requires patient-oriented decision making with a multidisciplinary approach. This report incorporates recent authoritative studies to provide detailed recommendations for managing atrial fibrillation in specific clinical settings. The principles of the Atrial fibrillation Better Care (ABC) pathway apply in these clinical settings. In addition, specific considerations are discussed for each of these conditions and populations.

2021 Korean Heart Rhythm Society Guidelines for Stroke Prevention in Atrial Fibrillation

Sun, 01 Aug 2021 00:00:01 +0100

Atrial fibrillation (AF) is a strong risk factor for ischemic stroke and systemic embolism. To prevent thromboembolic events in patients with AF, anticoagulation therapy is essential. The anticoagulant strategy is determined after stroke and bleeding risk assessments using the CHA₂DS₂-VASc and HAS-BLED scores, respectively; both consider clinical risk factors. Vitamin K antagonists (VKAs) are the sole anticoagulant option in AF patients with a prosthetic mechanical valve or moderate-severe mitral stenosis; in all other AF patients VKA or non-vitamin K antagonist oral anticoagulants are therapeutic options. However, antiplatelet therapy should not be used for stroke prevention in AF patients. Anticoagulation is not needed in AF patients with low stroke risk but strongly recommended in those with a with low bleeding risk. Left atrial appendage (LAA) occlusion offers an alternative in AF patients in whom long-term anticoagulation is contraindicated. Surgical occlusion or the exclusion of LAA can be considered for stroke prevention in AF patients undergoing cardiac surgery. In this article, we review existing data for stroke prevention and suggest optimal strategies to prevent stroke in AF patients.

Microbiome and Cancer Immunotherapy

Sun, 01 Aug 2021 00:00:01 +0100

Immune checkpoint inhibitors (ICIs) have achieved promising clinical results in cancer treatment over the past decade. However, the efficacy of ICIs is less than 30% in most tumor types, and studies are underway to identify the predictive factors responsive to ICIs. More than 1,000 species of microorganisms live in the human body, and the second human genome project, The Human Microbiome Project, has been conducted to understand human diseases through interactions with microbes. As the microbiome project has progressed, many studies have reported on the association between microorganisms and human diseases, including preclinical and clinical studies on the relationship between ICIs and the microbiome. Therefore, in this manuscript, the relationship between the microbiome and cancer, especially the effectiveness of ICIs, is reviewed.

Diagnosis and Management of Iatrogenic Endoscopic Retrograde Cholangiopancreatography ...

Sun, 01 Aug 2021 00:00:01 +0100

Endoscopic retrograde cholangiopancreatography (ERCP)-related iatrogenic perforations are identified when gas or luminal contents exit the gastrointestinal tract during ERCP. Although perforations are rare, mortality is high; prompt diagnosis and appropriate management are essential. A multidisciplinary approach is required. The vast majority of such patients can be safely managed medically and endoscopically but must be carefully selected. Endoscopic closure can be considered, depending on the type of perforation. In patients who are deteriorating or whose iatrogenic perforations are not securely closed endoscopically, surgery is mandatory.

Diagnosis and Management of Antibiotic Allergies

Sun, 01 Aug 2021 00:00:01 +0100

Drug allergies encompass a spectrum of immune-mediated hypersensitivity reactions with various mechanisms and clinical presentations. ?-lactam drugs are common causes of drug allergies. A detailed clinical history as well as skin and drug provocation tests, are essential to diagnose drug allergies. The key to successful treatment is avoidance or discontinuation of the offending drug, and replacing it with a safe alternative. Cross-reactivities among ?-lactam antibiotics should be considered when choosing alternative medications. Proper management of ?-lactam allergies is important at the individual and population levels, to reduce the likelihood of drug allergies and prevent antibiotic-related adverse outcomes.

Interpretation of Anti-Nuclear Antibody Tests

Sun, 01 Aug 2021 00:00:01 +0100

Anti-nuclear antibodies (ANAs) are autoantibodies against nuclear substances or other cellular components. ANA tests are used in the diagnostic process to screen patients with suspected rheumatic or autoimmune diseases. ANA-associated diseases are characterized by a high titer of antinuclear antibodies and include systemic lupus erythematosus, systemic sclerosis, and mixed connective tissue diseases. ANA test results must be cautiously interpreted as they can be positive not only in infections and oncological diseases but also for the healthy general population. The ANA test mainly uses the indirect immunofluorescence test, and the results are expressed in terms of the final titer and pattern. The ANA test can increase diagnostic value when used in conjunction with the evaluation of disease-related clinical symptoms.

A 10-Year Single-Center Experience of Adverse Drug Reaction Monitoring

Sun, 01 Aug 2021 00:00:01 +0100

Background/Aims: Despite proper use of pharmaceuticals, adverse drug reactions (ADRs) can lead to problems related to patient safety. We analyzed the characteristics of ADRs, particularly serious adverse events (SAEs), in a single tertiary medical institution. Methods: Spontaneous ADR report data collected from 2010 to 2019 in Seoul National University Hospital were assessed. Causality was evaluated according to the World Health Organization-Uppsala Monitoring Centre criteria. Age, sex, onset, severity, seriousness, and system organ class (SOC) of ADRs and SAEs were analyzed. Results: During the study period, a total of 49,955 individual case safety reports were assessed as possible, probable, or certain. Although the number of gastrointestinal ADR reports was high (25.9%), severe cases were uncommon (2.6%). By contrast, the number of hematologic disorders was low (6.6%) but 39.2% of them were severe. Among ADRs, 10.2% were assessed as SAEs, the proportion of which was high at extreme ages and in males. Body as a whole-general disorders were the most frequently reported SOC for SAEs, followed by skin and appendage disorders. Antineoplastic agents and antibiotics were the most common causative agents of SAEs and ADRs. Anaphylactic reaction was the most frequent SAE (6.5%). Conclusions: The proportion of SAE differs according to SOC and drug. Attention should be paid to SAEs in children and older adults because the rate of SAEs is significantly higher at extreme ages.

Stent Flange-Induced Esophageal Stricture Treated with an Oral Steroid

Sun, 01 Aug 2021 00:00:01 +0100

Esophageal stent complications include stent migration, tumor ingrowth, perforation, a broncho-esophageal fistula, and gastroesophageal reflux. Development of a new stricture at a flange site after stent removal has been predicted but not yet reported. We experienced the first case of a recurrent esophageal stricture induced by a stent flange after stent removal. A fully covered metallic stent, which had been inserted 2 months ago for treatment of an anastomotic stricture, triggered another stricture at the flange site. Although endoscopic balloon dilatations were repeated several times and then the 2nd stent for rescue therapy was inserted, the stricture was refractory to all treatment. Thus, we prescribed oral prednisolone with repeated endoscopic balloon dilation; the stricture eventually improved. The oral steroid seemed to suppress stricture development. If a stent flange-induced refractory stricture is encountered, an oral steroid combined with endoscopic balloon dilation may be helpful.

Fecal Microbiota Transplantation for Treating Steroid-Refractory Acute Graft-versus-Host ...

Sun, 01 Aug 2021 00:00:01 +0100

Restoring the microbiota via fecal microbiota transplantation (FMT) can be an effective treatment for steroid-refractory acute graft-versus-host disease (GVHD) of the gut. Here, we report two adult patients who underwent FMT to treat steroid-refractory acute GVHD of the gut. The first patient was a 43-year-old man who underwent allogeneic hematopoietic stem cell transplantation (HSCT) with cells from a matched sibling donor. The second patient was a 70-year-old woman who underwent haplo-identical HSCT with cells from her son. Gut GVHD developed at 7 and 4 weeks after HSCT, respectively. After undergoing FMT, the clinical symptoms improved; the first patient had a complete response and the second patient had a partial response. Microbial analyses using RNA gene sequencing showed that a diverse fecal microbiome was recovered by 4 weeks after FMT. FMT should be considered an effective therapeutic option for managing steroid-refractory acute GVHD of the gut.

Aquagenic Urticaria Treated with Omalizumab

Sun, 01 Aug 2021 00:00:01 +0100

Aquagenic urticaria is a rare form of physical urticaria in which a 1-2 mm wheal is produced by contact with water. Treatment options include antihistamines, ultraviolet monotherapy, topical barrier creams, and acetylcholine antagonists. Despite these pharmacologic measures, the symptoms are frequently refractory to therapy. Aquagenic urticaria lowers the patients quality of life and causes daily discomfort. Recently, a patient with aquagenic urticaria treated with omalizumab was reported. Here, we describe a 22-year-old man with a 3-year history of aquagenic urticaria confirmed by a water immersion test. Because he showed no improvement with antihistamines, the patient began omalizumab treatment and demonstrated an excellent response. This case provides new information for clinicians.

Aspirations as President of the Korean Medical Association: A Step for Members and Nation, to ...

Fri, 01 Oct 2021 00:00:01 +0100

Screening Tests for Early Diagnosis of Multiple Myeloma and Related Plasma Cell Disorders

Fri, 01 Oct 2021 00:00:01 +0100

Monoclonal gammopathy (MG) encompasses a diverse group of disorders characterized by the secretion of monoclonal immunoglobulins or their light-chain components. The incidence of multiple myeloma (MM) in South Korea is rapidly increasing, and it is important to be aware of its initial clinical presentations and the most efficient laboratory algorithms for early detection. Serum protein electrophoresis (SPE) and urine protein electrophoresis (UPE) are the primary screening tests for patients with clinically suspected MM or amyloid light-chain amyloidosis; these tests are reimbursed in South Korea. We reviewed clinical studies that applied national and international guidelines to evaluate test panels for early detection of MGs, including MM. The serum free light chain (sFLC) with SPE panel is recommended for the initial work up for diagnosis of MGs. In the case of a normal SPE, sFLC should be measured subsequently, so as not to miss the presence of M-protein. Use of this screening panel avoids medical expenses related to delayed diagnosis. Guidelines and recommendations suggest that no single method (SPE, serum immunofixation electrophoresis, sFLC, or UPE) should be used to exclude a diagnosis of MM. We believe that a screening test panel comprising SPE plus sFLC will increase the rate of early and accurate diagnosis of MM and related disorders.

The 2021 Korean Heart Rhythm Society Guidelines for a New Approach and Integrated Management of ...

Fri, 01 Oct 2021 00:00:01 +0100

The prevalence of atrial fibrillation (AF) is gradually increasing with the aging of the population, and there is also increasing interest in AF with the development of various single-lead electrocardiography measurement methods for diagnosis. Further, the current diagnosis and treatment policies for AF do not reflect its progression and complexity. In addition, the various factors related to AF diagnosis and treatment are not simple due to the diversification of tools, advances in treatment methods, and complex mechanism of AF. Therefore, there are many challenges to developing a simple AF classification system. To overcome these, there have been a number of attempts to systematically characterize AF according to treatment and prognosis rather than using a uniform classification. Further, as mentioned in the previous AF guidelines, further research is being conducted on an integrated patientphysician approach to AF. Such an approach would be the basis for consistent treatment based on the guidelines, and would help to improve patient outcomes. Further, for the integrated management of AF patients, some changes should be made to the current approach to develop a multidisciplinary approach, including changes to the behavior of team members, patients, their family members, and physicians. The Korean Heart Rhythm will introduce an integrated approach to the classification and structure of AF management, and provide guidelines for its application in clinical practice.

Recent Advances in Drug Susceptible Pulmonary Tuberculosis Diagnosis and Treatment

Fri, 01 Oct 2021 00:00:01 +0100

The most important thing for the management of drug susceptible pulmonary tuberculosis is to diagnose active pulmonary tuberculosis as soon as possible and prevent the occurrence of new patients through appropriate treatment. Therefore, it should be a priority to quickly detect tuberculosis mycobacterium and quickly exclude drug-resistant tuberculosis before treatment begins. To this end, recent guidelines recommend the general use of Mycobacterium tuberculosis (MTB) polymerase chain reaction (PCR) tests, Xpert MTB/RIF tests, and rapid sensitivity tests through line probe assay (LPA). In addition, if the results of the test are positive, it is important to establish an in-hospital reporting system so that rapid reporting can be made. The treatment principle for drug susceptible pulmonary tuberculosis is 2 months of initial intensive phase (isoniazid, rifampin, ethambutol, pyrazinamide) followed by 4 months of maintenance phase (isoniazid, rifampin). Despite global efforts to shorten the duration of the treatment, the treatment of drug susceptible pulmonary tuberculosis has not changed for more than 35 years, and problems such as increased side effects and reduced drug adherence are serious obstacles to tuberculosis management. Therefore, efforts have been steadily made to shorten the treatment period through the combination of new drugs worldwide, and after many failures, they are finally paying off. A recently published Study 31/A5349 study found that 4 months short-term regimen using rifapentine (RPT) and moxifloxacin (MFX) demonstrated non-inferiority in existing standard regimen, as the result, a revision of World Health Organization guidelines is scheduled that 4 months short-term regimen using RPT and MFX may be an alternative. However, it is unlikely that RPT/MFX 4 months short-term regimen will be applied immediately in Korea because the use of RPT is currently limited in Korea due to the high frequency of side effects.

Diagnosis and Treatment of Adult Growth Hormone Deficiency

Fri, 01 Oct 2021 00:00:01 +0100

Adult growth hormone (GH) deficiency is associated with insulin resistance, elevated cardiovascular risk profile, increased fat mass, reduced muscle mass, skeletal fragility, and impaired quality of life. GH replacement therapy improves body composition, exercise capacity, skeletal health, cardiovascular outcomes, and quality of life, while reducing mortality. Prior to initiation of GH replacement therapy, it is essential to diagnose GH deficiency via a GH stimulation test in adults suspicious of such deficiency. Therapy should be started using (individualized) low dose of GH, followed by titration to the normal range of insulin-like growth factor-1. Clinical improvements should be monitored and side effects should be minimized.

Cancer of Unknown Primary: Diagnosis and Treatment

Fri, 01 Oct 2021 00:00:01 +0100

Cancer of unknown primary (CUP) is a heterogenous group of cancers for which the anatomical site of origin is unidentifiable on the basis of standard evaluation and imaging. CUPs account for 2-5% of all malignancies and are characterized by early metastatic dissemination, aggressive clinical course, and poor response to palliative chemotherapy. It is important to identify favorable-risk CUP patients (10-20%), as they harbor chemo-sensitive and potentially curable tumors, and may require long-term disease control. Empirical combination chemotherapy has traditionally been the standard first-line therapy for most patients (80-90%), who do not belong to favorable-risk subsets; however, this approach has only modest benefits, with a median overall survival of < 1 year. Evidence supporting the clinical use of molecular tissue of origin (TOO) tests is still lacking. Two recent randomized clinical trials failed to show the benefit of TOO-based site-specific therapy over empirical chemotherapy. In an era of precision medicine, the use of comprehensive molecular profiling will provide opportunities to identify patient subsets who are susceptible to targeted therapies and immunotherapies.

Rapid Tests for the Diagnosis of Viral Infections

Fri, 01 Oct 2021 00:00:01 +0100

Rapid and accurate diagnostic tests for viral infections are essential for diagnosis, treatment, and patient isolation. Various rapid nucleic acid tests, rapid antigen tests, and rapid antibody tests have been developed and used to diagnose viral infections. In this paper, the types and characteristics of various rapid viral tests currently used in Korea, test items, and considerations when interpreting rapid test results are described.

Adverse Drug Reactions to First-line Anti-tubercular Drugs Based on Individual Case Safety ...

Fri, 01 Oct 2021 00:00:01 +0100

Background/Aims: Tuberculosis has incidence and mortality rates that are among the highest for all communicable diseases. Adverse drug reactions (ADRs) to anti-tubercular drugs are common, and have a major impact on treatment maintenance and prognosis. It is important to understand the characteristics of ADRs and establish a suitable management plan. Methods: We retrospectively reviewed patients with ADRs during treatment with first-line antitubercular drugs such as isoniazid, rifampicin, ethambutol, and pyrazinamide from 2009 to 2018. Age, sex, and total treatment period, and the onset, severity, seriousness, and system organ class of ADRs, were analyzed to understand the characteristics of first-line anti-tubercular drug-related ADRs. Results: A total of 1,606 of 5,482 patients (29.3%) experienced ADRs after administration of first-line anti-tubercular drugs. The incidence of ADRs related to isoniazid, rifampicin, ethambutol, and pyrazinamide was 22.2%, 21.3%, 24.5%, and 29.6%, respectively. A total of 2,098 ADR reports were made (mean of 1.3

Cardiac Arrest Related to Torsades de Pointes in a Patient Recovering from Diabetic Ketoacidosis

Fri, 01 Oct 2021 00:00:01 +0100

Diabetic ketoacidosis (DKA) is an acute complication related to severe hyperglycemia. While the mortality rate for DKA is low with appropriate therapy, several complications may lead to deterioration of the clinical course. Here, we report a case of a 23-year-old patient with DKA who suffered from a rare but hemodynamically unstable cardiac arrhythmia, polymorphic ventricular tachycardia with prolonged QT interval, or Torsades de Pointes. During the recovery phase of DKA, three episodes of Torsades de Pointes suddenly occurred, and were recovered by immediate defibrillation. The patient did not have structural heart disease or a genetic predisposition. To the best of our knowledge, this is the first report of an adult with DKA complicated with QT prolongation related to Torsades de Points after correction of ketosis. To manage DKA, more attention may be needed on changes in the QT interval as well as risk factors for Torsades de Points.

A Rare Case of Fibromuscular Dysplasia with Postpartum Renal Artery Rupture in a ...

Fri, 01 Oct 2021 00:00:01 +0100

Fibromuscular dysplasia (FMD) of the renal artery is a non-atherosclerotic, non-inflammatory vascular disease that causes stenosis, aneurysm, dissection, and occlusion of the vessel. We report a rare case of a postpartum FMD patient who presented with spontaneous acute perirenal hematoma due to renal artery aneurysm rupture after cesarean section. The 40-year-old patient presented with sudden onset of abdominal pain 2 days after an elective cesarean section performed at full gestational term. A computed tomography scan of the abdomen revealed perirenal hematomas with signs of FMD in both renal arteries. The bleeding was successfully controlled by transcatheter arterial embolization. Short-term continuous renal replacement therapy was performed until her renal function recovered. FMD of the renal artery is rare in pregnant patients. Additionally, aneurysm rupture can be life threatening and requires immediate medical attention and prompt management.

Status and Improvement of the Management of Patients with Mild Symptoms of COVID-19 in Regional ...

Wed, 01 Dec 2021 00:00:01 +0100

Heterologous Vaccination for Preparing COVID-19 Pandemic

Wed, 01 Dec 2021 00:00:01 +0100

Infectious disease pandemics are characterized by extreme uncertainty. From the more predictable response to seasonal influenza, which occurs each year, we have learned the importance of effective universal vaccines and therapeutic agents to protect high-risk groups. Heterologous vaccination with different types of vaccines to prevent COVID-19 is already recommended for various reasons: shortages of mass vaccine supply; critical adverse events, and potential superior efficacy as a booster dose. However, very few studies have examined the efficacy and safety of heterologous vaccination with mixed types. This review discusses the efficacy of vaccines currently approved in the Republic of Korea, including heterologous vaccination options.

SGLT2 Inhibition for Diabetic and Non-diabetic Kidney Disease

Wed, 01 Dec 2021 00:00:01 +0100

Chronic kidney disease (CKD) can be progressive, and its prognosis is worse because of increased mortality when it is associated with diabetes and cardiac disease. The outcomes of diabetic kidney disease (DKD) need to be improved, despite multifactorial interventions including glucose and blood pressure (BP) control, and the use of renin-angiotensin system (RAS) inhibitors, statins, and aspirin. Recent clinical trials suggest that sodium-glucose cotransporter-2 (SGLT2) inhibitors offer additional cardiorenal protection in DKD and non-diabetic CKD on top of RAS inhibition. The action of SGLT2 inhibitors is derived from the proximal tubule of the kidney, but their systemic effects beyond glucose-lowering involve hemodynamic and non-hemodynamic mechanisms. First, SGLT2 inhibitors restore tubuloglomerular feedback and relieve glomerular hypertension and albuminuria. Second, natriuresis and renal glycosuria lead to fluid and weight loss, resulting in BP lowering and prevention of heart failure. Third, SGLT2 inhibitors have anti-inflammatory and anti-oxidative actions that can reduce renal and cardiac inflammation and fibrosis, probably via adenosine monophosphate-activated protein kinase and sirtuin-1 activation. Finally, the proximal tubular workload is relieved, accompanied by increased erythropoiesis. Hypoxia-inducible factor 1 may be stimulated by renal outer medullary hypoxia when tubular sodium transport shifts from the proximal convoluted tubule to the proximal straight tubule and thick ascending limb, due to SGLT2 inhibition. These effects may also be beneficial in non-diabetic CKD, and we anticipate that SGLT2 inhibitors will prove effective for albuminuria reduction and preservation of kidney function in primary kidney diseases, including glomerulonephritis.

Appropriate Use of Glycopeptide Antibiotics and Therapeutic Drug Monitoring for Invasive Infections

Wed, 01 Dec 2021 00:00:01 +0100

Vancomycin and teicoplanin are representative glycopeptide antibiotics with activities against gram-positive cocci. The area under the drug concentrationtime curve (AUC)/minimal inhibitory concentration (MIC) has been extensively used as an indicator of the bacteriological response to glycopeptide antibiotics, and the trough concentration has been used as a surrogate marker for the AUC/MIC. However, the guidelines for therapeutic drug monitoring (TDM) are being revised in accordance with increasing pharmacokinetic understanding of glycopeptide antibiotics. This review describes the pharmacokinetic/pharmacodynamic characteristics of glycopeptide antibiotics and discusses their optimal use with appropriate TDM.

The Advantages and Disadvantages of Prokinetics

Wed, 01 Dec 2021 00:00:01 +0100

Prokinetics are medications that enhance gastrointestinal contractility; they improve the symptoms of patients with delayed gastrointestinal motility. Prokinetics have conventionally been used to stimulate gastrointestinal propulsion and to treat symptoms correlated with motility problems, including gastroparesis and constipation. 5-Hydroxytryptamine receptor 4 (5-HT₄) agonists, such as cisapride, very effectively increased human gastrointestinal tract motility. However, cisapride sometimes induced serious tachyarrhythmia; the drug was thus withdrawn from the market. Thereafter, many prokinetics have been developed to treat delayed gastrointestinal motility. However, some exhibit serious side-effects. Recently, a new, highly selective serotonin receptor agonist, prucalopride, has been introduced; there is as yet no evidence of serious cardiac side- effects. The drug has been approved by the Food and Drug Administration to treat chronic constipation. Thus, recently introduced, highly selective agents appear to show promise as treatments for gastrointestinal dysmotility; there seem to be no serious side-effects.

Differential Diagnosis of Hypoglycemia

Wed, 01 Dec 2021 00:00:01 +0100

Hypoglycemia is common but can lead to life-threatening consequences. Accurate diagnosis is important to establish the appropriate treatment strategy. Most cases of hypoglycemia are caused by hypoglycemic agents, although it can occur in individuals without diabetes. A systemic and comprehensive diagnostic approach is required to diagnose hypoglycemia in patients without diabetes. It is important to perform appropriate blood testing during an episode of hypoglycemia. This review will focus on the definition, differential diagnosis, causes, and treatment of hypoglycemia, particularly in people without diabetes.

Molecular Risk Stratification using Next-generation Sequencing in Acute Myeloid Leukemia

Wed, 01 Dec 2021 00:00:01 +0100

Chromosomal abnormalities are an important prognostic factor in cases of acute myeloid leukemia (AML). Molecular mutations have been reported to contribute to the pathogenesis and prognosis of AML. Next-generation sequencing (NGS) has revolutionized the speed and cost of genomic sequencing and enables the parallel analysis of many genes for molecular risk stratification. The molecular mutations currently included in risk stratification at AML diagnosis are c-kit, FLT3-ITD, NPM1, CEBPA (biallelic), RUNX1, ASLX1, and TP53. The importance of screening for mutations has been further emphasized by introducing novel therapeutic targets for molecular mutations, such as FLT3-TKD, IDH1, and IDH2. Molecular mutations are also used to evaluate measurable residual disease during treatment and to select the intensity of the treatment during consolidation and follow-up. Pretreatment leukemic marrow and blood should be stored at a biobank to perform NGS analysis in cases of AML at diagnosis. Samples from various time points during and after treatment should be obtained and stored under appropriate conditions.

Real-world Experience of Improvement in the Survival of Lymphoma and Myeloma Patients with ...

Wed, 01 Dec 2021 00:00:01 +0100

Background/Aims: The first autologous peripheral blood stem cell transplantation (ASCT) in Korea was performed for a small-cell lung cancer patient at Asan Medical Center (AMC) in 1993. Recently, lymphoma and myeloma have been the main indications; there has been progress in the treatments for these lymphoid malignancies. We explored the real-world experience of ASCT for lymphoma and myeloma at AMC over a 25-year period. Methods: We used the AMC ASCT registry, which has collected ASCT data prospectively since January 1993. Data for Hodgkin lymphoma, non-Hodgkin lymphoma, and multiple myeloma patients were analyzed. Patients transplanted up to December 2018 were included to assess adequate survival data. The ASCT time period was divided arbitrarily into 1994-1999, 2000-2009, and 2010-2018. In cases of multiple myeloma, we analyzed the 1st ASCT data only. Results: Survival of these lymphoid malignancy patients after ASCT has progressively improved. The increase in survival may be related to advances in various medical skills supporting ASCT. However, overall survival has improved much more than progression-free survival. This suggests that better salvage therapies after ASCT failure have mainly affected the improvement in overall survival. The hematopoietic cell transplantation-specific comorbidity index could not be used as a survival indicator in this analysis. Conclusions: This real-world experience study showed that the survival of lymphoid malignancy patients treated with ASCT has improved over the past 25 years.

The Change of Gastrointestinal Fellowship Program

Sat, 01 Feb 2020 00:00:01 +0100

Pulmonary Disease Related to E-Cigarettes

Sat, 01 Feb 2020 00:00:01 +0100

The potential role of E-cigarettes in smoking cessation is debatable, and whether they are harmful remains controversial worldwide. However, several cases of E-cigarette or vaping-associated lung injury (EVALI) have been reported in the United States. In this review, we discuss and summarize EVALI cases.

Utilization of Component-Resolved Diagnosis in Precision Allergology

Sat, 01 Feb 2020 00:00:01 +0100

It is very important to identify the causal allergen of each patient in the diagnosis and treatment of allergic diseases. An experimental method of specific IgE testing for single clinically meaningful antigens is called component resolved diagnosis (CRD). Since the introduction of CRD, many single antigens with clinical significance from animal and plant allergenic source have become known. Bet v 1, the major allergen of white birch pollen, can be an indication marker for allergen-specific immunotherapy if the patient is sensitized. Phl p 1, the group I allergen of timothy grass pollen, is an important marker that suggests that patients are truly sensitized to grass pollen. The major allergen of ragweed pollen, Amb a 1 and Art v 1, which is the major allergen of mugwort pollen, are clinically important to distinguish true sensitization. House dust mites have several clinically useful component allergens. Der p 1 and Der p 2 are the initiation molecules in the molecular spreading of allergic diseases caused by house dust mites. Among food allergens, Ara h 2 from peanut, which is closely related to anaphylaxis among several clinical manifestation of peanut allergy. Tri a 19, well known to omega-5 gliadin is important in patients with wheat-dependent exercise-induced anaphylaxis. It is conceivable that the molecular biological concept of CRD methods should lead to patient-customized treatment beyond diagnosis in the future. Primary prevention of the allergic diseases will apply, which will conceptually be called allergen immunprophylaxis. This is the right direction of future precision allergology.

Immunological Characteristics and Management of Kidney Transplantation

Sat, 01 Feb 2020 00:00:01 +0100

Kidney transplantation (KT) is the best way to improve the quality of life and survival of patients with end-stage renal disease. However, after KT the adaptive immune system plays important roles in the development of rejection via multiple pathways. Accordingly, the suppression or modulation of these pathways is key to allograft survival. Advances in our understanding of the immunology related to KT with the development of immunosuppressants have reduced the rate of acute rejection and improved short-term transplant outcomes. Nonetheless, de novo donor-specific antibodies and subsequent chronic rejection continue to be responsible for the poor long-term survival of transplanted patients. In addition, the morbidity and mortality rates in patients returning to dialysis after graft failure are high. Better long-term outcomes following KT require innovative treatment strategies that include a focus on de novo antibodies. Here, we review basic transplant immunology as well as the diagnostic tools and medications that contribute to successful KT. We also provide an update on newly developed immunosuppressants.

A Diagnostic Roadmap for Polycythemia

Sat, 01 Feb 2020 00:00:01 +0100

Polycythemia could be defined as an elevation in hemoglobin or hematocrit levels above normal. To figure out what induces polycythemia is very important since the causes of polycythemia are very variable and the approaches for the treatments are basically different. Polycythemia can be primary or secondary in origin. The secondary causes are all associated with increase in erythropoietin (EPO) levels. If serum EPO levels are elevated, one try to differentiate whether the elevation is a physiologic response to hypoxemia or is related to autonomous production. Patients with low arterial O₂ saturation (< 92%) should be further evaluated for the presence of heart or lung disease. Patients without hypoxemia who are smokers may have elevated EPO levels because of CO displacement of O₂. If carboxyhemoglobin levels are elevated, the diagnosis is smokers polycythemia. Patients without hypoxemia who do not smoke, either could be diagnosed as high oxygen affinity hemoglobinopathy or have EPO producing tumors. If EPO levels are low, the patients most likely have polycythemia vera which has almost JAK2 mutation.

Roles of Tumor Markers in Diagnosis and Treatment of Hepatocellular Carcinoma

Sat, 01 Feb 2020 00:00:01 +0100

There are a wide variety of tumor markers for hepatocellular carcinoma (HCC). Studies are ongoing regarding the roles of tumor markers in screening, diagnosis, treatment, and prognostic prediction of HCC. Serum alpha-fetoprotein (AFP) can be very useful for HCC surveillance, prognostic prediction, and treatment response evaluation in high-risk patients with HCC. Other tumor markers such as PIVKA-II and AFP-L3% have also been proven to be effective in HCC diagnosis, follow-up, and prognostic prediction; these markers are increasingly used with serum AFP in clinical trials. However, the roles of tumor markers in surveillance are poorly understood and still controversial, requiring further research. HCC surveillance in at-risk population is a critical issue in management of HCC. Further data regarding the predictive value and cost-effectiveness of tumor markers could facilitate their uses in HCC surveillance.

The Relationship between Serum Phosphorous Level and Arteriovenous Fistula Dysfunction in ...

Sat, 01 Feb 2020 00:00:01 +0100

Background/Aims: Maintaining vascular access (VA) is very important in the management of hemodialysis (HD) patients. Therefore, the identification of risk factors for decreased vascular access flow has clinical relevance. The aim of the present study was to investigate the impact of serum phosphorus (P) on autologous arteriovenous fistula flow in HD patients. Methods: Sixty-two maintenance HD patients who visited the dialysis unit of CHA Bundang Medical Center between November 2016 and December 2017 were included in the study. Serum P levels were obtained every month, and time-averaged serum P was calculated. All patients had left arm arteriovenous fistulas (AVF; side-to-side anastomosis). AVF flow was assessed by Transonic HD 03. Decreased AVF flow was defined as < 600 mL/min. Results: Decreased AVF flow was observed in 14 of 62 patients. In univariate analysis and multivariable analysis, higher serum P had a significant independent association with decreased AVF flow. Advanced age, reduced ejection fraction, low blood flow rate in dialysis, and higher serum calcium were not associated with AVF flow. Conclusions: The present study demonstrated that higher serum P was an independent risk factor for decreased autologous AVF flow in maintenance HD patients. Serial monitoring of serum P may be helpful in stratifying patients by risk of AVF dysfunction, and proper management of serum P levels may be helpful in maintaining flow through autologous AVFs.

Endoscopic Transpapillary Gallbladder Stenting for Acute Cholecystitis in a Patient with ...

Sat, 01 Feb 2020 00:00:01 +0100

Percutaneous transhepatic gallbladder drainage is an effective treatment for acute cholecystitis in poor surgical candidates. Endoscopic gallbladder drainage procedures, such as endoscopic ultrasound-guided gallbladder drainage, endoscopic gallbladder stenting, and endoscopic naso-gallbladder drainage, have been used as alternative treatments for acute cholecystitis. These procedures are associated with increased patient comfort and physiologic drainage. We report a case of endoscopic gallbladder stenting for acute cholecystitis in a 62-year-old male undergoing chemotherapy for metastatic pancreatic cancer. After endoscopic gallbladder stenting, the patients acute cholecystitis resolved and he was able to undergo scheduled chemotherapy. The inserted double-pigtail plastic stent will be left in situ permanently. The choice of drainage modality for acute cholecystitis will generally be based on resources, patient preferences, local expertise, and clinical context.

Pancreatic Cancer in a Young Male in His Twenties

Sat, 01 Feb 2020 00:00:01 +0100

Pancreatic cancer is one of the most lethal malignancies worldwide. The risk of developing pancreatic cancer increases with age. Pancreatic cancer is seen mostly in the elderly; patients under the age of 30 years are rare. Known risk factors for pancreatic cancer include genetic mutations, smoking, chronic pancreatitis, and diabetes mellitus. We report a case of pancreatic cancer in a 27-year-old man without the PRSS1 mutation. Chronic pancreatitis and smoking may have contributed to the development of pancreatic cancer in this patient. We also conducted a literature review on early onset pancreatic cancer.

Paroxysmal Nocturnal Hemoglobinuria Presenting with Chronic Abdominal Pain and Iron Deficiency ...

Sat, 01 Feb 2020 00:00:01 +0100

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired disorder of hematopoietic stem cells characterized by chronic intravascular hemolysis, nocturnal hemoglobinuria, thromboembolic events and secondary bone marrow failure caused by uncontrolled complement activation. Generally, chronic abdominal pain and iron deficiency anemia are considered typical symptoms of gastrointestinal diseases, but are also common in PNH. We report a case of PNH presenting with chronic abdominal pain and iron deficiency anemia, along with a relevant literature review.

Medical Tourism in Korea, Present and Prospect

Wed, 01 Apr 2020 00:00:01 +0100

Clinical and Epidemiological Characteristics of Coronavirus Disease 2019 in the Early Stage of ...

Wed, 01 Apr 2020 00:00:01 +0100

In December 2019, a novel coronavirus, which is now designated as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified as the etiology of pneumonia of unknown cause in patients from Wuhan of central China. Since the first report of coronavirus disease 2019 (COVID-19), the disease became pandemic causing the large-scale outbreak all over the world. In this review, we discuss the clinical and epidemiological characteristics of COVID-19 in the early stage of outbreak based on recent reports from China.

Lenalidomide for the Treatment of Myelodysplastic Syndrome

Wed, 01 Apr 2020 00:00:01 +0100

Myelodysplastic syndrome (MDS) is a disease affecting clinically and cytogenetically diverse groups of patients. Consequently, MDS patients differ in their response to the individual agents used to treat their disease. Lenalidomide, which has been covered by the national health insurance system of Korea since 2019, is used to relieve transfusion-dependent anemia and has been shown to achieve a genetic response in MDS patients, especially those carrying the del(5q) mutation. Although the mechanism of action of lenalidomide is not yet clear, it may block malignant cell proliferation directly by inhibiting haplodeficient phosphatase, but also act indirectly by killing malignant cells through an immunomodulatory effect. In clinical studies, low-risk patients with the del(5q) mutation who were treated with lenalidomide had a hematologic response rate of 5560% and a median survival of 22.5 years. The genetic response rate was 5073%, and the complete genetic response rate 3045%. However, in high-risk patients, the response rate was low (2030%). These results demonstrate the potential utility of lenalidomide as a first-line drug for transfusion-dependent, del(5q), low-risk patients in Korea.

Targeted Therapy for Non-Small Cell Lung Cancer

Wed, 01 Apr 2020 00:00:01 +0100

Treatment of progressive non-small cell lung cancer (NSCLC) has advanced remarkably, due in part to the development of targeted therapies. Several gene alterations, including EGFR, ALK, ROS1, and BRAF, play important roles in carcinogenesis. Therefore, many targeted agents focusing these gene alterations have been developed and proving their therapeutic efficacies in many clinical trials. Now we should test these gene mutations and should apply treatments individually and properly to ensure the maximal survival benefit of each patient. In this review, we summarize the target genes and respective therapeutic agents in NSCLC.

Osteoporosis in Patients with Chronic Kidney Disease

Wed, 01 Apr 2020 00:00:01 +0100

Osteoporosis in chronic kidney disease (CKD) is also referred to as CKD with low bone mineral density (BMD), because the cause of low BMD in CKD includes chronic kidney disease-mineral bone disorders (CKD-MBD) such as secondary hyperparathyroidism, osteomalacia, and adynamic bone disease. Diagnostic methods of osteoporosis in CKD include FRAX

Korean National Lung Cancer Screening

Wed, 01 Apr 2020 00:00:01 +0100

The results of large-scale clinical studies have shown that the lung cancer mortality rate can be reduced by lung cancer screening using low-dose computed tomography (LDCT) in high-risk populations. Lung cancer screening requires rigorous quality control to ensure that imaging can be introduced into evidence-based medical systems and that results can be effectively delivered to examinees. Cessation of smoking is indispensable for reducing mortality in parallel with lung cancer screening. Pulmonary nodules found in LDCT during the Korean National Lung Cancer Screening are categorized according to their characteristics, size, and time of discovery based on the Lung Imaging Reporting And Data System (Lung-RADS); management guidelines are followed according to categorization. To improve the efficiency of lung cancer screening, studies are currently ongoing to enable selection of high-risk groups using lung cancer prediction models and biomarkers. Based on the risk estimation classification of lung cancer, it is expected that the selection of screening subjects and the screening cycle can be differentiated, which will increase the efficiency of screening, reduce the risk of unnecessary radiation exposure, and reduce the cost of screening.

The Characteristics of Adverse Drug Reactions in Cancer Patients: An Analysis of Spontaneously ...

Wed, 01 Apr 2020 00:00:01 +0100

Background/Aims: Although the number of domestic adverse drug reactions (ADRs) reported in Korea is rapidly increasing, the analysis of ADRs in cancer patients remains limited. We sought to investigate the clinical features of ADRs in cancer patients. Methods: ADR data were collected from a spontaneous reporting system at single university hospital, between July 2010 and June 2015. ADR cases assessed to be unlikely or unclassifiable as per the criteria of the World Health Organization-Uppsala Monitoring Center were excluded. Additional medical information was retrospectively collected from chart reviews, and clinical features of ADRs were analyzed. Results: In total, 1,455 cases were reported. Of these, 822 ADRs (52.1%) were observed in cancer patients. The mean age of cancer patients was 60.8 years (range, 1790 years), and 45.9% were male. The most prevalent clinical features were gastrointestinal abnormalities (32.6%), such as nausea and vomiting, followed by skin (28.5%) and neurologic manifestations (26.0%). Fifty-one (6.2%) and 296 cases (36.0%) were classified as severe and moderate, respectively. The most common causative agents were parenteral nutrition (PN) supplements (40.4%), followed by antibiotics (17.8%), analgesics (16.7%), iodinated contrast media (ICM, 10.6%), and vitamins (3.9%). Antineoplastic agents were responsible for 2.9% of cases. PN supplements were commonly associated with severe reactions. Conclusion: Although it is well known that antibiotics, ICM, and analgesics induce ADRs, PN supplements, vitamins, and antineoplastic agents should also be considered as common causes of ADRs in cancer patients. Further investigation and monitoring to determine the causality associated with these agents is required.

Adolescent Type 2 Autoimmune Pancreatitis

Wed, 01 Apr 2020 00:00:01 +0100

There are two forms of autoimmune pancreatitis (AIP). Type 1 is associated with immunoglobulin G4 (IgG4)-related systemic fibro- inflammatory disease, whereas type 2 AIP is localized to the pancreas and not associated with IgG4. The number of children presenting with type 2 AIP has recently increased. Here, we report a case of type 2 AIP in a 16-year-old adolescent who presented with clinical acute pancreatitis and associated pancreatic masses. He was diagnosed with type 2 AIP based on pancreatic biopsy results showing granulocytic epithelial lesions and supportive radiological imaging and steroid responsiveness.

Azathioprine-Induced Non-Cirrhotic Portal Hypertension in a Patient with Crohn

Wed, 01 Apr 2020 00:00:01 +0100

Thiopurine-based drugs such as azathioprine and 6-MP are among the most common immunosuppressants used to treat inflammatory bowel disease, autoimmune hepatitis, various autoimmune diseases, and patients undergoing organ transplantation. The drugs are associated with various complications, of which one of the most serious is hepatotoxicity that may trigger non-cirrhotic portal hypertension. We report a case with this side-effect in a patient taking azathioprine to treat Crohns disease.

Atypical Hemolytic Uremic Syndrome Successfully Treated with Eculizumab

Wed, 01 Apr 2020 00:00:01 +0100

Atypical hemolytic uremic syndrome (aHUS) is a rare syndrome characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute renal injury, which results from uncontrolled complement activation. Delayed diagnosis and treatment of aHUS may result in end-stage renal disease (ESRD) and an associated dependence on dialysis. In extreme cases, it may cause death due to multi-organ failure. Eculizumab, a humanized monoclonal antibody against C5, inhibits the formation of the terminal membrane attack complex and is used to treat aHUS. Here, we report a 46-year-old male patient who suffered from aHUS relapse, despite prior treatment with repeated plasma exchange and hemodialysis. Eculizumab therapy improved his hematologic findings without use of hemodialysis.

Improvement Plan of Healthcare Delivery System in Korea

Mon, 01 Jun 2020 00:00:01 +0100

Preventive Measures during Outbreak of Coronavirus Disease 2019

Mon, 01 Jun 2020 00:00:01 +0100

Respiratory tract infections caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) originating from China began in late 2019 and became prevalent worldwide in early 2020. Korea was one of the closest countries to China and was forced to go through this pandemic. In the absence of vaccines or effective antiviral drugs, we have no choice but to re-use the old preventive measures used by humans in the past. In this review, I would like to discuss the preventive measures used in Korea during the pandemic.

Clinical Approach to Non-cystic fibrosis Bronchiectasis Based on Recent Clinical Guideline

Mon, 01 Jun 2020 00:00:01 +0100

Non-cystic fibrosis bronchiectasis is a common respiratory disease that is frequently encountered in daily practice. However, it has been regarded as an orphan lung disease and had been often neglected by the physicians. Fortunately, recent studies have unveiled many important clinical aspects of bronchiectasis. Accordingly, international evidence-based practice guideline such as the European Respiratory Society guideline and the British Thoracic Society (BTS) guideline have been published recently. However, as there is no domestic evidence-based guideline, we introduce clinical approaches to diagnose bronchiectasis and discuss important aspects of bronchiectasis based on most recently published the BTS guideline. In addition, we cover the treatment of bronchiectasis based on the BTS guideline. We hope newly assembled a Korean bronchiectasis study group, name the Korean Multicenter Bronchiectasis Audit and Research Collaboration (KMBARC) would contribute to publishing Korean bronchiectasis guideline, soon.

New Classification Criteria for Systemic Lupus Erythematosus

Mon, 01 Jun 2020 00:00:01 +0100

Systemic lupus erythematosus (SLE) is a prototypic autoimmune disease with highly variable clinical and immunological manifestations. Classification and diagnosis of SLE are complicated by the multi-organ nature of the disease and by our incomplete understanding of its pathophysiology. The 1997 update of the 1982 American College of Rheumatology (ACR) criteria for SLE has been widely used for classification of SLE. In order to improve clinical relevance and early diagnosis, the Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) group suggested the 2012 SLICC criteria. These sets of classification criteria have unweighted lists of various serological and clinical findings typical of SLE, can be fulfilled by reaching a sum score of points. The only exception is biopsy-proven lupus nephritis with autoantibodies in the 2012 SLICC criteria. In an attempt to overcome limitations of the previous sets of SLE classification criteria, the new 2019 SLE European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) classification criteria for SLE have been recently published. The 2019 EULAR/ACR criteria include positive ANA at least once as obligatory entry criterion; followed by additive hierarchically clustered and weighted criteria. The structure and weighting of criteria constitute a paradigm shift in the classification of SLE. In the validation cohort, the new criteria had a sensitivity of 96.1% and specificity of 93.4%. This review attempts to delineate the history, performance and limitations of the current sets of SLE criteria.

Treatment of Systemic Lupus Erythematosus

Mon, 01 Jun 2020 00:00:01 +0100

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the production of autoantibodies that result in the inflammation of multiple organs, including the skin and musculoskeletal, renal, nervous, cardiovascular, respiratory, and gastrointestinal systems. Treatment includes the use of immunomodulatory and immunosuppressive agents to target specific organ manifestations. The treatment goal in SLE is to reduce disease activity and prevent organ damage and death. Optimal long-term outcomes require not only treatment of the disease, but also the management of comorbidities. This paper reviews treatments of SLE with the aim of improving outcomes.

Vaccination of Patients with Systemic Lupus Erythematosus

Mon, 01 Jun 2020 00:00:01 +0100

Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease that affects various organs. SLE patients have an increased risk of infection compared to the general population. Immunosuppressive agents commonly used in SLE increase the risk of infection. Vaccination is a good way to reduce the risk of infection. However, some SLE patients are concerned that vaccination may worsen lupus disease activity or cause side effects. The latest SLE patient vaccination data were reviewed in this study, which focused on the safety, immunogenicity, and efficacy of influenza, pneumococcal, tetanus, hepatitis A, herpes zoster, and human papillomavirus vaccines. Korean immunization recommendations were also compared to those of other countries.

Diagnosis and Treatment of Hyperthyroidism in Pregnancy

Mon, 01 Jun 2020 00:00:01 +0100

Thyroid function fluctuates during pregnancy. Thus, assessments of thyroid activity during childbearing years represent an important health metric. Since anti-thyroid drugs are potentially teratogenic, drug dosing and timing should be carefully calculated. Normally, diagnosis and treatment of hyperthyroidism is performed to determine underlying causes (i.e., Graves' disease), to predict disease course and to make appropriate therapeutic decisions. In cases of maternal hyperthyroidism, these same measures also require the insight regarding the relationship between pregnancy and thyroid function, the effects of anti-thyroid drugs on pregnancy outcomes.

Donor Screening for Fecal Microbiota Transplantation

Mon, 01 Jun 2020 00:00:01 +0100

Fecal microbiota transplantation (FMT), which has been established as the standard treatment for recurrent Clostroides difficile infection, may also play a role in the management of other diseases associated with dysbiosis of the gut microbiota. To ensure efficacy and safety of FMT, an appropriate donor screening process is required. The main purpose of donor screening is to check for infectious diseases that could be transmitted to the recipient. The screening process involves a medical history questionnaire, and blood and stool testing. Several randomized clinical trials and large case series on FMT reported no, or few, adverse events related to infection by following this donor screening process. However, there is still concern over the transmission of antibiotic-resistant bacteria. In addition, a low donor acceptance rate due to rigorous screening makes donor recruitment difficult, and also imposes a significant cost burden. A consensus on the most crucial elements of donor screening is needed for wide application of FMT.

Predictors of Ischemic Cardiomyopathy in Patients with Acute Myocardial Infarction who ...

Mon, 01 Jun 2020 00:00:01 +0100

Background/Aims: Many patients with acute myocardial infarction (AMI) suffer from heart failure due to progressive ischemic left ventricular (LV) remodeling. This study investigated the predictors of ischemic cardiomyopathy (ICMP) in patients with AMI who underwent successful percutaneous intervention. Methods: A total of 547 patients with AMI were divided into two groups: ICMP (n = 66, 67.1

Successful Treatment of Acquired Perforating Dermatosis in a Peritoneal Dialysis Patient Using ...

Mon, 01 Jun 2020 00:00:01 +0100

Acquired perforating dermatosis (APD) triggers severe itching, and is observed most often in patients with diabetes mellitus (DM) and chronic kidney disease (CKD). Various treatments, such as topical steroids, topical and oral retinoids, allopurinol, and ultraviolet B (UVB) phototherapy, have been used. However, as the precise etiology is unknown, there are a lack of well-established treatment guidelines. We report a peritoneal dialysis patient with a diagnosis of APD who was resistant to topical steroids, phototherapy, allopurinol, and topical retinoids. Severe pruritus persisted, which compromised his ability to lead a normal life. As a final treatment option, we used oral isotretinoin and the patient experienced a dramatic improvement.

Renal Artery Stenosis Presenting at Sudden Flash Pulmonary Edema in a Patient with Solitary Kidney

Mon, 01 Jun 2020 00:00:01 +0100

Flash pulmonary edema is characterized by a sudden episode of dyspnea resulting from acute pulmonary venous congestion, which resolves rapidly. We report a case of renal artery stenosis presenting as flash pulmonary edema in a patient with solitary kidney treated by angioplasty with stent implantation. A 75-year-old man with solitary kidney visited the emergency room with acute shortness of breath. His blood pressure had risen to 206/90 mmHg and a chest radiograph revealed pulmonary edema. Echocardiography and coronary arteriography showed no clear abnormalities, but abdominal computed tomography revealed severe focal stenosis in the left proximal renal artery. A captopril renal scan found that the time to peak and half-time of radioactivity were delayed in the left kidney. Percutaneous transluminal angioplasty was performed, followed by stent implantation. After this procedure, the stenotic segment was completely dilated and blood pressure returned to the normal range.

A Fatal Pulmonary Event during Plasma Exchange in a Patient with Severe Fever with ...

Mon, 01 Jun 2020 00:00:01 +0100

Severe fever with thrombocytopenia syndrome (SFTS) caused by the SFTS virus (SFTSV), a novel Phlebovirus, is endemic to South Korea, central and northeastern China, and western Japan. SFTS poses a threat to public health because of its high mortality and secondary transmission. Ticks and domestic animals are hosts for SFTSV in endemic areas. There is no specific treatment for SFTS, and avoiding tick bites is the best way to prevent infection. Early therapeutic plasma exchange (TPE) is a rescue therapy in patients with rapidly progressive SFTS. Here, we present a patient with SFTS who was improving on TPE but died suddenly due to acute lung injury after TPE.

Advantages and Necessities of Telehealth Care Service

Sat, 01 Aug 2020 00:00:01 +0100

Considerations on Untact Healthcare, Another Name for Telemedicine

Sat, 01 Aug 2020 00:00:01 +0100

Severe Acute Respiratory Syndrome-coronavirus 2 Infection: Role of Angiotensin-converting Enzyme 2

Sat, 01 Aug 2020 00:00:01 +0100

A role of angiotensin-converting enzyme 2 (ACE2) in the coronavirus disease 2019 pandemic has been suggested, because it is the molecular receptor for severe acute respiratory syndrome-coronavirus 2 (SARS-CoV2). ACE2 is known to provide a protective effect for cardiac and vascular tissues, because it generally counteracts angiotensin II (Ang II) activity. ACE2 downregulation has been implicated in the pathogenesis of cardiovascular disease. ACE inhibitors and angiotensin receptor blockers may enhance ACE2 mRNA expression and enzyme activity. However, this has not been demonstrated in lung tissue. In the lungs, Ang II induces vasoconstriction to prevent ventilation perfusion mismatch, while also increasing vascular permeability (which can precipitate pulmonary edema). ACE2 is expressed in 0.67% of human lung cells, 80% of which are type 2 alveolar cells. Men (of all ethnicities) and Asian individuals have been shown to express higher levels of ACE2 than women and non-Asian individuals, respectively. However, there are no data from human studies indicating that high ACE2 expression increases the likelihood of SARS-CoV2 infection. In animal studies, an increase in Ang II caused by SARS-CoV2 or spike protein interactions, in turn due to ACE2 downregulation, has been identified as the key mechanism underlying lung injury. In human studies of SARS-CoV2 infection, ACE2 overexpression was shown to cause inflammatory apoptosis and a cytokine storm. The actions of ACE2 and Ang II in SARS-CoV2-infected vascular and lung tissues differ between animals and humans. ACE2 expression levels pre- and post-SARS-CoV2 infection should be differentiated.

The Effect of Long-term Sodium-glucose Cotransporter 2 Inhibitor Treatment on Renal Function in ...

Sat, 01 Aug 2020 00:00:01 +0100

Chronic kidney disease is developed commonly in type 2 diabetes mellitus (T2DM) and is the most common cause of end-stage renal disease and related cardiovascular complications. Meanwhile, despite the current standard of care including optimized glucose control and the use of single-agent blockade of the renin-angiotensin-aldosterone system (RAAS), patients with T2DM remain at increased risk for death and complications from cardiorenal causes. The recent studies using sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown not only glucose lowering effect, but also a reduction in blood pressure, weight loss, and a lowering cardiovascular risk. Regarding renal outcomes, the use of SGLT2 inhibitor slows the progression of kidney disease compared to placebo when added to standard care. However, concern has been raised that currently available SGLT2 inhibitors in Korea may be also associated with improved renal outcomes with long-term treatment. As a result, we aimed to evaluate the effect of long-term SGLT2 inhibitor treatment on renal function in the patients with T2DM using meta-analysis. (Korean J Med 2020;95:236-243)

Gastroparesis

Sat, 01 Aug 2020 00:00:01 +0100

Gastroparesis is a condition characterized by delayed gastric emptying without evidence of mechanical obstruction in the stomach. Its symptoms include nausea, vomiting, early satiety, abdominal bloating, and abdominal pain. Most cases of gastroparesis are either idiopathic, due to diabetes mellitus, or post-surgical complications. The diagnosis of gastroparesis requires upper endoscopy, contrast radiography, or validated gastric scintigraphy. Gastroparesis is managed with nutritional support and treatment of any underlying disorders, such as diabetes. Pharmacological treatments have been tried, including prokinetics and novel medications. Interventions focused on the pylorus have shown promising results.

Clinical Approach and Diagnosis of Syncope

Sat, 01 Aug 2020 00:00:01 +0100

Syncope, defined as a transient loss of consciousness, is commonly clinical encountered in patients of all ages at emergency and outpatient clinics. However, syncope shares various clinical features with other diseases (e.g., epilepsy), and the explicit cause may be difficult to identify because testing (e.g., electrocardiography) cannot be performed during a syncopal episode. Syncope due to a cardiac disorder may lead to a fatal outcome such as sudden cardiac death, whereas neurally mediated syncope has a much more favorable prognosis. Herein, we classify the causes of syncope and provide the clinical approach for each, focusing on recently updated guidelines.

Evaluation of the Recipient and Donor in Living Kidney Transplantation

Sat, 01 Aug 2020 00:00:01 +0100

Kidney transplantation is the treatment of choice for end-stage renal disease. A successful kidney transplant improves the quality of life and reduces the mortality risk of patients, as compared to maintenance dialysis. The number of patients awaiting kidney transplantation has steadily increased, and the gap between allograft supply and demand continues to widen despite initiatives to expand the use of nonstandard deceased-donor allografts. The use of organs from living donors is one strategy to address the need for transplants. A medical, surgical, and psychosocial evaluation is mandatory prior to living kidney donation to ensure that the donor candidate is in good health and has normal kidney function, is not a risk to the recipient with respect to transmission of infections and malignancy, and will not face unacceptable risks after donation.

Sex Differences in Cardiovascular Disease Risk Factors among Korean Adults

Sat, 01 Aug 2020 00:00:01 +0100

Background/Aims: The prevalence of cardiovascular disease among women is lower than that among men in middle age, but increases after middle age. This study was performed to compare the risk factors for cardiovascular disease according to sex in Koreans adults. Methods: Data from the National Health and Nutrition Examination Survey for the 5th, 6th, and 7th years (20102017) were analyzed. This study examined the risk factors for cardiovascular disease among adults. From the total of 41,386 patients, 11,529 patients were selected. Results: The overall prevalence of cardiovascular disease in Korean adults was 27.9%, and the prevalence was higher in women than in men (55.3% vs. 44.7%, respectively, p < 0.001). Women with cardiovascular disease were older than men (66.6

A Rare Case of Chronic Otitis Media Caused by Mycobacterium massiliense in a Healthy Adult

Sat, 01 Aug 2020 00:00:01 +0100

Mycobacterium massiliense (M. massiliense) is a novel nontuberculous mycobacteria (NTM) and an opportunistic pathogen that lives in the water, soil, food, and air. It is a subspecies of the rapidly growing mycobacteria Mycobacterium abscessus. This atypical pathogen has been reported mainly in patients with lung disease or those undergoing cosmetic or surgical procedures. A 62-year-old woman presented with productive otorrhea for 10 months, no history of surgery, and chronic otitis media. M. massiliense was identified from a tissue specimen using real-time polymerase chain reaction for NTM (Biosewoom, Seoul, Korea), and NTM was identified by acid-fast bacilli culture. Successful treatment consisted of clarithromycin for 4 months. No other case of chronic otitis media related to M. massiliense has been reported. This is the first confirmed case of chronic otitis media caused by M. massiliense in a healthy adult in South Korea.

Primary Pancreatic Diffuse Large B-Cell Lymphoma Involving the Stomach

Sat, 01 Aug 2020 00:00:01 +0100

Primary pancreatic lymphoma (PPL) is extremely rare, comprising fewer than 1% of non-Hodgkin lymphomas. The most common histological subtype of PPL is diffuse large Bcell lymphoma (DLBCL). A 46-year-old man presented with indigestion, epigastric pain, and weight loss for 2 months. Abdominal computed tomography showed a well-defined hypodense mass located at the pancreas head involving the stomach, as well as enlargement of several mesenteric and perigastric lymph nodes. Histological examination was performed by upper gastrointestinal endoscopy of the stomach and endoscopic ultrasound-guided fine-needle aspiration and biopsy of the pancreatic mass. Histology of the pancreatic mass and the stomach revealed pancreatic DLBCL, involving the stomach. The patient received chemotherapy and is currently in complete remission. We report a rare presentation of DLBCL, appearing as a primary pancreatic tumor involving the stomach, which we presume is the first such report in South Korea.

Kommerell Diverticulum as a Rare Cause of Dysphagia

Sat, 01 Aug 2020 00:00:01 +0100

Kommerell diverticulum is a rare congenital anomaly of the aortic arch characterized by dilation at the proximal descending aorta, which gives rise to an aberrant subclavian artery. Kommerell diverticulum is usually asymptomatic, but can also be associated with symptoms due to compression of the esophagus or trachea, and can rarely be fatal due to dissection or rupture of the diverticulum. Here, we report a rare case of dysphagia caused by compression of the esophagus by Kommerell diverticulum originating from the right-sided aortic arch.

Application of Patients Classification Systems in the Korean Health System: In the View of ...

Thu, 01 Oct 2020 00:00:01 +0100

Diagnostic Assessment of Nonalcoholic Fatty Liver Disease

Thu, 01 Oct 2020 00:00:01 +0100

Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide, and is characterized by fat accumulation at levels exceeding 5% in hepatocytes due to insulin resistance. The disease spectrum ranges from simple nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH)/NASH-related fibrosis or cirrhosis defined by histological findings. Unlike simple NAFL, NASH/NASH-related fibrosis or cirrhosis increases the risk of liver-related morbidity or mortality. Therefore, accurate diagnosis of NASH/NASH-related fibrosis or cirrhosis is needed for management of patients with these diseases. Currently, liver biopsy is the only way to confirm the presence of NASH in an individual with features of NAFLD, but this has some limitations, including sample error, interpretation error, and the invasiveness of the procedure. Therefore, there have been a number of attempts to develop noninvasive methods for differential diagnosis of NASH/NASH-related fibrosis or cirrhosis easily and quickly. Here, we review the assessments for diagnosing NAFLD and the methods for differential diagnosis of NASH/NASH-related fibrosis or cirrhosis.

Hospital Infection Control Practice in the COVID-19 Era: An Experience of University Affiliated ...

Thu, 01 Oct 2020 00:00:01 +0100

The novel coronavirus infectious disease 2019 (COVID-19) pandemic is a great threat to medical institutions to which patients with underlying diseases are admitted. COVID-19 outbreak must be prevented and minimized to spread to the hospital. Triage of symptomatic patients, healthcare workers, caregivers and visitors has to be implemented to the entrance system. To minimize the outbreak, early suspicion and detection, regular environmental cleaning and disinfection, appropriate personal protective equipment should be applied and monitored. Standard precaution and droplet precaution must be routinely emphasized to prevent COVID-19 nosocomial transmission. Healthcare institution needs to prepare to empower their infection control policy and resources to control COVID-19.

Selection of Optimal Adjuvant Chemotherapeutic Agents for Pancreatic Cancer Treatment

Thu, 01 Oct 2020 00:00:01 +0100

Pancreatic cancer generally has a dismal prognosis, with a 5-year overall survival rate of approximately 10%. At present, surgical resection is the only treatment with a curative aim; however, it is applicable to only 1520% patients with pancreatic cancer at the time of diagnosis and the median survival following treatment with surgery alone is only 1120 months. Many trials have shown that adjuvant chemotherapy offers improved outcomes over observation following surgical resection. Recently, modified folinic acidfluorouracilirinotecanoxaliplatin (FOLFIRINOX) treatment following surgical resection in patients with good performance status has shown an impressive 9-month increase in disease-free survival. However, patients included in the study were selected based on a narrow set of criteria, and adverse events during adjuvant chemotherapy remain a limitation. In this article, we review some key trials of adjuvant chemotherapy treatment for pancreatic cancer and discuss future perspectives including neoadjuvant treatment approaches.

Immuno-Target Therapy for Relapsed or Refractory Acute Lymphoblastic Leukemia

Thu, 01 Oct 2020 00:00:01 +0100

Standard post-remission therapy for adult patients with high-risk acute lymphoblastic leukemia (ALL) is allogeneic hematopoietic cell transplantation (allo-HCT). However, 2030% of patients treated with allo-HCT subsequently relapse, and their long-term survival outcomes are very poor even after the next allo-HCT. The poor survival outcomes reported by previous studies have mainly been due to low complete remission (CR) rates and high mortality from conventional salvage chemo-regimens, such as mitoxantrone plus etoposide plus cytarabine (MEC) or fludarabine plus cytarabine plus idarubicin (FLA-Ida). However, several novel agents with proven high remission rates and a good measurable residual disease response can now be administered. The representative novel agents recently introduced are blinatumomab (anti-CD19 bispecific T-cell engager) and inotuzumab ozogamicin (anti-CD22 antibody-calicheamicin conjugate). In South Korea, blinatumomab has been used since October 2016 and inotuzumab ozogamicin has been in use since October 2019 under coverage by the national insurance system. Studies on blinatumomab in Korea showed that this drug is effective when used as an early salvage line, even in patients who relapse after an initial allo-HCT. However, a previous study revealed that relapsed patients with a short CR duration of < 12 months post-HCT show a poor response to blinatumomab compared to patients with a longer CR duration. Also, some early relapsed cases with active acute graft-versus-host disease (GVHD) show aggravated GVHD with the use of blinatumomab. No real-world data are available in Korea for inotuzumab, but previous trials have reported a good CR and proceeding rates to allo-HCT comparable to blinatumomab. We have experienced hepatotoxicity including venoocclusive disease in post-HCT relapsed patients treated with inotuzumab.

Multidisciplinary and Multisociety Practice Guidelines for Reprocessing Flexible ...

Thu, 01 Oct 2020 00:00:01 +0100

Background/Aims: The area of endoscopic application has been continuously expanded since its introduction in the last century and the frequency of its use also increased stiffly in the last decades. Because gastrointestinal endoscopy is naturally exposed to diseased internal organs and contact with pathogenic materials, endoscopy mediated infection or disease transmission becomes a major concern in this field. Gastrointestinal endoscopy is not for single use and the proper reprocessing process is a critical factor for safe and reliable endoscopy procedures. What needed in these circumstances is a practical guideline for reprocessing the endoscope and its accessories which is feasible in the real clinical field to guarantee acceptable prevention of pathogen transmission. Methods: This guideline contains principles and instructions of the reprocessing procedure according to the step by step. And it newly includes general information and updated knowledge about endoscopy-mediated infection and disinfection. Results: Multiple societies and working groups participated to revise; Korean Association for the Study of the Liver, the Korean Society of Infectious Diseases, Korean College of Helicobacter and Upper Gastrointestinal Research, the Korean Society of Gastroenterology, Korean Society of Gastrointestinal Cancer, Korean Association for the Study of Intestinal Diseases, Korean Pancreatobiliary Association, the Korean Society of Gastrointestinal Endoscopy Nurses and Associates and Korean Society of Gastrointestinal Endoscopy. Through this cooperation, we enhanced communication and established a better concordance. Conclusions: We still need more researches in this field and fill up the unproven area. And our guidelines will be renewed accordingly.

Colon Leiomyoma Diagnosed and Treated with Endoscopy

Thu, 01 Oct 2020 00:00:01 +0100

Leiomyoma is a benign smooth muscle tumor that may occur throughout the entire digestive tract. It occurs more frequently in the stomach and the small intestine, but is rarely seen in the large intestine. Here, we report two cases of colon leiomyoma mimicking the appearance of colon polyps that were found incidentally. They were simultaneously diagnosed and treated by endoscopic mucosal resection. Careful and thorough endoscopic examination is required for differential diagnosis of polyps that may actually be subepithelial tumors.

Minimal Change Disease in a Patient with Multiple Endocrine Neoplasia Type 1

Thu, 01 Oct 2020 00:00:01 +0100

Multiple endocrine neoplasia type 1 (MEN 1) is an autosomal dominant disorder characterized by two or more tumors of the parathyroid gland, duodenum-pancreas, and anterior pituitary. Membranous nephropathy is the most common manifestation of paraneoplastic glomerulopathy. However, minimal change disease in patients with MEN 1 has yet to be reported. Here, we report a case of minimal change disease in a 59-year-old man with MEN 1, along with a review of the relevant literature.

A Case of Sweet

Thu, 01 Oct 2020 00:00:01 +0100

Sweets syndrome (SS) is an autoimmune-mediated acute febrile neutrophilic dermatosis with a number of possible etiologies, including infection, malignancy, and drug reactions. In contrast to its original description, it can rarely involve extracutaneous organs, including the central nervous system, cardiovascular system, lung, liver, gastrointestinal tract, spleen, and bone. To our knowledge, there have been only three cases of SS accompanied by acute kidney injury worldwide, and this is the first report in which the patient recovered completely from acute kidney injury as well as cutaneous lesions with early steroid administration. Here, we report a case of SS with acute kidney injury in a patient with myelodysplastic syndrome (MDS) whose skin lesions and renal function recovered fully with early diagnosis and steroid therapy along with a review of the relevant literature.

The Effect of Long-term Sodium-glucose Cotransporter 2 Inhibitor Treatment on Renal Function in ...

Thu, 01 Oct 2020 00:00:01 +0100

Review on the Current Public Health Care Policies

Tue, 01 Dec 2020 00:00:01 +0100

Psychological Effects of the Coronavirus Disease 2019 Pandemic

Tue, 01 Dec 2020 00:00:01 +0100

The novel coronavirus disease 2019 (COVID-19) pandemic has spread across the world, reducing social interactions and causing substantial psychological distress and economic losses. This review summarizes the psychological effects of the COVID-19 pandemic in terms of uncertainty, the loss of autonomy associated with preventive measures, and secondary stressors such as potential future economic losses.

Vaccines and Treatment of Coronavirus Disease 2019

Tue, 01 Dec 2020 00:00:01 +0100

In December 2019, a new strain of betacoronavirus, severe acute respiratory syndrome coronavirus 2, which causes coronavirus disease 2019 (COVID-19), emerged in Wuhan, China. Subsequently, the virus quickly spread worldwide and the World Health Organization declared COVID-19 a global pandemic on March 11, 2020. In response to the pandemic, many researchers are working on repurposing existing drugs to alter the course of severe COVID-19, and are testing experimental treatments. Among antiviral agents, remdesivir, an RNA-dependent RNA polymerase inhibitor, showed clinical benefit in a randomized clinical trial. In October 2020, the Food and Drug Administration approved remdesivir for treating hospitalized patients with COVID-19, making it the first drug approved for the disease. The race to produce safe, effective vaccines is also progressing at unprecedented speed, with over 200 under development and 45 candidates already being tested in human clinical trials (as of October 2020).

Allergen-Specific Immunotherapy Against Allergic Respiratory Diseases

Tue, 01 Dec 2020 00:00:01 +0100

Allergen-specific immunotherapy (AIT) can alter the natural course of an allergic disease. It is widely held that the efficacy of a given therapeutic modality should be proven by well-designed double-blind placebo-controlled randomized clinical trials and meta-analyses. In this article, the therapeutic efficacy of AIT for allergic respiratory diseases, such as allergic rhinitis and asthma, is reviewed. In addition, potential clinical and experimental predictors of the treatment response are reviewed for AITs requiring long-term treatment, and for some allergic rhinitis and asthma patients who show no response to AIT.

Clinical Approach for Patients with Hypertriglyceridemia-Induced Acute Pancreatitis

Tue, 01 Dec 2020 00:00:01 +0100

Hypertriglyceridemia is an important cause of acute pancreatitis, and its symptoms are similar to those of pancreatitis of other causes. Moreover, the possibility of recurrence renders accurate diagnosis critical, and treatment, lifestyle modifications, and education should be performed simultaneously. For treatment during the acute phase of the disease, insulin or plasmapheresis can be combined with modalities used for acute pancreatitis of other causes; fibrate administration is recommended. In addition, hypertriglyceridemia-induced acute pancreatitis requires daily management, such as continuous administration of lipid-lowering agents, and lifestyle modifications are needed even after completion of acute-phase treatment.

Applying Precision Medicine in Clinical Practice

Tue, 01 Dec 2020 00:00:01 +0100

Precision medicine is the modern era version of personalized medicine, which integrates data from genomics and clinical information to optimize the care delivered to patients. As next generation sequencing (NGS) revolutionized the speed and cost of genomic sequencing, precision medicine entered clinical practice in 2017 via the national reimbursement of oncology and rare diseases. In parallel, the digitalization of clinical data through electronic health recording (EHR) and hospital information systems has allowed data collection and analysis. This has led to the integration of biomarkers and clinical records, which have introduced precision medicine into clinical practice. Today, many countries and medical institutes are endeavoring to create systems that will enable precision medicine to be applied to clinical practice. These data systems will benefit the patient by providing accurate data based on his/her characteristics rather than the conventional approach of using average data. Internal medicine will transform into a data-driven science that enables physicians to translate molecular biomarkers and big data analysis into improved clinical care.

Difference of Clinical Outcomes According to Left Ventricular Hypertrophy and Its Subtype in ...

Tue, 01 Dec 2020 00:00:01 +0100

Background/Aims: Left ventricular hypertrophy (LVH) on clinical outcomes in patients with acute myocardial infarction (AMI) is not clear. This study was performed to investigate the effect of abnormal left ventricular geometry on clinical outcomes in Korean patients with AMI. Methods: A total of 852 consecutive patients with AMI were divided into two groups: normal left ventricular geometry (n = 470; 389 males) and LVH (n = 382; 214 males) groups. Major adverse cardiac events (MACEs) were defined as cardiac death, recurrent myocardial infarction, and rehospitalization. Results: During the clinical follow-up period of 21

Endoscopic Removal of Gastric Lipoma with Hemorrhage Using Endoscopic Submucosal Dissection

Tue, 01 Dec 2020 00:00:01 +0100

Most upper gastrointestinal lipomas occur in the duodenal second portion, and gastric lipomas are rare. Most lipomas are usually asymptomatic, but symptoms such as abdominal pain, intussusception, ulceration, and intestinal obstruction may occur depending on the size and location and, rarely, can cause bleeding. Endoscopic polypectomy, endoscopic mucosal resection, and surgical resection are the treatments of choice for lipomas with intestinal obstruction or bleeding. Upper gastrointestinal bleeding from lipoma is mostly of duodenal origin and very rarely from the stomach. Here, we report a case of successful treatment of gastric lipoma with massive bleeding by endoscopic resection.

Acute Kidney Injury after Administering Dapagliflozin to a Diabetic Patient with Acute Cerebral ...

Tue, 01 Dec 2020 00:00:01 +0100

Dapagliflozin is a recently developed oral anti-diabetic drug and SGLT2 inhibitor with well-known cardioprotective and renoprotective effects. Although a reduction of the glomerular filtration rate is induced by volume depletion and tubule-glomerular feedback during the early period after administering a SGLT2 inhibitor, the renal prognosis improves more with a decrease of proteinuria. However, the risk of acute kidney injury increases in heart failure and hypovolemia patients, and in those taking certain drugs, such as non-steroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers, or diuretics. We report acute kidney injury after dapagliflozin administration in a diabetic patient with acute cerebral infarction accompanied by right hemiplegia, motor aphasia, and dysphagia.

Minimal Change in Nephrotic Syndrome Associated with Mixed Connective Tissue Disease

Tue, 01 Dec 2020 00:00:01 +0100

Mixed connective tissue disease (MCTD) is a rheumatologic disorder that has combined features of systemic lupus erythematosus, systemic sclerosis, and rheumatoid arthritis with the anti-U1 ribonucleoprotein (RNP) antibody. Although renal involvement is not included in any of the diagnostic criteria, it has been observed in 20% of MCTD patients. The most common renal disease is immune complex nephropathy, histologically classified as membranous glomerulonephritis, but minimal change disease (MCD) is very rare and has only been reported once previously. A previously healthy 33-year-old woman presented with generalized edema, puffy hands, arthralgia, and Raynauds phenomenon. We diagnosed MCD with proteinuria (> 9 g/day) and hypoalbuminemia (< 1.0 g/dL) by renal biopsy, and MCTD with a simultaneously high titer of the anti-U1 RNP antibody. The patient was treated with 200 mg/day cyclosporine and 30 mg/day prednisolone. The proteinuria and hypoalbuminemia normalized 2 months later. We report a patient with severe MCD associated with MCTD.

Ethics Education for Internal Medicine Residency

Fri, 01 Feb 2019 00:00:01 +0100

Current Status of Bariatric Endoscopy in Obesity Control

Fri, 01 Feb 2019 00:00:01 +0100

Obesity and metabolic syndrome affect ~40% of individuals in the United States alone. They are significant conditions that can cause severe economic problems. Obesity is also a global issue, with ~400 million obese adults worldwide. Moreover, the number of overweight children is increasing. Bariatric surgery is the gold standard treatment for obesity; however, endoscopic approaches may have a significant role in improving metabolic syndrome and achieving weight loss. Many endoscopic methods have been introduced, some of which are currently available and some that are undergoing experimentation. Endoscopists have a role in the treatment of obesity because endoscopic therapies are expected to become safer and more efficacious in the coming years. Endoscopic bariatric therapies can be categorized as space occupying, malabsorption, and gastric volume reduction. In this review, we summarize the currently available endoscopic procedures.

New Oral Agent for Treatment of Anemia in Patient with Chronic Kidney Disease: Prolyl ...

Fri, 01 Feb 2019 00:00:01 +0100

Hypoxia inducible factor (HIF)-stabilizers are being developed for the renal anemia treatment. This small molecules inhibit prolyl hydroxylase domain (PHD)-containing enzymes, causing HIF activation instead of degradation under the state of normoxia, finally increase production of intrinsic erythropoiesis. Current treatment guidelines suggest that renal anemia should be treated mainly with iron and erythropoiesis stimulating agents (ESAs). But there are several complications and concerns such as hypertension, ESA refractory anemia and increased cardiovascular mortality in using ESAs. Advantages of HIF stabilizers over ESAs are orally available, no dose-up requirement for inflammation. So far new HIF stabilizers showed efficacy and safety in renal anemia treatment. This new therapeutic agent may emerge as a standard treatment option for renal anmia treatment.

2018 KHRS Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Korean ...

Fri, 01 Feb 2019 00:00:01 +0100

Non-vitamin K antagonist oral anticoagulants (NOACs) are alternatives to vitamin K antagonists to prevent stroke in patients with non-valvular atrial fibrillation (AF) and have emerged as the preferred choice. The use of NOACs is rapidly increasing in Korea after coverage by insurance since 2015. However, the rate of prescribing anticoagulants in Korean patients with AF remains low compared to other countries. Most of the NOAC anticoagulant prescriptions are issued at hospitals. As the prevalence rate of AF in Korea is expected to increase rapidly with the increase in the elderly population, the need to prescribe NOACs in primary care clinics will also increase. Therefore, The Korean Heart Rhythm Society organized the Korean Atrial Fibrillation Management Guideline Committee and analyzed all available studies based on the 2018 European Heart Rhythm Association Practical Guide on the use of NOACs for managing AF, as well as studies on Korean patients. The authors would like to introduce practical guidelines for NOAC prescriptions in Korean patients with AF.

The 2018 Korean Heart Rhythm Society Practical Guidelines on the use of Non-Vitamin ...

Fri, 01 Feb 2019 00:00:01 +0100

Although non-vitamin K-antagonist oral anticoagulants (NOACs) reduce major bleeding events in patients with atrial fibrillation more effectively than does warfarin, a significant bleeding risk remains. Patients exhibiting current bleeding and those who are expected to bleed require appropriate management, because NOAC discontinuation may increase the thromboembolic risk. This article details general management principles for patients experiencing current bleeding and those undergoing invasive surgery while on NOACs.

2018 Korean Heart Rhythm Society Guidelines for Non-Vitamin K Antagonist Oral Anticoagulants

Fri, 01 Feb 2019 00:00:01 +0100

Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative to vitamin K antagonists (VKAs) and have emerged as the treatment of choice in Korea. However, several questions remain regarding the optimal use of these agents in specific clinical situations. In this paper we discuss 1) patients with atrial fibrillation (AF) and coronary artery disease, 2) avoiding confusion with NOAC dosing across indications, 3) cardioversion in a patient treated with a NOAC, 4) AF patients who present with acute stroke while on NOACs, 5) NOACs in special situations, 6) anticoagulation in AF patients with a malignancy, and 7) optimizing VKA dose adjustments.

Differential Diagnosis and Treatment of Thrombotic Microangiopathy Syndrome

Fri, 01 Feb 2019 00:00:01 +0100

Diagnosis of thrombotic microangiopathy (TMA) is challenging due to its close association with other forms of microangiopathic hemolytic anemia, such as malignant hypertension and disseminated intravascular coagulation, and because other manifestations including cytopenia and acute kidney injury are manifestations of other medical comorbidities. Further challenges for accurate diagnosis include distinguishing between primary and secondary TMA, as well as between hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP). TTP is typically differentiated from HUS by the presence of more severe thrombocytopenia, along with a higher frequency of altered mental status with relatively preserved renal function. However, the clinical course can vary among patients, requiring polymerase chain reaction testing of patient stools for enterohemorrhagic Escherichia coli and a disintegrin and metalloproteinase with thrombospondin type 1 motif 13 (ADAMTS13) assay. To reduce the mortality rate, prompt initiation of plasmapheresis is important in cases where TPP cannot be excluded. Future advances enabling more rapid testing for ADAMTS13 levels will reduce the need for unnecessary plasmapheresis, so that treatment strategy can be more optimized.

Optimal Evaluation of the Results of Liver Function Tests

Fri, 01 Feb 2019 00:00:01 +0100

Physicians of all specialties are required to assess abnormal results of liver function tests. Many patients with abnormal results in liver function tests do not have primary liver disease; most of the frequently requested tests are influenced by myriad non-hepatic factors. The most common tests are those for serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and bilirubin. Hepatocellular injury is indicated by abnormally elevated AST and ALT levels compared to the ALP level. Cholestatic injury is indicated by an abnormally elevated ALP level compared to AST and ALT levels. The majority of bilirubin circulates as unconjugated bilirubin, and an elevated conjugated bilirubin level is a marker of hepatocellular or cholestatic injury. Obtaining a detailed medical history, a clinical examination, and optimal interpretation of abnormal results of liver tests can enable the determination of the cause of liver diseases, facilitating their diagnosis and therapy.

Impact of Gender Differences in Elderly Patients with Acute Myocardial Infarction

Fri, 01 Feb 2019 00:00:01 +0100

Background/Aims: It is well known that gender differences are associated with clinical outcomes in patients with acute myocardial infarction (AMI). However, it is not clear whether gender differences affect the prognosis of elderly patients with AMI. Methods: We analyzed the incidence of in-hospital complications and mortality in the Korea Acute Myocardial Infarction Registry-National Institutes of Health from November 2011 to June 2015. This study included elderly patients (? 75 years) diagnosed with AMI. Results: A total of 2,953 patients were eligible for this study. Among them, 1,529 (51.8%) patients were female, and the mean age of the female group was older than that of the male group (80.7

Multidrug-Resistant, Gram-Negative Bacteria in Hospitalized Elderly Patients from Non-Hospital ...

Fri, 01 Feb 2019 00:00:01 +0100

Background/Aims: We investigated the risk of multidrug-resistant, gram-negative bacteria (MDRGNB) in hospitalized elderly patients from non-hospital long-term care facilities (LTCFs) and the antibiotic prescription pattern. Methods: All clinical cultures obtained within 48 hours of hospitalization from elderly patients of at least 55 years of age arriving at a 623-bed, public teaching hospital in Seoul, Republic of Korea from LTCFs between April 1, 2011 and April 1, 2012 were collected retrospectively. Results: During this period, 365 elderly persons from 13 LTCFs were hospitalized. This study enrolled 135 patients who had cultures performed. In this group, 27.4% harbored MDRGNB at hospitalization. The presence of MDRGNB during prior hospitalization was the only risk factor that predicted harboring it (p = 0.043, odds ratio = 5.00, confidence interval = 1.049-23.834). Combinations of antibiotics or carbapenems were used initially in 35.6% of the patients, and this did not affect the mortality rate in this population. Conclusions: Hospitalized elderly patients from non-hospital LTCFs need more attention. Judicious antibiotic selection is needed according to the risk factor of harboring MDRGNB for antibiotics stewardship.

Multiple Metachronous Malignancies: One Patient with Five Primary Malignancies

Fri, 01 Feb 2019 00:00:01 +0100

We report a case of a 73-year-old male with multiple, metachronous primary malignancies. He presented with adenocarcinoma of the stomach with transverse colon invasion followed by bladder cancer, hypopharyngeal cancer, urothelial cancer, and hepatocellular carcinoma, in that order, over 10 years. While these multiples malignancies were separate entities, they shared several etiologic factors, including smoking. To the best of our knowledge, this is the first description of five metachronous malignancies in a Korean patient.

Biventricular Hypertrophic Cardiomyopathy with Severe Right Ventricular Outflow Track Obstruction

Fri, 01 Feb 2019 00:00:01 +0100

Hypertrophic cardiomyopathy (HCM) has diverse pathophysiological and clinical features, according to the extent and severity of the hypertrophy development. Hypertrophy mostly involves the left ventricle and sometimes causes a left ventricular outflow tract obstruction. Right ventricular involvement is less frequent, and even the severe form of a right ventricular outflow tract (RVOT) obstruction by concurrent right ventricular hypertrophy in a patient with HCM is rare. We report a case of biventricular HCM with a clinically, morphologically, and hemodynamically significant RVOT obstruction, which had been treated successfully with surgical myectomy.

Malignant Melanoma of the Pancreas and Liver Mimicking a Neuroendocrine Tumor

Fri, 01 Feb 2019 00:00:01 +0100

Among metastatic pancreatic tumors, malignant melanomas are rare. Here, we report a very rare case of a malignant melanoma that involved only the pancreas and liver, and was difficult to differentiate from a neuroendocrine tumor of the pancreas with a liver metastasis. A 65-year-old- male with no history of a malignant melanoma exhibited hypervascular hepatic and pancreatic tumors on computed tomography and contrast-enhanced endoscopic ultrasonography. He lacked lesions of the skin, eye, and gastrointestinal tract on physical examination, upper endoscopy, and a whole-body positron emission tomography-computed tomography scan; these sites are common primary sites of malignant melanoma. Finally, endoscopic ultrasound-guided pancreatic core biopsy and percutaneous ultrasonography-guided liver biopsy confirmed malignant melanoma of the pancreas and liver.

A Case of Hemostatic Disorder Due to Thrombocytopenia Caused by a Type B Dialysis Reaction

Fri, 01 Feb 2019 00:00:01 +0100

The biocompatibility of dialysis membranes has significantly reduced adverse responses to dialysis, such that nowadays they are rarely reported. We report the case of a patient diagnosed and subsequently treated for thrombocytopenia caused by a dialysis reaction, as an example of a hemostatic disorder mistaken for an immature arteriovenous fistula. The peridialysis pattern of the platelet count helped to confirm the diagnosis. Further studies of the negative effects of dialysis are needed, including risk factors, predictors, treatment, and prevention.

Pigmented Villonodular Synovitis Developing in the Knee of a Rheumatoid Arthritis Patient ...

Fri, 01 Feb 2019 00:00:01 +0100

Pigmented villonodular synovitis is a benign tumor arising from synovial fibroblasts or histiocytes. There are diffuse and localized forms: the former involves the entire synovium and the latter consists of nodules, small tumefactions, or pedunculated masses. The knee is the joint most commonly affected and the clinical diagnosis is difficult, so initial misdiagnosis is common. We report a case of pigmented villonodular synovitis developing in the knee of rheumatoid arthritis (RA) patient, mistaken for an RA flare-up.

Relative Association of Overhydration and Muscle Wasting with Mortality in Hemodialysis ...

Fri, 01 Feb 2019 00:00:01 +0100

The Current Status of Hospital Medicine in Korea, 2019

Mon, 01 Apr 2019 00:00:01 +0100

Current Stem Cell Therapy for Osteoarthritis

Mon, 01 Apr 2019 00:00:01 +0100

Osteoarthritis is a musculoskeletal disease representative of an aging society. As medical conditions are usually complicated in an aging population, osteoarthritis becomes more frequently encountered in the physicians office. There is a growing need, therefore, for physicians to pay attention to this common orthopedic condition. Cartilage degeneration, arthritic pain, and joint dysfunction are major manifestations of osteoarthritis, and degenerated cartilage is difficult to repair with conventional treatment modalities. Scientists and physicians have developed various therapeutic strategies, including the use of stem cells. Here, we discuss previous and current progress in cartilage regenerative therapy against osteoarthritis.

Chimeric Antigen Receptor T-Cell Therapy for Diffuse Large B-Cell Lymphoma

Mon, 01 Apr 2019 00:00:01 +0100

CD19 chimeric antigen receptor T-cell (CAR-T) therapy, a genetically engineered cell therapy, showed unprecedented efficacy in the treatment of relapsed or refractory diffuse large B-cell lymphoma. Two agents, axicabtagene ciloleucel and tisagenlecleucel, were approved by the Food and Drug Administration in 2017. However, CAR-T therapy is a treatment with complex logistics and high costs, as well as inherent adverse events, including cytokine-release syndrome and neurotoxicity. In addition, predictive biomarkers for efficacy and toxicity are lacking. Industry-academy cooperation is urgently required to develop CAR-T therapy that is effective, safe, and affordable for patients in Korea.

Vascular Calcification in Patients with Chronic Kidney Disease

Mon, 01 Apr 2019 00:00:01 +0100

Cardiovascular morbidity and mortality are very common in patients with chronic kidney disease, which may result in part from vascular calcification. Vascular calcification requires osteoblastic trans-differentiation of vascular smooth muscle cells through an active and highly regulated process that is morphologically and functionally similar to bone formation in a number of ways. Multiple studies have been published on this topic, but the precise mechanism of vascular calcification remains unclear. This review presents recent insights into the mechanism of vascular calcification, as well as therapies that modulate mineral metabolism.

Carbapenem-Resistant Enterobacteriaceae: Rapid Laboratory Diagnosis and Surveillance Culture ...

Mon, 01 Apr 2019 00:00:01 +0100

Carbapenem-resistant Enterobacteriaceae (CRE) are increasing rapidly worldwide and in South Korea, which is a major problem for patient treatment and infection control. CRE is mainly due to carbapenem-hydrolyzing ?-lactamase, which spreads through genetic mobile elements. Therefore, the rapid detection of carbapenemase-producing CRE (CP-CRE) and carrier surveillance are very important for infection control. Most clinical microbiology laboratories use automated real-time PCR methods for the rapid detection of CP-CRE; in some cases, additional accurate molecular tests are necessary. For the surveillance of risk groups, the complementary use of liquid culture and real-time PCR methods is important, taking into consideration their advantages and disadvantages. Furthermore, the expansion of surveillance targets is also necessary.

New Diagnostic Guidelines for Idiopathic Pulmonary Fibrosis

Mon, 01 Apr 2019 00:00:01 +0100

Idiopathic pulmonary fibrosis (IPF) is a progressive fibrosing interstitial lung disease characterized by worsening lung function and dyspnea. The prognosis of IPF patients is poor, as median survival is approximately 3 years. However, recently developed IPF-specific therapies have shown improved efficacies in terms of reducing lung function decline and mortality. Therefore, the early recognition and accurate diagnosis of IPF are crucial. In 2018, new guidelines for the diagnosis of IPF were published by the Fleischner Society and by the American Thoracic Society/European Respiratory Society/Japanese Respiratory Society/Latin American Thoracic Society (ATS/ERS/JRS/ALAT). Both guidelines emphasize the need for a thorough history taking and physical examination to exclude an alternative diagnosis, such as exposure-related or connective tissue disease. The most informative initial examination is high-resolution computed tomography, the results of which can indicate the need for bronchoalveolar lavage or surgical lung biopsy, based on a multidisciplinary discussion of the findings and the patients clinical condition. A multidisciplinary discussion of the clinico-radiologic-pathologic findings is currently the gold standard in the diagnoisis of IPF and will allow the more effective and timely treatment of these patients.

Analysis of Overall Survival According to Bone Marrow Aspiration Results in Non-Hodgkin

Mon, 01 Apr 2019 00:00:01 +0100

Background/Aims: The staging work-up for patients with non-Hodgkins lymphoma includes bone marrow aspiration and biopsy. Consistent results of both procedures can clarify the diagnosis. However, no clear guidelines have been established regarding positive results for bone marrow aspiration alone. The aim of this study was, therefore, to analyze the overall survival (OS) for the clinical diagnoses of these patients using morphological methods. Methods: We performed a retrospective analysis of patients who were consecutively enrolled in the Korea University Lymphoma Registry from 1991 to 2016. OS was compared according to the bone marrow group: without bone marrow involvement (BMA-/BMBx-), with positive results for aspiration and negative results for biopsy (BMA+/BMBx-), and with bone marrow involvement in biopsy (BMBx+). OS was assessed using the Kaplan-Meier method and multivariate analysis. Results: Of 1,735 patients, 1,326 were analyzed and 409 were excluded. In the Kaplan-Meier survival analysis, OS was significantly worse for patients in the BMBx+ group compared with those in the BMA-/BMBx- group (p < 0.001). However, there was no significant difference in OS between patients in the BMA+/BMBx- group and those in other groups (vs. BMA-/BMBx-, p = 0.163; BMBx+, p = 0.292). In multivariate analysis, by adjusting survival-related variables, the BMA+/BMBx- group showed marginal significance compared to the BMA-/BMBx- group (p = 0.081), and showed significance in the subgroup of indolent non-Hodgkins lymphoma patients (p = 0.003). Conclusions: This study suggested that even if there are positive results in bone marrow aspiration alone in patients with non-Hodgkin lymphoma, attention to patient characteristics, involving significance as a poor prognosis for OS, is required.

Comparison of the Efficacy and Safety of Warfarin and Antiplatelet Therapy in Patients with ...

Mon, 01 Apr 2019 00:00:01 +0100

Background/Aims: The optimal strategy for anticoagulation treatment in patients with atrial fibrillation (AF) and end-stage renal disease (ESRD) has not been established. We evaluated the efficacy and bleeding risk of warfarin and antiplatelet agents in patients with AF and ESRD. Methods: We retrospectively reviewed the medical records of 256 patients with AF and ESRD and included 158 patients (age, 63.7

Recurrent Pancreatitis Caused by Afferent Loop Syndrome with Pathologic Features of Type II ...

Mon, 01 Apr 2019 00:00:01 +0100

Afferent loop syndrome (ALS) is a rare cause of recurrent pancreatitis. Recurrent pancreatitis in association with ALS can develop due to impaired outflow of pancreatic juice or reflux of enteric secretions caused by increased intraluminal duodenal pressure. Here, we report a case of ALS presenting as recurrent acute pancreatitis due to chronic intermittent partial obstruction of the third portion of the duodenum caused by postoperative adhesion. Interestingly, pancreatic histology showed a granulocytic epithelial lesion, which is a diagnostic feature of type 2 autoimmune pancreatitis (AIP, idiopathic duct centric chronic pancreatitis [IDCP]). From this case we learned that the diagnosis of type 2 AIP should be made in the appropriate clinical setting.

Pancreatic Neuroendocrine Tumor with Primary Hepatic B Cell Lymphoma

Mon, 01 Apr 2019 00:00:01 +0100

Pancreatic neuroendocrine tumors (NETs) frequently accompany metastatic lesions, and hepatic metastases are the most common of all NETs. However, another disease may also be present, potentially leading to misdiagnosis and metastasis of a NET. Clinicians should consider an active diagnostic evaluation for metastatic lesions, including liver biopsy, particularly when the hepatic lesion has distinct characteristics from the primary tumor. In our case, the patient had both a pancreatic NET and a primary hepatic lymphoma. She underwent laparoscopic distal pancreatectomy with splenectomy, and progress of the primary hepatic lymphoma was observed in the outpatient clinic.

Myocardial Infarction Associated with Anomalous Origin of the Left Coronary Artery from the ...

Mon, 01 Apr 2019 00:00:01 +0100

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare coronary artery anomaly and double right coronary artery (RCA) is a very rare coronary anomaly. Because patients with ALCAPA usually die within 1 year of being born due to myocardial infarction (MI) and heart failure, ALPACA is very rarely seen in adults. Here, we report an extremely rare asymptomatic case of MI, presumably caused by ALCAPA and double RCA, and provide a review of the literature. This is the first reported case of coronary artery anomaly that had both ALCAPA and double RCA.

Posterior Nutcracker Syndrome with Microscopic Hematuria

Mon, 01 Apr 2019 00:00:01 +0100

Nutcracker syndrome (NCS) refers to left renal vein compression with impaired blood outflow. The etiology of NCS has been attributed to various anatomic anomalies. Posterior NCS is caused by compression of the retroaortic left renal vein between the aorta and spine. The classic symptoms of NCS include left flank pain with gross or microscopic hematuria. The frequency and severity of the syndrome vary from asymptomatic microhematuria to severe pelvic congestion. For this reason, diagnosis of NCS is difficult and often delayed. Here, we report a case of posterior NCS that was incidentally discovered.

Severe Sinus Bradycardia Requiring Cardiac Pacing in a Lupus Patient Who Was Successfully ...

Mon, 01 Apr 2019 00:00:01 +0100

Symptomatic sinus bradycardia in adults with systemic lupus erythematosus (SLE) is rare. Here, we report a case of severe sinus bradycardia requiring temporary cardiac pacing in a SLE patient successfully treated using methylprednisolone pulse therapy.

Antimicrobial Therapy for Infections Caused by Carbapenem-Resistant Gram-Negative Bacteria

Mon, 01 Apr 2019 00:00:00 +0100

Current Status of Medical Disputes, Prospects and Cautions

Fri, 31 May 2019 00:00:01 +0100

Current and Prospect on Measles Outbreak

Fri, 31 May 2019 00:00:01 +0100

Measles is a highly contagious infectious disease characterized by fever, rash, cough, coryza, and conjunctivitis. The causative organism is the measles virus transmitted via the respiratory route. Before the introduction of an effective vaccine, measles was one of most prevalent diseases worldwide. Mortality may occur in patients with complications, including pneumonia, which is the most common cause of measles-associated death. The diagnosis of measles is based on clinical symptoms and laboratory tests, including the detection of measles virus-specific antibodies or measles virus ribonucleic acid and cultured viruses. The treatment for measles is primarily supportive care. In Korea, availability of the measles vaccine has substantially reduced the incidence and mortality of the disease. The World Health Organization verified the elimination of measles in March 2014; however, small outbreaks continue to be reported. Although a large proportion of measles cases occur in infants less than 1 year old, the disease has been reported in young adults with a history of measles vaccination. Here, we review the current literature on measles and discuss the importance of measles prevention in Korean adults.

The Cancer Precision Medicine Diagnosis and Treatment (K-MASTER) Enterprise

Fri, 31 May 2019 00:00:01 +0100

Precision trials, using reasonably integrated biomarker targets and molecularly selective anticancer agents, have become a major concern for both patients and their physicians. As next-generation sequencing, which is a parallel analysis method, becomes quicker, easier, and more accurate, precision medicine-based approaches are becoming more generalized in determining treatments for cancer patients. However, it is not applicable to all cancer patients because of current high prices, limited reimbursement coverage, low prevalence of driver genetic mutations, and lack of treatable drugs. To solve these problems, the Republic of Korea has been operating the Cancer Precision Medicine Diagnosis and Treatment (K-MASTER) Enterprise since its establishment in June 2017. The aim of the project was to conduct large-scale genomic analyses, appropriate matching targeted clinical trials, and data management, which incorporates genomic and clinical information. In this review, we introduce the goals and composition of this project and describe the progress of the project to date.

Updated Treatment of Chronic Hepatitis B

Fri, 31 May 2019 00:00:01 +0100

Chronic hepatitis B virus (HBV) infection is a major cause of liver cirrhosis and hepatocellular carcinoma in Korea. The prevalence of HBV infection is gradually decreasing in Korea, but 3.0% of the total population still suffers from HBV- related chronic liver diseases. In this review, we summarize the updated clinical practice guideline for management of chronic hepatitis B, as revised by the Korean Association for the Study of the Liver in 2018.

Updated Guideline for Diagnosis of Hypertension in Chronic Kidney Disease Patients: Based on ...

Fri, 31 May 2019 00:00:01 +0100

Hypertension affects the majority of patients with chronic kidney disease (CKD) and increases the risk of cardiovascular disease, end-stage renal disease and mortality. Previously, many hypertension guidelines have suggested blood pressure targets in patients with CKD. Recently, the American College of Cardiology/American Heart Association 2017 Guideline for Hypertension suggests a new definition for hypertension and therapeutic targets, which were equally applicated to patients with CKD. These changes reflect the results of the Systolic Blood Pressure Intervention Trial (SPRINT) study, but the renal outcome of intensive blood pressure control was not good. Furthermore, the majority of hypertension guidelines including those of the Korean Society of Hypertension and the European Society of Hypertension have retained the traditional definition. Herein, we intend to analyze in detail the effect of intensive blood pressure control on kidney through the post-hoc analyses of the SPRINT study.

Measurement and Interpretation of Dual-Energy X-ray Absorptiometry Bone Density Measurements

Fri, 31 May 2019 00:00:01 +0100

Dual-energy X-ray absorptiometry (DXA) is a widely used technology used to diagnosis osteoporosis and monitor changes in bone mineral density (BMD). The present paper reviews the clinical application of DXA in evaluating osteoporosis, including indications for BMD testing, interpretation of DXA results, diagnosis of osteoporosis, and serial BMD follow up. As the clinical utility of DXA depends on the quality of the scan acquisition, the precision assessment of DXA is also discussed.

Cost-Effectiveness Analysis of Hospice-Palliative Care for Adults with Terminal Cancer in South ...

Fri, 31 May 2019 00:00:01 +0100

Background/Aims: Although there is growing interest in hospice-palliative care, little information is available on the effects of such care in South Korea. Addressing this research gap, i.e., determining the cost-effectiveness of hospice-palliative care in South Korea, will help guide policy. Thus, the aim of this study was to evaluate the cost-effectiveness analysis of hospice-palliative care in adults diagnosed with terminal cancer. Methods: We used a Markov model to construct a decision tree, for an analysis comparing the general ward with the hospice- palliative ward in terms of patient quality of life and cost-effectiveness. Cost and quality of life were estimated based on published Korean studies. Cost-effectiveness was calculated as the incremental cost relative to the incremental effect. Additionally, a one-way sensitivity analysis was performed to test the robustness of the results. Results: Hospice-palliative ward care was more cost-effective than general ward care. The incremental cost was 290,401 Korean won (KRW) and the incremental effect was -0.25. The incremental cost-effectiveness ratio was -1,174,045 KRW. A similar pattern of results was obtained in the sensitivity analysis. Conclusions: Our results suggest that hospice-palliative ward care is more cost-effective than general ward care.

Liver Metastasis of Synchronous Small Rectal Neuroendocrine Tumors in the Absence of Risk Factors

Fri, 31 May 2019 00:00:01 +0100

The incidence of rectal neuroendocrine tumors (NETs) has increased worldwide, including in Korea. Rectal NETs are usually single lesions, but synchronous multiple lesions are reported in 2-4.5% of patients. Small rectal NETs (? 10 mm) are usually confined to the submucosal layer and rarely give rise to lymph node or distant metastases. Here we describe the case of a 54-year-old woman referred to National Cancer Center for the management of two rectal subepithelial tumors. Because computed tomography revealed a small hepatic nodule suggesting atypical hemangioma rather than metastasis, endoscopic submucosal dissection was performed. However, the size of the nodules increased during follow-up. The pathologic results of a liver biopsy confirmed metastatic NET. This case was unusual in that synchronous small rectal NETs and distant liver metastasis occurred in the absence of any risk factors for metastasis. Thus, patients with rectal NETs should be carefully evaluated, especially for the possibility of metastasis.

Immunoglobulin G4-Related Gastric Ulcer Mimicking Advanced Stomach Cancer in a Patient with ...

Fri, 31 May 2019 00:00:01 +0100

Type I autoimmune pancreatitis (AIP), a form of chronic pancreatitis, is included within the spectrum of immunoglobulin G4-related diseases (IgG4-RD). IgG4-RD can involve the salivary glands, bile ducts, kidneys and retroperitoneum, and the pancreas, and responds well to corticosteroid treatment. However, gastric involvement in IgG4-RD has been rarely reported. Here we report the case of a 56-year-old man with type I autoimmune pancreatitis who presented with a giant gastric ulcer mimicking advanced gastric cancer, which was subsequently determined to be IgG4-RD. Both the patients symptoms and his ulcerative lesions in the stomach responded to steroid treatment, which obviated the need for major surgery such as gastrectomy. Our case demonstrates the importance of recognizing potential gastric involvement in IgG4-RD, especially in a patient with concurrent AIP/IgG4-RD or a history of the disease, who is evaluated for an intractable and/or atypical gastric ulcer. A prompt diagnosis and proper management will avoid unnecessary surgery.

Concurrent, Prolonged Use of Bedaquiline and Delamanid for Multidrug-Resistant Tuberculosis

Fri, 31 May 2019 00:00:01 +0100

Bedaquiline and delamanid were recently approved for the treatment of multidrug-resistant tuberculosis (MDR-TB) in Korea. A treatment duration of 24 weeks was established based on phase 2 clinical trial data, although the combined use of these two drugs is typically not recommended because it may exaggerate QT prolongation. Here, we present a case of prolonged treatment (48 weeks) with a combination of bedaquiline and delamanid for pulmonary MDR-TB. The patient had previously been diagnosed with extensively drug-resistant TB but had been left untreated for the past 9 years due to a shortage of effective drugs. A combination of bedaquiline and delamanid successfully treated MDR-TB, highlighting the potential efficacy of these drugs for patients with drug-resistant TB infections.

Tacrolimus-Induced Fever in a Patient Undergoing Kidney Transplantation

Fri, 31 May 2019 00:00:01 +0100

Tacrolimus is widely used with other immunosuppressive agents to prevent rejection of a kidney transplant (KT). However, tacrolimus-induced fever is very rarely diagnosed. We report a case of tacrolimus-induced fever after KT. A 53-year-old female was diagnosed with cytomegalovirus (CMV) viremia. She had received a KT 2 months previously. Ganciclovir was started immediately at that time. A fever developed on day 12 of admission. Because of dysuria and a residual urine sensation with pyuria, we started intravenous antibiotics to treat urinary tract infection. Although other infectious reasons were ruled out and CMV viremia and the urinary tract infection improved, the fever spike did not improve. Thus, we suspected drug-induced fever. First, the ganciclovir and antibiotics were discontinued. However, the fever continued. To exclude tacrolimus-induced fever, tacrolimus was discontinued and cyclosporine was used with other immunosuppressive agents. Tacrolimus was discontinued after 1 day and the fever was no longer confirmed.

Infliximab-Induced Lupus in Crohn

Fri, 31 May 2019 00:00:01 +0100

Infliximab (IFX) is an anti-tumor necrosis factor (TNF) monoclonal antibody used to treat rheumatoid arthritis, ankylosing spondylitis, and Crohns disease. Rarely, anti-TNF-induced lupus (ATIL) may occur. ATIL differs from classical drug-induced lupus. We report a 49-year-old woman who developed polyarthralgia after 2 years of IFX treatment for Crohns disease. Based on the autoantibody profiles, ATIL was diagnosed and low-dose glucocorticoid, hydroxychloroquine, and celecoxib were prescribed. However, arthralgia and hemolytic anemia developed. Because the anti-dsDNA titers waxed and waned, she was switched to vedolizumab, a monoclonal antibody to the human lymphocyte ?4?7 integrin. Six months after switching treatment, the arthralgia had improved and the anti-dsDNA antibody normalized. Here, we report a case of ATIL that resolved after switching from infliximab to vedolizumab.

The Distributed Research Network, Observational Health Data Sciences and Informatics, and the ...

Wed, 31 Jul 2019 00:00:01 +0100

The Cause and Treatment of Acute Kidney Injury

Wed, 31 Jul 2019 00:00:01 +0100

Acute kidney injury (AKI), characterized by an acute decline in renal function, commonly develops in hospitalized patients and is associated with increased morbidity and mortality. Recent studies have identified new therapeutic strategies for its management. In this review, we will discuss the definition, etiology, and general treatment of AKI.

Updated Guidelines for the Management of Pancreatic Cystic Neoplasm

Wed, 31 Jul 2019 00:00:01 +0100

Pancreatic cystic neoplasms are becoming increasingly frequent, presenting a number of challenges in clinical practice. While several guidelines have been published to address these, they are largely composed of expert opinions based on relatively low-level evidence. Their recommendations are similar in general, but there are many differences in detail. Pancreatic neoplasms have differing malignant potential, based on the histologic type and clinical and radiological features of the cysts. It is necessary to stratify the malignancy risk of each cyst, using proper evaluation methods, and to manage it appropriately, with surgical resection or surveillance. In addition, risks associated with surgical resection, costs associated with long-term follow-up, and patient discomfort and anxiety must be considered in the proper management of pancreatic cystic neoplasms. In this review, we introduce four recently published guidelines.

Korean Heart Rhythm Society 2019 Practical Guidelines on Antithrombotic Therapy for AF Patients ...

Wed, 31 Jul 2019 00:00:01 +0100

The choice of an adequate antithrombotic regimen for atrial fibrillation patients undergoing emergent or elective percutaneous coronary intervention (PCI) should be based on the ischemic event and on the risk of bleeding. Recent randomized controlled trials have consistently demonstrated that dual antithrombotic therapeutic regimens, using non-vitamin K anticoagulants and clopidogrel, are superior to triple or dual therapy with warfarin and aspirin. This report incorporates findings of recent notable studies to provide concrete, clinically useful details and recommendations for bleeding risk assessment and optimal antithrombotic therapeutic strategies after PCI. In addition, we introduce guidelines for antithrombotic management after structural heart disease intervention.

Treatment of Mycobacterium abscessus Pulmonary Disease

Wed, 31 Jul 2019 00:00:01 +0100

Mycobacterium abscessus is the second most important pathogen in pulmonary disease caused by nontuberculous mycobacteria (NTM), following Mycobacterium avium. Mycobacterium abscessus is classified into three subspecies: M. abscessus subsp. abscessus, M. abscessus subsp. massiliense, and M. abscessus subsp. bolletii. Mycobacterium abscessus is the most difficult to treat NTM due to its resistance to many antibiotics. Treatment should include an initial regimen of 2-3 injectable and oral antibiotics for several weeks or months, followed by inhaled amikacin and 1-3 oral antibiotics, depending on the subspecies and drug susceptibility patterns, including macrolide susceptibility. The continuation phase should be continued for a minimum of 12 months after culture conversion. Suitable injectable antibiotics include amikacin, imipenem, cefoxitin, and tigecycline, while oral antibiotics include macrolides (azithromycin or clarithromycin), clofazimine, linezolid, and moxifloxacin. Surgery can be a useful adjunctive therapy for some patients with refractory disease. However, the overall treatment prognosis is still unsatisfactory. Therefore, novel and more effective interventions are required for the treatment of M. abscessus pulmonary disease.

Urticaria: Classification and Diagnosis

Wed, 31 Jul 2019 00:00:01 +0100

Urticaria is a common cutaneous disease characterized by recurrent and transient wheals and pruritus, sometimes accompanied angioedema. The classification of urticaria is based on the duration of the disease and whether extrinsic triggers are identified or not. Acute urticaria is usually occurred by specific causes, such as drug, food, and infection, etc. Therefore, acute urticaria can be remitted within 6 weeks just by avoiding the exposure to the causes. However, chronic urticaria defined as repeatedly occurred itchy wheals and/or angioedema for at least 6 weeks, has a significant effect on patients quality of life. Chronic inducible urticaria can be triggered by various physical stimuli including dermographism, delayed pressure, cold, heat, cholinergic stimuli, sunlight, and exercise. Chronic spontaneous urticaria (CSU) is diagnosed when no specific extrinsic cause is identified in the patients. CSU due to autoimmune mechanism accounts for 30-50%, autologous serum skin test and anti-thyroid autoantibody can be evaluated. However, various physical stimuli, emotional or physical stress, drugs, particularly aspirin and non-steroidal anti-inflammatory drugs can exacerbate urticaria in 30-75% of patients with CSU. Allergic diseases and autoimmune diseases are more common in CSU patients than in general populations. To assess the severity of urticaria and to adjust treatment step, urticaria activity score over 7 days, calculated by the number of wheals and the severity of pruritus, is recommended by recent international guidelines.

Rapid Antigen Detection Test for Diagnosis of Bacterial Pharyngitis

Wed, 31 Jul 2019 00:00:01 +0100

Pharyngitis is a prevalent disease of the upper respiratory tract that requires treatment with an antibiotic. Group A streptococci (GAS) are the most frequent etiologic agents of bacterial pharyngitis. Because GAS are susceptible to penicillin, routine antibiotic susceptibility testing is not needed. Generally, patients with bacterial pharyngitis have high fever, cervical lymphadenopathy and tenderness, and tonsillar exudative discharge without symptoms of the common cold (e.g., cough, rhinorrhea, and sneezing). However, differentiating bacterial pharyngitis from viral pharyngitis based only on their clinical manifestations is problematic. Therefore, a bacterial culture or a rapid antigen detection test (RADT) is required for the diagnosis of bacterial pharyngitis. Although bacterial culture is the gold standard for diagnosis of bacterial pharyngitis, its accuracy is affected by the technical expertise of the technician, and there is a delay of 1-2 days before the results become available. In contrast, the sensitivity of RADT has increased to over 90%, making them suitable for screening purposes. The result of a RADT is available within 5-10 minutes, obviating the need for a second visit to obtain the results of culture. Use of a RADT would enable the optimal antibiotic to be administered earlier, reducing the overuse of antibiotics.

The Colonoscopic Characteristics and Clinical Manifestations Associated with Lower ...

Wed, 31 Jul 2019 00:00:01 +0100

Background/Aims: Patients with chronic kidney disease (CKD) have a high risk of gastrointestinal tract bleeding because of platelet dysfunction attributable to uremia, a poor blood supply, and frequent use of anticoagulant agents. We describe the colonoscopic characteristics of lower gastrointestinal tract bleeding (LGIB) in patients with CKD. Methods: A total of 230 hospitalized patients with CKD who underwent colonoscopy because of suspected LGIB between January 2003 and August 2016 were reviewed retrospectively. We categorized CKD into five stages according to the estimated glomerular filtration rate and compared the colonoscopic findings and clinical manifestations among these five subgroups. Results: Of the 230 patients with CKD suspected of LGIB, 73 (31.7%, 103 cases) were colonoscopically confirmed to exhibit LGIB. Their mean age was 65.7

Primary Squamous Cell Carcinoma of the Gallbladder Diagnosed by Endoscopic Ultrasound-Guided ...

Wed, 31 Jul 2019 00:00:01 +0100

Squamous cell carcinoma of the gallbladder (GB) is uncommon and often presents at an advanced stage; therefore, it is associated with more aggressive behavior and a worse prognosis than those of adenocarcinoma. Herein, we report the case of an 82-year-old woman presenting a weight loss of 5 kg and epigastric discomfort over the previous 3 months. Abdominal computed tomography and magnetic resonance cholangiopancreatography revealed an infiltrative mass in the GB with hepatic invasion. Endoscopic ultrasound-guided fine needle biopsy using a 20-G core needle was performed, and the pathological examination revealed keratin pearls and an intracellular bridge, which are characteristics of squamous cell differentiation consistent with squamous cell carcinoma. Endoscopic ultrasound-guided fine needle biopsy was useful for obtaining an accurate histological diagnosis of GB masses without the need for surgery.

Extensive Pylephlebitis and a Liver Abscess Combined with Streptococcus Intermedius Sepsis

Wed, 31 Jul 2019 00:00:01 +0100

Pylephlebitis (septic thrombophlebitis of the portal venous system) is a rare but serious complication of intra-abdominal infections that drain into the portal venous system. Its diagnosis is based on imaging; computed tomography may reveal a thrombus in the portal vein. Bacteremia may also be evident. As the symptoms are nonspecific, early clinical diagnosis is difficult, and delayed treatment can compromise outcomes. We report a case with extensive pylephlebitis and a liver abscess associated with Streptococcus intermedius sepsis; the case was treated successfully with antibiotics and anticoagulants. Such cases have not been widely reported.

Birt-Hogg-Dub

Wed, 31 Jul 2019 00:00:01 +0100

Birt-Hogg-Dub

Cryptococcal Meningitis Complicated by a Brain Abscess and an Abdominal Pseudocyst Following ...

Wed, 31 Jul 2019 00:00:01 +0100

Ventriculoperitoneal (VP) shunt insertion is the standard treatment for hydrocephalus; shunt-associated infection is the most common complication after surgery. However, fungal infections are unusual. We present a case of cryptococcal meningitis complicated by a brain abscess and an infected intra-abdominal pseudocyst that developed 14 weeks after VP shunt insertion to treat hydrocephalus in a 74-year-old patient. Cryptococcal central nervous system (CNS) infection has a high mortality rate; however, diagnosis is challenging. Therefore, prompt diagnosis and treatment are required when a cryptococcal CNS infection is suspected in patients with VP shunts.

Appropriate Medical Technology in the Era of the 4th Industrial Revolution

Tue, 01 Oct 2019 00:00:01 +0100

Strengths and Limitations of Meta-Analysis

Tue, 01 Oct 2019 00:00:01 +0100

Meta-analysis is a statistical method that combines and synthesizes multiple studies and integrates their results. Meta-analysis increases the sample size, and in turn, the power to study the effects of interest by combining primary studies and providing a precise estimate of the effects. Data synthesized from meta-analyses are usually more beneficial than the results of narrative reviews. In a meta-analysis, the decisions are transparent, and statistical analysis yields an objective measure of the integrated quantitative evidence. The biases of narrative reviews can be limited or overcome by conducting a meta-analysis. The systematic approach and transparency in meta-analysis help to resolve conflicts and uncertainties between studies, while leading to significant conclusions. However, this method is controversial and may not always be the best tool. Moreover, meta-analysis has several shortcomings, and in some cases, it may not be appropriate. Although meta-analysis has been criticized due to its limitations, there are solutions to such problems. The aim of this review is to describe and discuss the strengths and weaknesses of meta-analysis.

Lipid-Lowering Therapy Guidelines

Tue, 01 Oct 2019 00:00:01 +0100

The major guidelines for lipid-lowering therapy (LLT) have been revised recently. Although higher cardiovascular risk-aggressive LLT with greater absolute clinical benefit is the main idea underlying all guidelines, there are some differences in the details among them. The US guidelines recommend pharmacological LLT based on a patients risk category, independently of their low-density lipoprotein-cholesterol (LDL-C) level. However, the European and Korean guidelines consider the patients risk category and LDL-C at the same time. Lifestyle modifications are suggested in parallel in all guidelines. The newest US guidelines have characteristically revived target LDL-C values in some patient groups and indications for non-statin drugs (ezetimibe and PCSK9 inhibitors), whereas the European and Korean guidelines have maintained target LDL-C values as usual. It is universally accepted that statins are the first-line agent. Adding ezetimibe, bile acid sequestrants, or PCSK9 inhibitors is recommended as a second line treatment. Appreciating the trend and background of the newest LLT guidelines will be essential to maximize cardiovascular prevention in patients.

Changes in Gastrointestinal Physiology in Obese Patients

Tue, 01 Oct 2019 00:00:01 +0100

Obesity is a prevalent disease with significant morbidity and mortality. It is a state of chronic low-grade inflammation due to excess body fat. Weight homeostasis is maintained through changes in various gastrointestinal hormones caused by dietary intake. However, being overweight or obese breaks the balance of these appetite-related gastrointestinal hormones and creates resistance to the actions of these hormones. The sensitivity of vagal afferent neurons to peripheral signals becomes blunted. Cytokines produced by excessive fat tissue damage our normal immune system, making us vulnerable to infection. In addition, various changes in gastrointestinal motility occur. Therefore, this review focuses on the various changes in gastrointestinal hormones, the immune state, the vagus nerve, and gastrointestinal movement in obese patients.

The Role of the Gut Microbiota in Obesity

Tue, 01 Oct 2019 00:00:01 +0100

Obesity is a critical target for public health interventions worldwide. There are many causes of obesity, and the importance of the gut microbiota in its pathogenesis has recently been recognized. The composition and function of the gut microbiota play a role in obesity and metabolic disease, yet the underlying mechanisms are unclear. Advances in our understanding of the link between obesity and the gut microbiota have suggested the potential of its manipulation for treating obesity. In this review, we summarize current knowledge of the interactions between the gut microbiota and obesity as well as the therapeutic potential of its modulation.

Diagnosis of Obesity and Related Biomarkers

Tue, 01 Oct 2019 00:00:01 +0100

Obesity is associated with various comorbidities, such as type II diabetes, hypertension, dyslipidemia, and cardiovascular disease. Gastrointestinal complications are also frequent and obesity is a direct cause of nonalcoholic fatty liver disease, and are risk factors for gastroesophageal reflux disease, pancreatitis, gallstone disease, diarrhea, dyssynergic defection, and various gastrointestinal cancers. Diagnosis is usually made by measuring body mass index (BMI). Although BMI is correlated with body fat mass, it may overestimate subjects with high muscle mass and underestimate subjects with low muscle mass. Co-measurement of waist circumference as a reflection of abdominal obesity for subjects with BMIs ranging from 25 to 35 kg/m² has been recommended; however, it is still an anthropometric diagnosis that does not clearly discriminate subjects at risk for developing comorbidities. Biomarkers reflect the underlying biological mechanisms of obesity and can be used to characterize the obesity phenotype (i.e., at high risk for disease development) as well as a target for disease-causing factors. In this article, we describe the conventional diagnosis, biomarkers of obesity, and current challenges.

Obesity and Functional Gastrointestinal Disorders

Tue, 01 Oct 2019 00:00:01 +0100

The prevalence of obesity and functional gastrointestinal disorders (FGIDs) is increasing worldwide. Obesity has been linked to gastroesophageal reflux disease, irritable bowel syndrome, functional dyspepsia, and various FGIDs. However, the relationship between obesity and FGIDs remains unclear. The purpose of this paper is to evaluate the published studies on this topic and clarify the relationship between obesity and the pathophysiology of various FGIDs.

A Diagnostic Roadmap for Raynaud

Tue, 01 Oct 2019 00:00:01 +0100

Raynaud's phenomenon (RP) is a reversible vasospasm that is aggravated by cold or emotional stress. Before confirming RP, it is essential to consider other possible causes including compressive neuropathy, sensori-neuropathy, thyroid disease, hematologic conditions and offending drugs. RP is typically characterized by the three-step color change that turns pallor (white), cyanosis (blue), and then erythema (red) of reperfusion. Once RP is diagnosed, it is important to determine whether it is primary or secondary RP. To distinguish primary from the secondary RP, the specialized tests performing in clinical practice are antinuclear antibody (ANA) and nailfold capillary microscopy (NFC). The combination of ANA and NFC is most helpful for discriminating secondary RP due to autoimmune rheumatic disease. Thereby, normal findings of NFC in primary RP distinguished from secondary RP should be understood. Patients with primary RP usually improves with symptomatic treatment focused on lifestyle modification and patient education, but those with secondary RP should be treated together with associated disease or causes.

Diagnosis of Food Hypersensitivity and Food Intolerance in Patients with a Functional ...

Tue, 01 Oct 2019 00:00:01 +0100

Patients with a functional gastrointestinal disorder (FGID) frequently report abdominal discomfort and bloating after ingesting specific foods. However, evidence on the relationship between foods and symptoms is lacking. In addition, the diagnosis of food hypersensitivity and food intolerance does not seem to be established yet. Food hypersensitivity can be divided into immunologically mediated and non-immunologically mediated forms. The immunologically mediated forms are specifically termed food allergies, whereas the non-immunologically mediated forms are referred to as food intolerances. Various diagnostic tools are required to make an accurate diagnosis of a food allergy or a food intolerance. First, a thorough examination of the history and basic tests to rule out other organic diseases are needed. Next, diagnostic tests for immunoglobulin E-mediated food allergies are required and diseases, such as celiac disease and lactose intolerance, should be differentiated. A diagnosis for non-celiac gluten sensitivity (NCGS) is also required. A double blind, randomized, placebo-controlled, dietary challenge test can be used for diagnosing NCGS and food intolerance. Diagnostic tests for food intolerance, in which scientific evidence is lacking, may result in a misdiagnosis of food hypersensitivity or food intolerance in patients with a FGID. Therefore, an accurate diagnosis of food hypersensitivity or food intolerance based on reliable tests is required.

Primary Lymphoma of Pancreatic Mucosa-Associated Lymphoid Tissue (MALT)

Tue, 01 Oct 2019 00:00:01 +0100

Primary lymphoma of pancreatic mucosa-associated lymphoid tissue (MALT) is extremely rare. Initial suspicion of primary pancreatic lymphoma is hampered by its low incidence. However, it should always be included in a differential diagnosis of pancreatic mass with unusual features, because an accurate diagnosis can avoid unnecessary surgical intervention. A 70-year-old woman presented with melena associated with a mass on the pancreatic head. Endoscopic ultrasonography-guided core-needle biopsy of the pancreatic mass revealed MALT lymphoma. The patient is currently undergoing radiation therapy. We present a case of primary lymphoma of the pancreatic MALT with a review of the literature.

Gastroenteropancreatic Neuroendocrine Tumor with Hepatic Metastasis Misdiagnosed as ...

Tue, 01 Oct 2019 00:00:01 +0100

The liver is the most common site of metastasis of neuroendocrine tumors (NETs). Gastroenteropancreatic (GEP)-NETs are rare, and the distinction between hepatocellular carcinoma (HCC) and metastatic NET can be difficult due to the similarity of their histological characteristics. Herein, we report a case of GEP-NET with hepatic metastasis, which was first misdiagnosed as HCC by liver biopsy and subsequently re-diagnosed after surgery as primary GEP-NET.

Mycophenolate Mofetil Overdose Induced Ventricular Tachycardia in a Patient with Systemic Lupus ...

Tue, 01 Oct 2019 00:00:01 +0100

Mycophenolate mofetil (MMF) is an immunosuppressive agent used to treat severe lupus, including lupus nephritis. Common adverse effects of MMF include gastrointestinal and hematological manifestations; however, cardiac toxicity in association with MMF has not been reported. We present a 21-year-old woman with lupus nephritis who developed ventricular tachycardia 2 hours after an overdose of MMF (34 g). Ventricular bigeminy was documented 12 hours after the MMF overdose. Transthoracic echocardiography showed no evidence of structural heart disease. The ventricular arrhythmia was successfully treated with potassium replacement, hydration, and cholestyramine. This case suggests that an overdose of MMF can induce ventricular tachycardia, and electrocardiogram monitoring is critical to identify this rare cardiac complication of MMF.

Medical Disputes from the Physician

Sun, 01 Dec 2019 00:00:01 +0100

Clinical Research from a Health Insurance Database: Practice and Perspective

Sun, 01 Dec 2019 00:00:01 +0100

Health insurance big data not only provide real-world evidence of unmet needs in actual clinical practice but also of breakthroughs in the medical industry which will shape the future of health care. Big data are also expected to transform the existing medical paradigm and provide a truly personalized medical age. However, questions about research through the collection and utilization of various big data in various fields have also been raised because quality limitations cannot be overlooked. Therefore, many challenges remain to be overcome in the use of big data research as a basis for changing medical practice. Intervention and interpretation by clinical medical experts are required in judging the scientific trustworthiness of the big data analysis process and the validity of the results. Therefore, healthcare big data research cannot achieve its goal by the efforts of researchers alone. Teams of data analysis scientists, epidemiologists, statistics experts, and clinical researchers are required to collaborate closely with team members, from the design phase to expert consultation, through regular meetings. In addition, it is necessary, in the creation of a healthier community, to cooperate with government agencies that provide data based on the whole nation or the worlds population, as well as interest groups representing the people, and policy-making organizations. In this paper, we describe the knowledge, practical clinical applications, and future research directions and prospects for the next phase of health care, from the design of clinical research using health insurance big data to report writing.

New Approach to Chronic Cough: An Introductory Guide Based on Recent Clinical Practice Guidelines

Sun, 01 Dec 2019 00:00:01 +0100

The cough reflex is a vital protective mechanism for the lower airways against aspiration, but when dysregulated, it becomes a clinical problem. Indeed, chronic cough is an important clinical issue as it is common in the general population and causes considerable morbidity. Anatomic diagnostic protocols were the first breakthrough in the management of patients with chronic cough; however, as systematic approaches are not always successful, a new paradigm of cough hypersensitivity syndrome has been proposed. The introduction of this paradigm has provided new opportunities for managing chronic cough, including development of new cough assessment tools and effective cough control therapies. However, it also warranted re-appraisal of existing clinical evidence and refinement of our clinical pathways. Against this background, international and domestic evidence-based practice guidelines based on a strict methodology have been published recently. In this review, we introduce clinical approaches based on the concept of cough hypersensitivity syndrome and discuss key aspects of recently published guidelines for chronic cough in adults.

Medical Treatment with Somatostatin Analogues in Acromegaly: Position Statement

Sun, 01 Dec 2019 00:00:01 +0100

Acromegaly is a chronic disorder caused by excessive growth hormone (GH) secretion. In most cases, the excess GH originates from GH-producing pituitary adenomas. Surgery is the preferred first-line treatment for patients with acromegaly, but medical management is considered when the disease persists after surgery or in cases where patients refuse surgery or are poor candidates for surgery. Somatostatin analogues are commonly used to treat acromegaly. The Korean Endocrine Society and the Korean Neuroendocrine Study Group have developed a position statement for the use of somatostatin analogues in the medical treatment of acromegaly. This position statement is based on evidence from the current literature and expert opinions. In the case of discrepancies among expert opinions, the experts voted to determine the recommended approach.

Sepsis

Sun, 01 Dec 2019 00:00:01 +0100

Diagnosis and treatment criteria were recently updated based on the Sepsis-3 guidelines, which recommend the sequential organ failure assessment for accurate characterization of organ dysfunction. Large randomized controlled trials have found neutral results with early goal-directed therapy. To improve outcomes, treatment bundles incorporating standards for early sepsis treatment, including antibiotic and steroid treatment, were developed. Thus, future research should address the effects of steroids and immune-modulating agents on refractory septic shock as well as the development of new coagulopathy therapies and dynamic assessment tools.

Interpretation of the Results of Arterial Stiffness Tests

Sun, 01 Dec 2019 00:00:01 +0100

Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Early detection of subclinical atherosclerosis is important for reduction of cardiovascular risk. However, the current diagnostic strategy, which focuses on traditional risk factors or the use of risk scoring, is unsatisfactory. Arterial walls thicken and stiffen with age, a process known as arteriosclerosis. There is a close interaction between arterial stiffness and atherosclerosis. Increased luminal pressure and shear stress caused by arterial stiffening result in endothelial dysfunction, accelerate the formation of atheromas, and stimulate excessive collagen production and deposition in the arterial wall. Carotid intima-media thickness (CIMT) has been shown to predict cardiovascular risk in many large studies. However, there is controversy regarding the value of CIMT for prediction of cardiovascular risk because of differences in study design, specifically with respect to CIMT measurements. Pulse wave velocity (PWV) is the most widely used measure of arterial stiffness; measurement of PWV is simple, non-invasive, and reproducible. Many clinical studies and meta-analyses have shown that PWV has predictive value in cardiovascular disease beyond traditional risk factors, both in the general population and in patients with various diseases. Brachial pressure has been a poor surrogate for aortic pressure for more than 50 years. However, recent studies have shown a closer relationship between central blood pressure and intermediate cardiovascular phenotypes or cardiovascular target organ damage, compared to the respective relationships with brachial blood pressure. Considering the non-invasiveness and ability to collect multiple types of clinical data, measurement of CIMT, PWV, and central blood pressure may be useful to identify patients at high risk for development of cardiovascular disease.

Bowel Wall Thickness, Elasticity, Intestinal Permeability, and Inflammatory Cytokines in ...

Sun, 01 Dec 2019 00:00:01 +0100

Background/Aims: Previous studies have reported that endotoxemia is associated with pathogenesis and complications in cirrhosis. Endotoxin stimulates the secretion of inflammatory cytokines, which contributes to the development of complications. In addition, endotoxin easily invades the gut barrier system because of the increased intestinal permeability due to portal hypertensive enteropathy. In this report, we explored changes in cytokine levels and intestinal permeability and measured the thickness and elasticity of the bowel wall using ultrasonography in cirrhotic patients. Methods: We enrolled 40 patients with cirrhosis classified as Child-Pugh B or C and 20 healthy volunteers. Abdominal ultrasonography examinations were used to evaluate bowel wall parameters in the ascending colon and terminal ileum. Intestinal permeability was measured using dual sugar absorption tests with lactulose and mannitol. Levels of tumor necrosis factor (TNF)-? and IL-10 were determined from blood samples. We compared these outcomes between cirrhotic patients and healthy controls and between Child-Pugh B and C patients. In addition, we explored the correlation between cytokine levels, intestinal permeability ratio, and bowel wall parameters in cirrhotic patients. Results: In cirrhotic patients, the ascending colon wall elasticity decreased (20.4 vs. 10.9 kPa, p = 0.048) and the terminal ileum wall thickness increased (4.2 vs. 1.9 mm, p < 0.001). The intestinal permeability ratio and levels of the cytokines TNF-? and IL-10 increased (0.219 vs. 0.017, p < 0.001; 22.47 vs. 13.48 pg/mL, p < 0.001; and 14.91 vs. 8.57 pg/mL, p = 0.019, respectively) in cirrhotic patients. However, there were no significant differences between Child-Pugh classes and no significant correlations between bowel wall parameters and intestinal permeability or cytokine levels. Conclusions: Ultrasonography revealed bowel wall thickening and decreases in elasticity; in addition, intestinal permeability and cytokine levels increased in cirrhotic patients compared with healthy controls.

Stage 1A Pancreatic Cancer Initially Manifesting as Clinical Acute Pancreatitis

Sun, 01 Dec 2019 00:00:01 +0100

Pancreatic cancer has a poor prognosis due to the difficulty of early diagnosis. Observation is recommended for early diagnosis of pancreatic cancer in elderly patients with risk factors such as newly diagnosed diabetes and chronic pancreatitis. A 66-year-old male suffered from acute pancreatitis of uncertain etiology. Initial pancreatic imaging showed a main pancreatic duct stricture at the pancreas body/tail junction and minimal duct dilatation without a visible mass. Eight months later, however, pancreatic imaging revealed a pancreatic mass at the previous stricture site with progression of the upstream duct dilation. The patient underwent distal pancreatectomy, and a pathologic examination showed stage 1A pancreatic cancer with a predominantly intraductal spreading pattern. We report a case of stage 1A pancreatic cancer that initially manifested as acute obstructive pancreatitis, which enabled early diagnosis of pancreatic cancer.

Spontaneous Splenic Rupture in a Peritoneal Dialysis Patient

Sun, 01 Dec 2019 00:00:01 +0100

Atraumatic splenic rupture (ASR) in a patient undergoing peritoneal dialysis (PD) is uncommon, but can be life-threatening. According to recent systematic reviews, the major causes of ASR are 1) neoplastic (30.3%), 2) infectious (27.3%), 3) non-infectious inflammatory (20.0%), 4) iatrogenic (9.2%), 5) mechanical (6.8%), and 6) idiopathic (6.4%). It is diagnosed by imaging studies, most commonly ultrasonography and computed tomography (CT). Due to its rarity, the early diagnosis of ASR is difficult, and no standard treatment has been described. Here, we report a case of idiopathic ASR in a patient undergoing PD. The diagnosis was established by abdominal CT scan, and splenectomy was performed. Thus, hemoperitoneum in a PD patient should raise suspicion of ASR. Early diagnosis and appropriate treatment will lead to a better outcome.

Eggerthella Lenta Bacteremia after Appendectomy in a Healthy Patient

Sun, 01 Dec 2019 00:00:01 +0100

Eggerthella lenta (E. lenta) has been reported to cause bacteremia in patients with gastrointestinal tract disorders or malignancies and in immunocompromised patients. Cases of E. lenta have been increasing with the recent development of testing equipment. The mortality rate due to E. lenta bacteremia is high. The authors report a case of E. lenta bacteremia in an immunocompetent patient.

Choosing Wisely Campaign for Appropriate Health Care

Thu, 01 Feb 2018 00:00:01 +0100

Relief System for Adverse Drug Reactions in Korea

Thu, 01 Feb 2018 00:00:01 +0100

The relief system for adverse drug reactions is a reimbursement system for non?fault injury from drugs that started with the intent of relieving victims of adverse drug reactions despite normal use of the medicines. In Korea, the relief system for adverse drug reactions started on December 19, 2014. To date, the deliberation process for 100 cases of adverse drug reactions has ended, of which 78 cases received relief reimbursement. As this is the early phase of system implementation, efforts to stabilize the system are needed. It is very important for clinicians to participate actively in mediating between the victims of adverse drug reactions and the Korea Institute of Drug Safety & Risk Management, to establish an effective relief system. It is also important to implement the most favorable relief system considering the socioeconomic and medical environment in Korea.

Novel Therapeutics for Recurrent or Metastatic Gastric Cancer

Thu, 01 Feb 2018 00:00:01 +0100

Despite advances in cancer therapy, gastric cancer has a poor prognosis and high cancer-related mortality. Based on the molecular characteristics of cancer, specific targeted therapies have shown clinical benefits for various tumors. In addition, immunotherapy using immune checkpoint inhibitors has led to a paradigm shift in cancer treatment and shown remarkable results in some solid tumors. Although immunotherapy has been actively applied to gastric cancer, the efficacy is unsatisfactory compared with other solid tumors, such as melanoma and lung cancers. This is because of the complex mechanism of gastric cancer, tumor heterogeneity, heterogeneity among patients, and the absence of appropriate biomarkers to predict response. An effective new cancer treatment strategy that combines targeted therapies and various immunotherapies based on biological markers such as tumor mutation burden and microsatellite instability is urgently needed. Furthermore, customized treatment is necessary to overcome tumor heterogeneity.

The 2017 Update of the Clinical Guidelines for ST-Segment Elevation Myocardial Infarction of ...

Thu, 01 Feb 2018 00:00:01 +0100

The 2017 Clinical Guidelines for ST-segment elevation myocardial infarction of the European Society of Cardiology updated many important aspects of the pre-hospital phase, the selection of a reperfusion strategy, interventional and pharmacological treatment, and patient quality assessment. The principal changes are a clear definition of the first medical contact, elimination of the door-to-balloon time from consideration, recommended radial access intervention, a recommendation that drug-eluting stents should be preferred to bare metal stents, recommended complete revascularization during hospitalization, and early discharge of selected patients. Routine manual thrombus aspiration and oxygen supplementation for patients who are not hypoxemic are now discouraged.

Diagnostic Approach to Nonalcoholic Steatohepatitis

Thu, 01 Feb 2018 00:00:01 +0100

Approach to the Patient with Metabolic Alkalosis Accompanied by Hypokalemia

Thu, 01 Feb 2018 00:00:01 +0100

Simulation Results for Contamination Comparisons by Various Use Protocols of Personal ...

Thu, 01 Feb 2018 00:00:01 +0100

Background/Aims: Due to a lack of scientific evidence and unstandardized protocols, the correct use of personal protective equipment (PPE) is not always easy for healthcare personnel (HCP). This study aimed to generate experimental evidence to reduce contaminations during PPE doffing. Methods: With institutional review board approval, 4 standardized HCP were recruited to examine selected PPE protocols based on consultations with 10 invited Korean infection control leaders. Using fluorescent powder and ultraviolet light, each PPE protocol was evaluated for contaminations by comparing methods or steps. Pictures of contaminated areas and videos of HCP practice were evaluated for case analysis by linking all collected data using assigned study experiment codes. Results: A total of 38 simulation experiments were conducted during December 14-20, 2016. No significant difference was found among minor variations in PPE protocols. Rather, after an intensive, 1-minute patient care simulation (e.g., physical assessment), severe powder contaminations on the front and under the sleeves of coveralls were found. Even after the outer-glove surface was wiped clean, partial contaminations still remained, especially between fingers and on fingertips. Moreover, after cleaning glove surface contaminations using wipes, each doffing step caused different contaminations. Among different types of N95 respirators, the foldable N95 type was the most stable during doffing processes, with less possibility of contamination. Conclusions: Based on this studys findings with visual evidence of contaminations during PPE doffing processes, some meaningful recommendations were feasible, such as the use of disposable long-sleeve aprons over coveralls. Further study is necessary to evaluate these recommendations.

Hepatic Arterial Infusion Chemotherapy Using the Port System in Advanced Gallbladder Cancer

Thu, 01 Feb 2018 00:00:01 +0100

Gallbladder (GB) cancer is relatively rare and has a poor prognosis, with a median survival time of less than 3 months. It is resistant to chemotherapy. Therefore, the role of systemic chemotherapy is limited. However, administering the anticancer agent directly into the hepatic artery can result in a higher drug concentration in the cancer tissue. In this paper, we report a case of advanced GB cancer treated with hepatic arterial infusion chemotherapy (HAIC) using the port system. The patient received six cycles of HAIC with 5-fluorouracil (750 mg/m²) and cisplatin (25 mg/m²); each cycle lasted for 4 days every month. The tumor showed objective response during HAIC, and the patient survived for 15 months from the first therapy. HAIC using the port system might be a promising therapeutic modality for treating locally advanced GB cancer.

Treatment by Transradial Urokinase Infusion and Percutaneus Transhepatic Thrombectomy in ...

Thu, 01 Feb 2018 00:00:01 +0100

Mesenteric venous thrombosis has a low prevalence and nonspecific clinical symptoms, and it may cause bowel infarction and death. Early diagnosis and prompt surgical intervention with anticoagulants are important to patients. We examined a 27-year-old woman complaining of diffuse abdominal pain and hematochezia, and diagnosed extensive mesenteric venous thrombosis with intestinal infarction and pulmonary thromboembolism. In light of the patients symptoms, an operation seemed necessary. However, because of the high risk of mortality, we decided to look for another option. The patient was successfully treated with intensive medical care and a radiological procedure in spite of intestinal infarction.

Massive Pulmonary Embolism with Thrombus-in-Transit Entrapped by a Patent Foramen Ovale

Thu, 01 Feb 2018 00:00:01 +0100

Thrombus-in-transit in pulmonary embolism is associated with high mortality and refers to a free-floating clot in the right atrium or right ventricle, indicating that deep vein thrombosis is present en route to the pulmonary artery. Thrombus entrapped in a patent foramen ovale (PFO) is a rare condition and is associated with paradoxical systemic embolism. Here, we report a case of acute pulmonary embolism with thrombus-in-transit through a PFO in a 68-year-old woman with a diagnosis of metastatic pancreatic cancer undergoing palliative chemotherapy. She presented with syncope after acute onset of exertional dyspnea and was diagnosed with cardiogenic shock due to massive pulmonary embolism with thrombus-in-transit on admission to the emergency room. We treated her with systemic thrombolysis and anticoagulation therapy instead of surgical thrombectomy. We show that hemodynamically unstable pulmonary embolism with thrombus-in-transit entrapped by a PFO may be successfully treated with systemic thrombolysis without paradoxical embolism.

Peritoneal Dialysis-associated Peritonitis Caused by Chryseobacterium indologenes

Thu, 01 Feb 2018 00:00:01 +0100

Chryseobacterium indologenes (C. indologenes) is a nonmotile, gram-negative bacillus that is widely distributed in nature. Generally considered nonpathogenic, C. indologenes rarely infects humans and is not normally present in the human microflora. C. indologenes infections have been observed in cases of peritoneal dialysis (PD)-associated peritonitis, although the incidence of these infections is low. Although C. indologenes is generally susceptible to trimethoprim-sulfamethoxazole, levofloxacin, ciprofloxacin, piperacillin-tazobactam, and cefepime, no guidelines have been established for the treatment of PD-associated peritonitis. Here we report the first case of PD-associated peritonitis in Korea with C. indologenes identified as the sole etiologic agent. The patient recovered after intraperitoneal antibiotic treatment without the need for Tenckhoff catheter removal.

Successful Remission of Recurrent Anaphylaxis after Omalizumab Administration in a Patient with ...

Thu, 01 Feb 2018 00:00:01 +0100

Mastocytosis is a disorder characterized by abnormal mast cell proliferation and accumulation in one or more tissues. It presents in two major variants: cutaneous mastocytosis and systemic mastocytosis. Because the symptoms are related to mast cells, histamine receptor antagonists and leukotriene receptor antagonists are recommended as therapeutic options. Here, we report a 54-year-old male patient with a history of urticaria pigmentosa who presented with recurrent anaphylaxis. His serum tryptase level was 31.7 ng/mL and mast cell infiltration was observed in his bone marrow. He had frequent attacks of anaphylaxis despite treatment with ketotifen, levocetirizine, and montelukast. Symptoms related to systemic mastocytosis were controlled and the patient exhibited no recurrence of anaphylaxis following the introduction of monthly omalizumab injection. Omalizumab can be considered as a treatment option in patients with systemic mastocytosis unresponsive to conventional oral medications.

Decisions on Life-Sustaining Treatment at the End of Life

Sun, 01 Apr 2018 00:00:01 +0100

Determination of Health Insurance Fee Schedule and Strengthening Policy for Health Insurance ...

Sun, 01 Apr 2018 00:00:01 +0100

The resource-based relative value scale (RBRVS) was introduced in Korea as a payment system in 2001. However, the health insurance fee schedule had many problems. Unbalanced insurance fee schedules still occur, and the relative value was not divided between physicians work and practice expenses. Furthermore, malpractice fees were not included in the total RBRVS. The first refinement project of the health insurance relative value scales was conducted in 2003 and the second project started in 2010. In the first project, final relative values were calculated under budget neutrality by medical departments, and imbalances within the departments were resolved. However, imbalances still existed between departments. In the second project, final relative values were classified and computed by the type of medical treatment. The final RBRVS has been applied step by step since 2017 and the imbalance problem of the insurance fee schedule has been partially resolved. The government recently announced strengthening the plan for health insurance coverage. The current coverage rate for total medical costs by national health insurance is 63%. The purpose of this plan was to increase the coverage rate by up to 70%. The government has suggested detailed plans but there remain many controversial issues and limitations with regard to the practical aspects. Thus, further research and suggestions are needed.

2018 KHRS Guidelines for Stroke Prevention Therapy in Korean Patients with Nonvalvular Atrial ...

Sun, 01 Apr 2018 00:00:01 +0100

Atrial fibrillation (AF) is the most common cardiac abnormality associated with ischemic stroke. Anticoagulant therapy plays an important role in the prevention of stroke associated with AF. Risk stratification and selection of oral anticoagulants in patients with AF are usually performed according to international guidelines from Europe or the United States of America. However, pivotal trials enrolled only a small number of Asian subjects, limiting the application of international guidelines to Korean patients with AF. The Korean Heart Rhythm Society organized a Korean AF Management Guideline Committee and analyzed all available studies regarding the management of AF, including studies on Korean patients. Expert consensus or guidelines for the optimal management of Korean patients with AF were achieved after a systematic review with intensive discussion. This article provides general principles for appropriate risk stratification and selection of anticoagulation therapy in Korean patients with AF.

2018 KHRS Expert Consensus Recommendation for Oral Anticoagulants Choice and Appropriate Doses: ...

Sun, 01 Apr 2018 00:00:01 +0100

Oral anticoagulants (OAC) are necessary to prevent thromboembolism in patients with atrial fibrillation (AF). OACs used in Korea are composed of warfarin and non-vitamin K antagonist OAC. Risk stratification and selection of OACs in patients with AF is usually performed by international guidelines for AF management. However, these guidelines do not always reflect the unique characteristics of AF patients in Korea as they were established based on a small portion of the Asian population and, therefore, have limited application to Korean patients. In addition, under certain conditions, the choice of OACs and doses according to the international guidelines are unsuitable for Korean AF patients. Recently, robust clinical data of Korean AF patients have become available. The Korean AF Management Guideline Committee, as part of the Korean Heart Rhythm Society, analyzed all available studies regarding management of AF including those focusing on Korean patients. Expert consensus and guidelines for optimal management of AF patients in Korea were established following systematic reviews and intensive discussions. This article provides the appropriate choice of OACs and dose for management of Korean AF patients with various clinical conditions.

2018 Korean Heart Rhythm Society Guidelines for The Rate Control of Atrial Fibrillation

Sun, 01 Apr 2018 00:00:01 +0100

Atrial fibrillation (AF) is characterized by irregular and relatively rapid heart rate, which occasionally causes symptoms such as palpitations, dyspnea, or reduced exercise capacity. Controlling the ventricular rate is a mainstay for the symptom management of patients with AF. Rate control can be achieved with beta-blockers, non-dihydropyridine calcium channel blockers, digoxin, or combination therapy. Rhythm control is an option for patients in whom appropriate rate control cannot be achieved or who have persistent symptoms despite rate control. The choices of drug and target heart rate are usually specified by international guidelines for AF management. However, pivotal trials included in those guidelines enrolled only a small number of Asian subjects, which limit application of those guidelines to a Korean population. The Korean Heart Rhythm Society organized the Korean AF Management Guideline Committee and analyzed all available studies regarding management of AF including studies with Korean patients. Then, expert consensus or guidelines for optimal management in Korean patients with AF were achieved after systematic review with intensive discussion. This article provides general principles for rate control therapy in Korean patients with AF.

2018 Korean Heart Rhythm Society Guidelines for Antiarrhythmic Drug Therapy in Non-valvular ...

Sun, 01 Apr 2018 00:00:01 +0100

Rhythm control therapy is the main strategy for restoring and maintaining sinus rhythm in patients with non-valvular atrial fibrillation (NVAF). Sinus rhythm is better restored and maintained with antiarrhythmic drugs than with placebo treatment. In addition, catheter ablation or combination therapy is more effective than antiarrhythmic drugs for treating NVAF. However, in most clinical trials to date, rhythm control therapy has resulted in neutral clinical outcomes compared with rate control therapy. The decision to undergo rhythm control therapy should be based on age, atrial fibrillation (AF)-related symptoms, type of AF, structural heart disease, and underlying comorbidities. For now, rhythm control therapy is indicated to improve symptoms in patients with NVAF who have refractory symptoms after adequate rate control therapy. The Korean Heart Rhythm Society organized the Korean AF Management Guideline Committee and analyzed all available data, including South Korean patients with NVAF. This review article provides general principles and detailed methodology for rhythm control therapy in South Korean patients with NVAF.

Diagnosis of Severe Asthma: Definition and Identification

Sun, 01 Apr 2018 00:00:01 +0100

Severe asthma is associated with substantial morbidity, use of healthcare resources, and long-term sequelae including declining lung function and frequent exacerbations. The identification of severe asthma is challenging due to the heterogeneity of the disease, the complexity of diagnosis, and the impact of comorbidities. A structured approach to the assessment of severe asthma may be helpful to the practicing clinician. First, it is important to confirm a diagnosis of asthma. The lack of a response to treatment or the requirement for high doses of medication to control symptoms are signs of disease mimickers, comorbidities, or the influence of environmental factors. Second, medication adherence and the inhaler technique should be checked in advance. Third, the phenotypic characteristics of patients confirmed to have severe asthma can indicate the therapies likely to be most effective. Further research that seeks to define the phenotypes of severe asthma based on endotype will enable the development of novel and effective therapeutic options for patients with severe asthma.

Treatment of Severe Asthma

Sun, 01 Apr 2018 00:00:01 +0100

Severe asthma represents 3-10% of all cases of asthma, but accounts for > 60% of total asthma-related medical costs. Uncontrolled asthma symptoms and frequent asthma exacerbations associated with severe asthma have profound adverse effects on patients quality of life. The concepts of difficult-to-treat asthma and severe asthma are different; severe asthma represents one kind of difficult-to-treat asthma. Misdiagnosis, nonadherence, and comorbidities may also be causes of difficult-to-treat asthma. This review discusses important principles in the treatment of difficult-to-treat asthma and severe asthma.

Biologic Treatment of Severe Asthma

Sun, 01 Apr 2018 00:00:01 +0100

Beyond the existing scope of asthma treatment, a number of biologics have recently been developed based on the immunopathological mechanism of severe asthma. Severe asthma has a wide variety of phenotypes or endotypes, more than half of which are associated with eosinophils or type 2 inflammation. This paper introduces newly developed biologics and those that are under development for treatment of asthma. The most successful biologics developed to date are anti-IgE and anti-interleukin (IL)-5 antibodies, followed by anti-IL-4, anti-IL-13, anti-prostaglandin D2 type 2 receptor, and anti-thymic stromal lymphopoietin antibodies. However, further studies on drugs that target type 1 inflammation are required.

Point-of-Care Diagnostics for Infectious Diseases: Present and Future

Sun, 01 Apr 2018 00:00:01 +0100

Recent Advances of Peroral Cholangioscopy

Sun, 01 Apr 2018 00:00:01 +0100

Analysis of Hemodialysis Therapy Variation Associated with Periodic Hemodialysis Quality ...

Sun, 01 Apr 2018 00:00:01 +0100

Background/Aims: The appropriateness assessment of hemodialysis therapy by Korean Health Insurance Review & Assessment service was conducted five times. The purpose of this study was to analyze the effect of the appropriateness assessment on the clinical hemodialysis treatment through the analysis of the medical expenses. Methods: The medical insurance claims during the three months before and after the second, third, and fourth appropriateness assessment and the patient survival rate were analyzed according to the appropriateness rating level. Results: The medical costs per patient during the three months before and after the assessment period were 6 to 8% lower than that of the assessment period. The medication cost (drug fee) was the best part of the evaluation because the cost differences according to the appropriateness rating grade were obvious. In addition, the cost of erythropoietin gradually decreased over each evaluation period, but there was no cost decrease in other drugs and the diabetic drug was even slightly increased. Patient survival rate according to the appropriateness rating grade was not large, but grade 2 was the best which was followed by grade 1 and grade 3, 4, and 5 were almost the same. Patient survival rate according to the appropriateness rating grade was not significant. Conclusions: The variation of medical costs associated with the assessment implicates the necessity of all year-round assessment. In addition, drug costs among the medical expenses seem to be the best reflected part of the evaluation grade because of the difference in grade of appropriateness assessment.

Type 2 Autoimmune Pancreatitis with Ulcerative Colitis Manifesting as Acute Pancreatitis

Sun, 01 Apr 2018 00:00:01 +0100

Autoimmune pancreatitis (AIP) occurs in two forms. Type 1 AIP is an IgG4-related systemic fibro-inflammatory disease. Type 2 AIP is not associated with altered levels of IgG4, and involves only the pancreas. Here, we report a case of type 2 AIP manifesting as acute pancreatitis in a 20-year-old male with ulcerative colitis. The patient was definitely diagnosed with type 2 AIP based on typical pancreatic imaging, supportive histology, history of ulcerative colitis, and steroid responsiveness.

Transvenous Implantation of an Implantable Cardioverter Defibrillator in a Patient Who Had ...

Sun, 01 Apr 2018 00:00:01 +0100

Transvenous implantation of an implantable cardioverter defibrillator in patients with a prosthetic valve in the tricuspid position is difficult because a defibrillator lead cannot be implanted into the right ventricle through the prosthetic valve. Hence, there are three options: epicardial implantation, subcutaneous implantable cardioverter defibrillator implantation, and cardiac vein implantation. Here, we report the transvenous implantation of an implantable dual-chamber cardioverter defibrillator in a patient who had undergone tricuspid valve replacement with a prosthetic valve. The patient was a 70-year-old female with a prosthetic valve in the tricuspid position who had experienced two events of sudden cardiac arrest. We successfully performed the procedure by implanting the defibrillator lead into the middle cardiac vein.

Diabetic Ketoacidosis Following Colonoscopy in Fulminant Type 1 Diabetes: A Case Report

Sun, 01 Apr 2018 00:00:01 +0100

Fulminant type 1 diabetes is a distinct subtype of type 1 diabetes mellitus that is characterized by sudden, complete destruction of pancreatic beta cells at the disease onset. Since the disease was first described in 2000 in Japan, a number of case reports have also been published in Korea. However, this disease entity is still not well defined. A 48-year old man with no medical history was admitted with diabetic ketoacidosis. Fulminant type 1 diabetes was diagnosed and he was discharged with multiple insulin injections. His serum glucose level was well controlled in the outpatient clinic. A month later, diabetic ketoacidosis occurred again following a diagnostic colonoscopy. This case suggests that fulminant type 1 diabetes is an aggressive disease in which small stimuli can provoke ketoacidosis. Therefore, for tests that require fasting, close observation by medical staff and patient education about the disease is essential.

Acute Thrombotic Thrombocytopenic Purpura with Right Heart Failure Following Total Knee ...

Sun, 01 Apr 2018 00:00:01 +0100

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening condition characterized by microangiopathic hemolytic anemia, thrombocytopenia, renal insufficiency, neurological abnormalities, and fever. Cardiac involvement is not uncommon and can be fatal; however, right ventricular heart involvement after surgery is rare. Here, we report a case of TTP presenting with right ventricular heart failure after total knee replacement surgery. TTP was successfully treated with four rounds of plasma exchange. The patient made a full recovery and was discharged after 11 weeks.

A Case of Beh

Sun, 01 Apr 2018 00:00:01 +0100

Beh

Korean Society of Gastrointestinal Endoscopy (KSGE) Guidelines for Endoscope Reprocessing

Sun, 01 Apr 2018 00:00:01 +0100

Investigation and Proposals of Korean Diagnosis Related Group and Patient Classification System

Fri, 01 Jun 2018 00:00:01 +0100

Occupational Radiation Exposure and Health Effects among Medical Workers

Fri, 01 Jun 2018 00:00:01 +0100

Medical radiation workers occupy the largest group of radiation workers and is rapidly increasing worldwide. They expose to protracted low-dose radiation and include a large proportion of women. The purpose of this article is to provide an overview of occupational radiation exposure and health effects among medical radiation workers through literature review and from the findings of Korean medical radiation workers studies. Occupational radiation exposure increases the risk of many chronic diseases including cancer, cataract, cardiovascular diseases, thyroid diseases, and others. Although Korean medical radiation workers had a more favorable mortality than in general population, male workers experienced higher mortality from all cancers, leukemia, cancers of the stomach and the colon, and diseases of circulatory system after adjusting for the lower overall mortality. The potential adverse health risks from occupational radiation exposure are not negligible in medical radiation workers if current working level remains. Therefore, effective prevention efforts are needed to reduce the risks of diseases from occupational radiation exposures.

Treatment of Early Gastric Cancer: Endoscopic Submucosal Dissection with LASER

Fri, 01 Jun 2018 00:00:01 +0100

In 2000, endoscopic resection is very useful treatment modality for early gastric cancer. The Needle Knife (Olympus, Tokyo, Japan) and Insulated Tip Knife (Olympus) are used for endoscopic dissection of gastrointestinal tumors in clinical practice. The depth of penetration and the high power delivered to soft tissue by electrocautery with these needles are not well controlled, and therefore may increase the risk of complications such as intestinal perforation and bleeding lasers 2-?m in wavelength offer efficient tissue cutting with limited thermal damage in biological tissue. Light amplication by the sumulated emission of radiation dissection demonstrated good maneuverability, clean and rapid cutting, and excellent hemostasis. And, now we would like to evaluate the clinical outcomes of the endoscopic submucosal dissection with using laser and capabilities in the future.

Recent Update on RANKL Inhibitor

Fri, 01 Jun 2018 00:00:01 +0100

The prevalence of osteoporosis is continuing to increase with growing elderly population. A variety of anti-osteoporotic agents have been used for the prevention and treatment of osteoporosis and osteoporotic fractures. Novel therapeutic agents based on the newly discovered mechanisms in bone biology have been recently introduced. Denosmab, a fully human monoclonal antibody to the receptor activator of nuclear factor-?B ligand, is a new therapeutic agent that inhibits osteoclast differentiation, activity, and survival. In the fracture reduction evaluation of denosumab in osteoporosis every 6 months (FREEDOM) trial, denosumab treatment for 36 months significantly increased bone mineral density at all skeletal sites evaluated, thereby resulting in a significant reduction in the risk of vertebral, nonvertebral, and hip fractures. In the FREEDOM Extension study, in which denosumab treatment was continued for up to 10 years, denosumab showed a continued improvement in bone mineral density and a consistently low fracture risk similar to rates observed in the denosumab group during the FREEDOM trial. Denosumab also offered a favorable safety profile with generally low and stable adverse event rates. Denosumab was indicated for treatment of postmenopausal women with osteoporosis at high risk for fracture, treatment to increase bone mass in men with osteoporosis, treatment of bone loss in men receiving androgen deprivation therapy for prostate cancer, and treatment of bone loss in women receiving adjuvant aromatase inhibitor therapy for breast cancer. For these patients, denosumab is an important option for the prevention and treatment of osteoporosis and osteoporotic fractures.

Medical Treatment of Cancer Pain: Drug Therapy according to Guidelines Will Improve the Quality ...

Fri, 01 Jun 2018 00:00:01 +0100

Cancer pain is the most common and troublesome symptom for cancer patients. The more the cancer patient gets to the end of the life, the worse the pain. There are many clinical practice guidelines for cancer pain, and most pain can be controlled with appropriate medication by guideline. We would like to summarize various domestic and foreign clinical practice guidelines relatively simply. According to the clinical practice guidelines, medical treatment including opioids will greatly improve the quality of life of cancer patients.

Diagnosis and Treatment of Non-Squamous Lung Cancer Based on Molecular Tumor Testing

Fri, 01 Jun 2018 00:00:01 +0100

Interpreting Rheumatologic Lab Tests

Fri, 01 Jun 2018 00:00:01 +0100

Effect of Alcohol Consumption on Seroconversion in Helicobacter pylori-Seronegative Koreans

Fri, 01 Jun 2018 00:00:01 +0100

Background/Aims: Helicobacter pylori (H. pylori) seroconversion may develop in seronegative adults. Although a positive correlation has been reported between alcohol consumption and seroconversion in Korea, an inverse correlation has been reported in other countries. The aim of this study was to investigate the risk factors for seroconversion in Korea. Methods: We included Korean adults who were H. pylori-negative negative in their annual serum immunoglobulin G and pepsinogen assays, and in upper gastrointestinal endoscopy. Subjects with a history of H. pylori eradication or gastrectomy were excluded. The criteria for heavy alcohol consumption were ? 15 drinks/week for males and ? 8 drinks/week for females. Results: Of 267 H. pylori-seronegative subjects, 26 (9.7%) exhibited seroconversion at a mean follow-up time of 39.0

A Hepatic Lymphoma Mimicking Multiple Liver Metastases or an Intrahepatic Cholangiocarcinoma

Thu, 04 Jan 2018 00:00:01 +0100

A primary hepatic lymphoma (PHL) is a rare malignancy; misdiagnosis and mistreatment are very common. We report the case of a 56-year-old female who presented with a 2-week history of upper abdominal pain. She exhibited no risk factors for hepatocellular carcinoma (HCC) and her serum tumor marker levels were normal. A computed tomography scan and gadolinium-enhanced magnetic resonance imaging of the liver revealed multiple liver masses, suggestive of multiple liver and lung metastases or an intrahepatic cholangiocarcinoma with lung metastasis. A diagnosis of PHL (a diffuse large B cell lymphoma) was confirmed by biopsy followed by immunohistochemistry. This case emphasizes that a PHL must be considered in the differential diagnosis of space-occupying liver lesions in patients with no risk factors for HCC and normal levels of serum tumor markers. It is notable that neither B cell lymphoma symptoms nor an elevated lactate dehydrogenase level were apparent in this case. We thus report a case of PHL mimicking multiple liver metastases or an intrahepatic cholangiocarcinoma, and we review the literature.

Endoscopic Closure of a Gastric Perforation Developing as a Complication after Percutaneous ...

Fri, 01 Jun 2018 00:00:01 +0100

Percutaneous endoscopic gastrostomy (PEG) is a relative safe but invasive procedure associated with both minor and major complications. Gastric perforation is one of the major complications, usually requiring surgical intervention. As most patients undergoing PEG have severe, chronic underlying diseases and are in a poor general condition, surgical intervention may substantially increase the risk of subsequent complications. A 75-year-old female suffering from an advanced glioblastoma underwent PEG to allow enteral nutrition in a local hospital. Four days later, she presented with fever and confusion. Three days after that, she presented with a generalized tonic-clonic seizure and was referred to the Asan Medical Center emergency room. Diagnostic work-up revealed PEG tube dislocation and a gastric wall defect. Therefore, the PEG tube was removed and endoscopic primary closure was performed using a detachable snare, hemoclips, and fibrin glue. Three weeks after closure, fluoroscopy revealed no leakage and the patient resumed enteral feeding without any complication.

Severe Sepsis and Empyema Caused by Nocardia

Fri, 01 Jun 2018 00:00:01 +0100

Pulmonary nocardiosis is a rare opportunistic infection that commonly affects immunocompromised hosts, such as patients with organ transplants, acquired immunodeficiency syndrome, or prolonged immunosuppression. Recently, we encountered a case of pulmonary nocardiosis with empyema that progressed to severe sepsis. The patient was treated in the intensive care unit. Thereafter, medical thoracoscopy was performed to improve drainage of the pleural fluid. Nocardia was identified in the culture of the pleural fluid.

A Case of Synchronous Lung Squamous Cell Carcinoma and Diffuse Large B-cell Lymphoma

Fri, 01 Jun 2018 00:00:01 +0100

A 65-year-old male was referred to our hospital for evaluation of a right pleural effusion. Thoracic computed tomography (CT) revealed a huge central mass with right hilar and subcarinal lymph node conglomerates. An endobronchial mass was incidentally found in the right upper lobe bronchus, and endobronchial ultrasound-guided transbronchial needle biopsy of the mediastinal lymph nodes was thus also performed at the time of bronchoscopy. The two biopsies revealed squamous cell carcinoma and diffuse large B-cell lymphoma (DLBCL), respectively. As the pathology of the mediastinal lymph nodes was unknown, the lung cancer could not be accurately staged. Thus, we treated the DLBCL; follow-up positron emission tomography/CT after two cycles of chemotherapy showed that the conglomerate mass had disappeared but the right upper lobe lesion remained. Lung cancer staging thus became more accurate and radical treatment could be considered. To the best of our knowledge, this is the first report of a co-existing squamous cell carcinoma of the lung and DLBCL of the intrapulmonary lymph nodes.

Pyrazinamide-Induced Urticaria and Angioedema: a Case Report

Fri, 01 Jun 2018 00:00:01 +0100

Pyrazinamide (PZA) is an anti-tuberculosis drug and an essential component of the standard four-drug regimen for tuberculosis. Here, we report a case of immediate angioedema secondary to PZA administration intended for pulmonary tuberculosis treatment. A previously healthy 48-year-old woman was diagnosed with pulmonary tuberculosis and tuberculous lymphadenitis. Thirty minutes after taking the first dose of isoniazid, rifampicin, pyrazinamide, and ethambutol, the patient developed facial edema, generalized rash, and dizziness. An oral provocation test was performed on the four drugs, and 1,000 mg pyrazinamide showed a positive result characterized by 50 minutes of urticaria, angioedema, and hypotension. As the prevalence of tuberculosis increases, prescriptions for anti-tuberculosis drugs may increase as well. Clinicians should be aware of the possibility of immediate hypersensitivity as well as delayed hypersensitivity to anti-tuberculosis drugs.

2018 KHRS Guidelines for Stroke Prevention Therapy in Korean Patients with Nonvalvular Atrial ...

Fri, 01 Jun 2018 00:00:01 +0100

Narcotics Monitoring with Narcotics Information Management System

Wed, 01 Aug 2018 00:00:01 +0100

Transmission and Prevention of Healthcare-Associated Infections

Wed, 01 Aug 2018 00:00:01 +0100

To prevent the transmission of pathogens in hospitals, implementation of transmission-based precautions is essential, such as precautions to prevent airborne, droplet, and contact transmissions. However, it is impossible to identify all hidden asymptomatic carriers. Emphasis has therefore been placed on the use of standard precautions, including hand hygiene and cough etiquette. Recently, the possibility of the spread of imported emerging infectious diseases in medical institutions has also become an area of focus. Prevention of the spread of infections in hospitals should be a top priority to ensure the highest quality of care.

2018 Korean Heart Rhythm Society Guidelines for Detection and Management of Risk Factors and ...

Wed, 01 Aug 2018 00:00:01 +0100

A number of concomitant conditions and cardiovascular diseases are closely related to the development of atrial fibrillation (AF), AF recurrence, and AF-associated complications. Detection, prevention, and treatment of such conditions are essential for the prevention of AF and its disease burden. This article discusses the clinical conditions and concomitant diseases associated with AF including heart failure, hypertension, diabetes, obesity, chronic respiratory diseases, and kidney disease based on the 2016 European Society of Cardiology guidelines for the management of AF and recently updated clinical data, particularly in patients with heart failure. Furthermore, we provide recommendations for the prevention, diagnosis, and management of these conditions.

The 2018 Korean Heart Rhythm Society Guidelines for Integrated Management of Korean patients ...

Wed, 01 Aug 2018 00:00:01 +0100

Atrial fibrillation (AF) is the most common form of sustained arrhythmia in elderly patients. However, AF is often detected during health screening, or accidentally during testing for other diseases; some patients lack clinical symptoms. Nevertheless, AF increases the incidence of ischemic stroke and other thrombotic events, and compromises cardiovascular prognosis in terms of heart failure, dementia, and hospitalization. Therefore, initial AF management should be performed at the point of primary care, not only in specialized medical centers. We wish to propose a five-step management protocol for AF. We review the evidence supporting integrated management by primary care physicians new to AF, and by specialized physicians who often diagnose and manage AF. Further, we also outline a structured goal-based follow-up protocol; this is an important part of integrated management.

New Classification Criteria and Guideline for Management of Gout

Wed, 01 Aug 2018 00:00:01 +0100

Gout is a chronic systemic metabolic disease characterized by recurrent attacks of inflammatory arthritis resulting from the precipitation of monosodium urate crystals, which has various clinical and pathological manifestations. The disease is associated with multiple comorbidities, an impaired quality of life, and a heavy economic burden. The incidence and prevalence of gout is increasing in many developed and developing countries, as in Korea. Gout is diagnosed by confirming monosodium urate crystals in the synovial fluid or affected tissue. If crystal documentation is unavailable, new gout classification criteria presented by the American College of Rheumatology and European League Against Rheumatism (ACR/EULAR) in 2015 can be applied. There are many guidelines for managing gout published in the United States, Japan, and Europe. However, there are no guidelines for the tailored management of gout for Korean patients. This review describes a new classification for the diagnosis of gout and management guidelines.

Major Changes to the 2017 Revision of the World Health Organization Classification of ...

Wed, 01 Aug 2018 00:00:01 +0100

The World Health Organization (WHO) Classification of Tumors of Haematopoietic and Lymphoid Tissues was recently published in a revised fourth edition. The categories of myeloproliferative neoplasms (MPNs) have not significantly changed since the 2008 fourth edition of the classification; however, newly discovered mutations including CALR and CSF3R and improved characterizations and standardizations of morphological features of some entities, particularly BCR-ABL1-negative MPNs, have impacted the diagnostic criteria of disease entities, increasing the reliability and reproducibility of diagnoses. The 2017 revised edition attempts to incorporate new clinical, prognostic, morphologic, and genetic data that have emerged since the last edition. This article reviews the major changes in the classification and their rationale for MPN classification within the revised 2017 WHO system.

New Classification System of Achalasia: Chicago

Wed, 01 Aug 2018 00:00:01 +0100

Optimal Usage of Fecal Calprotectin for Intestinal Diseases

Wed, 01 Aug 2018 00:00:01 +0100

Predictors of One-Year Mortality in Smokers with Acute Myocardial Infarction

Wed, 01 Aug 2018 00:00:01 +0100

Background/Aims: It is well known that smoking is associated with clinical outcomes in patients with acute myocardial infarction (AMI). In this study, we aimed to predict the one-year mortality in AMI patients that smoked. Methods: Of the AMI patients who were enrolled in the Korean Acute Myocardial Infarction Registry-National Institutes of Health study, 5,110 were current smokers (57.1

Mode of Human Immunodeficiency Virus Transmission in Korea: The Korea HIV/AIDS Cohort Study

Wed, 01 Aug 2018 00:00:01 +0100

Background/Aims: Global efforts to prevent human immunodeficiency virus (HIV) infection and strengthen treatment programs have reduced the annual incidence of HIV infection. However, the incidence recently increased unexpectedly in Korea. Therefore, to understand the cause of the increase in HIV infection incidence in Korea, it is important to identify the mode of HIV transmission. Methods: We included HIV-infected individuals enrolled in the Korea HIV/AIDS (acquired immune deficiency syndrome) Cohort from December 2006 to January 2018. The subjects were older than 18 years and were receiving care at 21 participating hospitals. They were interviewed by their physician at enrollment, and an epidemiological survey was conducted using a standardized questionnaire provided by a professional counseling nurse. Results: There were 1,474 subjects: 1,377 men and 97 women. Their mean age was 41.4

Hepatoid Carcinoma of the Pancreas Presenting as Acute Pancreatitis

Wed, 01 Aug 2018 00:00:01 +0100

Hepatoid carcinoma is extrahepatic neoplasm showing similar morphologic, immunohistochemical features with hepatocellular carcinoma. Its a very rare disease and has been reported most frequently in the stomach. Herein, we report a case of hepatoid carcinoma of pancreas presented with acute pancreatitis. The hepatoid carcinoma was diagnosed by his needle biopsy specimen and it showed pleomorphic nuclei and predominantly eosinophilic and occasionally clear cytoplasm in hematoxylin and eosin staining, and positive for HepPar-1 and cytokeratin 19 in immunohistochemical staining. Surgical treatment seems to be the best choice, if possible. However, there is no standard regimen for palliative chemotherapy. In our case, the patient was treated with 5-Fluorouracil (5-FU), folinic acid, irinotecan, oxaliplatin (FOLFIRINOX). The response was stable disease up to 4 month of follow up.

Successful Endovascular Therapy for Bilateral Popliteal Thrombotic Occlusions

Wed, 01 Aug 2018 00:00:01 +0100

The popliteal artery is a relatively short vascular structure, but acute occlusion can decrease blood flow into the lower extremities and cause subsequent critical limb ischemia, amputation, and even mortality. Further, peripheral artery disease patients frequently have combined cardio-cerebrovascular disease. Here, we report a rare case of sudden bilateral thrombotic total occlusion in the popliteal arteries of a patient with dilated cardiomyopathy and left ventricular thrombi. This patient has been successfully managed by endovascular therapy and subsequent intra-arterial thrombolytic therapy.

Renal Failure with Branchio-Oto-Renal Syndrome

Wed, 01 Aug 2018 00:00:01 +0100

Branchio-oto-renal (BOR) syndrome is a rare autosomal dominant disorder that is characterized by preauricular pits, branchial fistula, branchial cyst, hearing impairment, and kidney anomalies. Hearing impairment is the single most common feature of BOR syndrome, affecting 89% of patients. Preauricular pits (77%), kidney anomalies (66%), branchial fistula (63%), external auditory canal anomalies (41%) are also common. For most patients, BOR syndrome does not affect life expectancy. The major life-threatening feature of this condition is kidney dysfunction, which occurs with about 6% of kidney anomalies. Therefore, once BOR syndrome is recognized in a patient, careful evaluation to detect renal anomalies and treatment of any kidney involvement are necessary. No case reports of BOR syndrome involving adult-onset end-stage kidney disease have been published in the Korean medical literature. We report a case of end-stage kidney disease in a 19-year-old male patient with BOR syndrome, together with a review of the pertinent literature.

A Rare Case of Primary Spinal Cord Germinoma Treated with Single Radiation Therapy after Surgery

Wed, 01 Aug 2018 00:00:01 +0100

A 32-year old male came to our hospital with chief complaint of paraplegia. He had symptom of radiating pain to right leg 3 months ago before paraplegic symptom appeared. Magnetic resonance (MR) imaging from outside hospital showed intramedullary mass involving from T8 to T10 level of spinal cord. According to the imaging result, tumor removal with total laminectomy was performed between T8 and T10 level in our hospital. Pathologic result was compatible with germinoma. Spine radiation (39.6 Gy/22 fx) from T7 to T12 level without chemotherapy was performed 3 weeks later since tumor removal. Follow-up MR imaging showed no recurrence without any distant metastasis. And our patients neurologic symptom had been improved. According to this case, postoperative radiotherapy is thought to be effective to primary spinal germinoma.

Acute Eosinophilic Monoarthritis in a Patient with Toxocariasis

Wed, 01 Aug 2018 00:00:01 +0100

Eosinophilic synovial effusion is rarely observed in patients with inflammatory nature of synovial fluid, and the differential diagnosis includes parasitic arthritis. Toxocariasis is the one of the most common forms of helminthiasis worldwide and has been reported as a common cause of peripheral blood eosinophilia in Korea. However, joint involvement has been rarely reported in adults with toxocariasis in the English-language literature. Here, we report the first Korean case of a female presenting with acute monoarthritis with an increased number of eosinophils in the peripheral blood and synovial fluid, who was finally diagnosed with toxocariasis.

Current Insurance Issue of Ultrasound

Mon, 01 Oct 2018 00:00:01 +0100

The Most Common Mite- and Tick-borne Infectious Diseases in Korea: Scrub Typhus and Severe ...

Mon, 01 Oct 2018 00:00:01 +0100

The incidence of mite- and tick-borne infectious disease is increasing with climate change and the development of diagnostic tools. Tick-borne infectious diseases include Lyme disease, anaplasmosis, ehrlichiosis, severe fever with thrombocytopenia syndrome (SFTS), and Japanese spotted fever. Rickettsial pox and scrub typhus are mite-borne infectious diseases. Scrub typhus and SFTS are the most common mite- and tick-borne infectious diseases in Korea, respectively. They are often difficult to diagnose at an early stage of disease. To make a definite diagnosis of mite- and tick-borne infectious disease, polymerase chain reaction (PCR) tests or serologic testing for antibodies during the acute and convalescent periods are necessary. If patients with nonspecific symptoms, such as fever, headache, nausea, and vomiting, have a history of outdoor activity or a tick bite, it is reasonable to consider the possibility of mite- or tick-borne infectious diseases clinically. There are no vaccinations against mite- and tick-borne infectious diseases. Therefore, preventing mite or tick bites is the best way to prevent the diseases.

A New Medical Therapy for Axial Spondyloarthritis

Mon, 01 Oct 2018 00:00:01 +0100

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been the first choice of treatment for axial spondyloarthritis (axSpA); cyclooxygenase (COX)-2 inhibitors reduce both inflammation and bone formation. When NSAID treatment fails, tumor necrosis factor inhibitors (TNFis) can be used to treat active axSpA, but, presently, TNFis cannot completely prevent radiographic progression. Theoretically, as TNF is a strong pro-inflammatory cytokine triggering bone resorption, TNFis should stimulate bone formation. Recently, it was discovered that the IL-23/-17 axis is associated with enthesitis development and bone formation in a mouse model. The anti-IL-23 monoclonal antibody ustekinumab has been approved as treatment for moderate-to-severe plaque psoriasis and psoriatic arthritis. However, in axSpA patients, ustekinumab effectiveness was low and a phase 3 clinical trial was terminated. The anti-IL-17A monoclonal antibody secukinumab has been approved as treatment for moderate-to-severe plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis. In a 3-year extension of the MEASURE 1 observational study, the mean change in modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) from baseline to week 104 was 0.30

Takayasu Arteritis: Update on Monitoring of Disease Activity and Management

Mon, 01 Oct 2018 00:00:01 +0100

Takayasu arteritis (TAK) is a chronic inflammatory disease characterized by granulomatous vasculitis of the aorta and its major branches. The rarity of the disease along with its heterogeneous clinical presentation typically lead to late diagnosis and delayed treatment. Furthermore, clinical and serological indices for monitoring disease activity are suboptimal, with no definitive evidence supporting therapeutic approaches in TAK. Nevertheless, there have been recent advances in disease assessment with new scoring systems (Indian Takayasu Arteritis Score), biomarkers including pentraxin 3 and soluble human leukocyte antigen-E, and imaging modalities such as ¹⁸F-fluorodeoxyglucose-positron emission tomography. Most of the new information for management of TAK has come from increasing experience with biological agents, such as tumor necrosis factor inhibitors and tocilizumab, used in the treatment of resistant TAK. A number of potential new therapeutic targets that may be useful for the treatment of TAK have been reported, and randomized controlled trials are needed to establish optimal therapeutic approaches

Antimicrobial Therapy for Infections Caused by Carbapenem-Resistant Gram-Negative Bacteria

Mon, 01 Oct 2018 00:00:01 +0100

Carbapenem-resistance emerging in Gram-negative pathogens, such as Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii, has become a major human health problem globally. The therapeutic options available for carbapenem-resistant pathogens are very limited. Antibiotics such as colistin, tigecycline, fosfomycin, and aminoglycosides are often the only ones that can be used to treat carbapenem-resistant pathogens. Carbapenem may still be an option in certain circumstances. The administration of combination therapy for carbapenem-resistant pathogens is controversial. This review presents the current knowledge of available antimicrobial therapeutic options for infections due to carbapenem-resistant pathogens in Korea.

Evaluation and Management of Hypertensive Patients According to New Hypertension Guideline

Mon, 01 Oct 2018 00:00:01 +0100

Understanding of Allergen-Specific IgE Test

Mon, 01 Oct 2018 00:00:01 +0100

Thromboembolic Events as Prognostic Clinical Markers in Advanced Pancreatic and Biliary Tract Cancer

Mon, 01 Oct 2018 00:00:01 +0100

Background/Aims: Venous thromboembolic events (VTEs) are common events in patients with advanced cancer. We analyzed the clinical characteristics of VTEs in advanced pancreatic and biliary tract cancer to determine the clinical significance, especially in palliative settings. Methods: Seventy-nine patients with advanced pancreatic cancer or biliary tract cancer who had thromboembolic events were retrospectively reviewed. We investigated the correlation between clinical course and thromboembolic events, and the laboratory risk factors, such as complete blood count profile. Results: The 79 patients consisted of 40 men (50.6%) and 39 women (49.4%) with a median age of 65 years old (range: 41-80). Forty-three patients (54.4%), had thromboembolic events without any symptoms. Pulmonary thromboembolism occurred in only 31 cases (39.2%), and combined thrombosis at more than two sites occurred in 17 cases (21.5%). Of the 51 patients with active chemotherapy, 45 showed progressive disease. The median survival times were 11.9 weeks in all patients, 15.3 weeks in the treatment group, and 3.4 weeks in the palliative group. There was no difference in survival time between patients treated with dalteparin only and those treated with dalteparin combined with thrombolytic intervention. Conclusions: VTE can be poor prognostic indicator in pancreatic and biliary tract cacner patients, suggestive of progressive disease and a sign of short life expectancy, requiring hospice and terminal care.

Efficacy and Tolerability of Linezolid for Treatment of Infectious Spondylitis

Mon, 01 Oct 2018 00:00:01 +0100

Background/Aims: Infectious spondylitis requires long-term antibiotic treatment; however, the use of intravenous antibiotics during this period has high social and monetary costs due to hospitalization. Linezolid has high oral bioavailability and is not affected by changes in renal or hepatic function. We investigated the clinical and microbiological effects of linezolid in infectious spondylitis caused by beta-lactam resistant gram-positive bacteria. Methods: Clinical data from patients who were treated with linezolid for at least four weeks were collected retrospectively from electronic medical records at the Seoul National University Hospital, Seoul National University Bundang Hospital, and Boramae Medical Center from 2006 to 2016. Results: Twenty Korean patients were treated with linezolid for at least four weeks during the study period. Of these, 14 patients were cured, four failed, and two cases of mortality occurred due to other causes than infectious spondylitis. Ten of 13 patients who had previously been assessed as vancomycin treatment failure were cured by linezolid. Bacteremia occurred in 14 patients, and 10 of these showed persistent bacteremia at the time of linezolid administration. Eight of these cases of persistent bacteremia were cured by linezolid. Median duration of linezolid treatment was 40.5 days (28-90 days). Severe cytopenia (grade II or more of National Cancer Institute criteria) was the most common adverse event, with incidences of 11.11% for neutropenia, 12.96% for anemia, and 20.37% for thrombocytopenia. Conclusions: Linezolid can be used as an effective antibiotic agent in patients with infectious spondylitis, especially when treatment failure of the first-line treatment is expected.

Praziquantel Treatment of Eosinophilic Gastritis Suspected to Be Due to Cerebral Sparganosis

Mon, 01 Oct 2018 00:00:01 +0100

Eosinophilic gastritis is characterized by eosinophilic infiltration of the gastrointestinal tract, which is associated with abdominal pain, diarrhea, nausea, and vomiting. The possible etiologies of secondary eosinophilic gastritis, including drug reactions, parasitic infestation, and malignancy, must be evaluated. Herein we report the case of a 65-year-old North Korean defector who presented with nausea and vomiting for 1 year. Secondary (reactive) eosinophilic gastritis caused by cerebral sparganosis was suspected after a workup that included brain magnetic resonance imaging, cerebrospinal fluid tapping, and gastric mucosal biopsy. The patient showed dramatic clinical improvement with high-dose praziquantel treatment. Even though secondary (reactive) eosinophilic gastritis caused by parasites is very rare, this case shows the importance of considering parasitic infection in eosinophilic gastritis.

Esophago-Mediastinal Fistula Due to Tuberculous Mediastinal Lymphadenitis

Mon, 01 Oct 2018 00:00:01 +0100

Tuberculosis rarely involves the esophagus, and most esophageal tuberculosis occurs secondary to adjacent tuberculous lymphadenitis. An esophago-mediastinal fistula is a very unusual complication of tuberculous lymphadenitis. Herein, we report a case of an esophago-mediastinal fistula due to tuberculous lymphadenitis. A 28-year-old woman who had dysphagia was assessed by chest computed tomography, endoscopy, esophagogram, and a lymph node biopsy. An esophago-mediastinal fistula was found and an antituberculous agent was considered initially. However, because of her severe dysphagia, she managed with endoscopic clipping as an alternative. However, the fistula remained on follow-up esophagography. A gastrostomy was eventually performed, and she was treated with an antituberculous agent. The fistula had closed after 4 weeks of medication. Antituberculous agents are the mainstay treatment for esophago-mediastinal fistula due to tuberculous lymphadenitis; endoscopic clipping may be a complementary treatment.

Eosinophilic Myocarditis-Associated Toxocariasis

Mon, 01 Oct 2018 00:00:01 +0100

Human toxocariasis is a common helminthozoonosis due to the infestation of toxocara canis or toxocara cati larvae, and is a common cause of blood eosinophilia in Korea. Toxocariasis has various clinical manifestations depending on the involved organ, and cardiac involvement can range from asymptomatic to fulminant myocarditis with cardiogenic shock. Treatment of toxocariasis is based on corticosteroid and anthelmintic therapies. Here, we report a case of a 57-year-old male with eosinophilic myocarditis caused by toxocariasis as diagnosed via serial echocardiography follow up.

Ileocecal Mucosal Involvement of Blastic Plasmacytoid Dendritic Cell Neoplasm without Skin Lesions

Mon, 01 Oct 2018 00:00:01 +0100

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a relatively rare hematological malignancy, and most cases present with characteristic skin lesions. The skin lesions appear as nodules, plaques, and bruise-like macules with redness or ulcerations. BPDCN without skin lesions is rare. Cases with hepatosplenomegaly, pulmonary involvement, multiple lymphadenopathies, renal masses, sinonasal sinus, and subcutaneous masses have also been reported. Here, we report the first case of ileocecal valve involvement of BPDCN without skin lesions.

Systemic Sclerosis and Pleural Effusion in a Patient with Ankylosing Spondylitis

Mon, 01 Oct 2018 00:00:01 +0100

Systemic sclerosis (SSc) is a chronic autoimmune disorder characterized by endothelial and fibroblast dysfunction, resulting in progressive fibrosis of the skin and internal organs. Ankylosing spondylitis (AS) is an arthritic condition affecting the axial skeleton and peripheral joints. An association between SSc and AS is relatively rare, as the two diseases share few characteristics. Here, we present a case of limited SSc in a 44-year-old man who exhibited low-grade AS, and discuss several cases of coexisting SSc and AS in the literature. Patients with both diseases showed several common features, including male predominance, middle age, and combined interstitial lung disease. However, unlike our case, the patients reported in the literature had advanced ankylosis and diffuse SSc.

Changes in Regulation of Internal Medicine Residency Training and Evaluation of Teaching Hospitals

Sat, 01 Dec 2018 00:00:01 +0100

Recent Advances in Anti-Obesity Agents

Sat, 01 Dec 2018 00:00:01 +0100

Obesity is a chronic disorder that is a significant risk factor for diabetes, cardiovascular diseases, malignancy, and other chronic diseases. Lifestyle modifications form the basis of most treatments for obesity, but it has become clear that such modifications alone are not enough for many obese patients. When a behavioral approach is insufficient, pharmacological treatment may be recommended. In recent years, the US Food and Drug Administration (FDA) has withdrawn several therapeutic options for obesity due to their side effects, but has approved four novel anti-obesity agents. Until recently, orlistat was the only drug approved for the management of long-term obesity, but the US FDA approved the novel anti-obesity drugs lorcaserin and phentermine/topiramate in 2012, and naltrexone/bupropion and liraglutide in 2014. The present review discusses the different pharmacotherapeutic options for the treatment of obesity.

Diagnosis and Treatment of Latent Tuberculosis Infection: The Updated 2017 Korean Guidelines

Sat, 01 Dec 2018 00:00:01 +0100

A small number of viable tuberculosis bacilli can reside in an individual with latent tuberculosis infection (LTBI) without obvious clinical symptoms or abnormal chest radiographs. Diagnosis and treatment of LTBI are important for tuberculosis (TB) control in public and private healthcare facilities, particularly in high-risk populations. The updated 2017 Korean guidelines for TB recommend that tuberculin skin tests, interferon-gamma release assays, or a combination of them can be used for the diagnosis of LTBI, depending on the age and immune status of the patient as well as their TB contact history. For diagnosis of LTBI, exclusion of active TB is essential, and the possibility of healed TB in those without a history of treatment for TB but at risk of its development must be considered. The treatment options for LTBI include isoniazid, rifampicin, isoniazid/rifampicin, and isoniazid/rifapentine. The benefits and risks of these agents based on the age of the patient and their hepatotoxicity must be considered when selecting the appropriate drug. Standardized diagnosis and treatment of LTBI based on the updated 2017 guidelines will contribute to the control of TB in Korea as well as to further revisions of the guidelines.

An Update on Hypertriglyceridemia-Induced Acute Pancreatitis

Sat, 01 Dec 2018 00:00:01 +0100

Hypertriglyceridemia a major cause of acute pancreatitis, accounting for up to 10% of all cases. The pathophysiological mechanism of hypertriglyceridemia-induced acute pancreatitis (HTGP) is presumed to involve the hydrolysis of triglycerides by pancreatic lipase resulting in an excess of free fatty acids and elevated chylomicrons, which are thought to increase plasma viscosity and induce ischemia and inflammation in pancreatic tissue. Although the clinical course of HTGP is similar to other forms of acute pancreatitis, the clinical severity and associated complications are significantly higher in patients with HTGP. Therefore, an accurate diagnosis is essential for treatment and prevention of disease recurrence. At present, there are no approved guidelines for the management of HTGP. Different treatment modalities such as apheresis/plasmapheresis, insulin, heparin, fibric acids, and omega-3 fatty acids have been successfully implemented to reduce serum triglycerides. Following acute phase management, lifestyle modifications including dietary adjustments and drug therapy are important for the long-term management of HTGP and the prevention of relapse. Additional studies are required to produce generalized and efficient treatment guidelines for HTGP.

Micronutrient Deficiencies That Should Be Considered in Intestinal Diseases

Sat, 01 Dec 2018 00:00:01 +0100

Blood Tests for the Diagnosis of Adrenal Diseases

Sat, 01 Dec 2018 00:00:01 +0100

Impacts of Diastolic Function on Clinical Outcomes in Young Patients with Acute Myocardial ...

Sat, 01 Dec 2018 00:00:01 +0100

Background/Aims: The impact of left ventricular (LV) diastolic function and filling pressure on clinical outcomes in young patients with acute myocardial infarction (AMI) has been poorly studied. Therefore, the aim of this study was to investigate the impact of LV diastolic function and LV filling pressure on major adverse cardiac events (MACEs) in young patients with AMI. Methods: A total of 200 young patients (males < 45 year, females < 55 year) with AMI were divided into two groups according to the diastolic function; normal (n = 46, 39.5

Relative Association of Overhydration and Muscle Wasting with Mortality in Hemodialysis ...

Sat, 01 Dec 2018 00:00:01 +0100

Background/Aims: Assessment of fluid status in hemodialysis patents is very important. Overhydration in hemodialysis is associated with generalized edema, cardiovascular complications, and hypertension. The aim of this study was to determine the factors correlated with mortality of hemodialysis patients, assessing body muscle mass and fluid status using bioelectrical impedance analysis(BIA). Methods: This study enrolled 93 patients who underwent hemodialysis between January 2010 and May 2015 at CHA Bundang Medical Center. Medical records of enrollees up to June 2017 were reviewed retrospectively. These included laboratory results (serum albumin, C-reactive protein [CRP], lipid profile, etc.) and BIA data (extracellular water, intracellular water, total body water, soft lean mass, fat free mass, skeletal muscle mass, etc.). Results: Eleven of 93 patients had expired by May 2017. Among the surviving subjects, mean age was younger, CRP levels were lower, albumin levels were higher, and extracellular water/total body water (ECW/TBW) ratios were lower than in the expired patient group. Kaplan-Meier survival analysis revealed that overhydration (ECW/TBW > 0.4) was associated with higher mortality. Conclusions: In hemodialysis patients, overhydration is an important factor in mortality, and BIA could be a reliable modality in its assessment. We suggest that, for hemodialysis patients, overhydration is more of a risk factor for mortality than is muscle wasting.

Solitary Jejunal Tuberculosis with Intestinal Obstruction in an Immunocompetent Patient

Sat, 01 Dec 2018 00:00:01 +0100

Intestinal tuberculosis is an infection of the gastrointestinal tract by the Mycobacterium tuberculosis complex. To the best of our knowledge, solitary intestinal tuberculosis accompanied by intestinal obstruction, particularly in the middle of the small intestine, is extremely rare. We report a case of solitary jejunal tuberculosis in a 49-year-old man with no underlying disease. He was admitted a few days after the onset of diffuse abdominal discomfort. Upon evaluation, we initially considered a malignancy of the distal jejunum with ileus due to the presence of a mass. Therefore, he underwent laparoscopic resection of the small bowel. Unexpectedly, the histologic specimen showed a chronic caseating granulomatous lesion with acid-fast bacilli. Ultimately, he was diagnosed with solitary jejunal tuberculosis. He was successfully treated with anti-tuberculosis drugs without any complications.

Autoimmune Pancreatitis Featuring a Pseudocyst Requiring Drainage despite Steroid Therapy

Sat, 01 Dec 2018 00:00:01 +0100

Autoimmune pancreatitis (AIP) is rarely associated with pancreatic pseudocysts. AIP-associated pseudocysts requiring drainage despite steroid therapy are rather rare. We report a case of AIP with an infected pseudocyst requiring drainage despite steroid therapy. A 68-year-old male was diagnosed with AIP via pancreatic imaging, a high serum immunoglobulin G4 level, and steroid responsiveness. The AIP was accompanied by a pancreatic pseudocyst. Steroid therapy was prescribed, but the pancreatic pseudocyst became aggravated during steroid tapering. Endoscopic ultrasonography-guided cyst drainage was required; the pseudocyst then became completely resolved.

Early-Onset Postcardiac Injury Syndrome after Percutaneous Coronary Intervention Recovered with ...

Sat, 01 Dec 2018 00:00:01 +0100

Postcardiac injury syndrome (PCIS) is an inflammatory process that usually occurs within 1 to 6 weeks after an injury to the pericardium, epicardium, or myocardium. As more interventions are performed for complicated coronary artery obstructive lesions, there have been some recent reports on PCIS following percutaneous coronary intervention (PCI). The medical management of PCIS depends on nonsteroidal anti-inflammatory drugs (NSAIDs), in addition to colchicine or steroids. An 80-year-old male patient underwent a PCI. Unfortunately, the guidewire piercing failed but he showed no immediate signs of complication. However, 5 hours after the procedure, he complained of chest discomfort. An electrocardiogram showed widespread ST elevation. Chest X-ray and computed tomography showed pulmonary congestion with pleural effusion, while thoracic echocardiography showed a moderate amount of pericardial effusion. NSAIDs were initiated, but there was no improvement of symptoms. We describe an unusual case of atypical earl onset PCIS after PCI, recovered rapidly by steroids.

Pneumocystis Pneumonia Developing during Treatment of Recurrent Renal Cell Cancer with Nivolumab

Sat, 01 Dec 2018 00:00:01 +0100

Nivolumab is an immune checkpoint inhibitor approved for the treatment of metastatic cancers. Here, we report the case of a 65-year-old male with recurrent renal cell carcinoma. After six cycles of nivolumab treatment, positron emission tomography/computed tomography (PET/CT) was performed to evaluate the response. PET/CT revealed diffuse ground glass opacities in both lungs. He developed a cough, sputum, chills, and a febrile sense. After bronchoscopic bronchoalveolar lavage, pneumocystis pneumonia was finally diagnosed.

Cancer of Unknown Primary Site Mimicking Retroperitoneal Fibrosis

Sat, 01 Dec 2018 00:00:01 +0100

Retroperitoneal fibrosis (RPF) is a rare disease characterized by marked fibro-inflammatory tissue in the retroperitoneum. Approximately 70% of cases of RPF are idiopathic, while the rest can be secondary to several other causes. The diagnosis is mainly obtained by imaging modalities such as computed tomography (CT). However, histological examination should be considered when the clinical manifestations and imaging studies suggest malignancy. In particular, in malignant diseases with retroperitoneal metastases, abnormal collagen plaques are formed from an exuberant desmoplastic response, which may not be distinguishable from RPF on CT scans. Therefore, even if CT suggests RPF, biopsy is essential to identify malignant disease because it typically results in a fatal prognosis. Here, we report a case of metastatic adenocarcinoma of unknown primary site that developed only in the retroperitoneum and was initially diagnosed as RPF based on CT findings.

2018 Korean Heart Rhythm Society Guidelines for Detection and Management of Risk Factors and ...

Sat, 01 Dec 2018 00:00:01 +0100

Unsolved Enigma of Publishing Korean Language Journals

Wed, 01 Feb 2017 00:00:01 +0100

Guidelines for the Management of Adrenal Incidentaloma: the Korean Endocrine Society, Committee ...

Wed, 01 Feb 2017 00:00:01 +0100

An adrenal incidentaloma is an adrenal mass found in an imaging examination performed for reasons unrelated to suspected adrenal disease. The prevalence of adrenal incidentaloma increases with age; there is no gender difference, but it is often accompanied by obesity, diabetes mellitus, or hypertension. The detection of adrenal incidentaloma is expected to rise with the rapid development of imaging technology and increasing frequency of imaging studies. The Korean Endocrine Society is promoting appropriate practice guidelines to meet the rising incidence of adrenal incidentaloma, in cooperation with the Korean Adrenal Gland and Endocrine Hypertension Study Group. In this paper, we discuss important core issues for treating adrenal incidentaloma, along with the most important factors for healthcare providers who treat and manage affected patients. Initially, we identified 47 recommendations using the Delphi technique, after evaluating core propositions. We reduced these to the 20 most critical recommendations.

Implantable Cardioverter-defibrillator for Primary Prevention of Sudden Cardiac Death in ...

Wed, 01 Feb 2017 00:00:01 +0100

The insertion of implantable cardioverter-defibrillators (ICD) in patients with non-ischemic cardiomyopathy (NICM) has been recommended by recent guidelines. However, current evidence shows limited benefits to inserting ICDs in patients with NICM. Recently, the defibrillator implantation in patients with non-ischemic systolic heart failure (DANISH) trial, a large randomized trial of more than 1,100 patients with NICM, was conducted to compare the primary prevention of all-cause mortality between optimal medical therapy, cardiac resynchronization therapy, and ICD implantation. The DANISH trial revealed no differences in all-cause mortality between the groups after 5 years. However, in patients younger than 68 years of age, the rate of death from any cause was significantly lower in the ICD group compared to the control group. In addition, the rate of sudden cardiac death was lower in the ICD group compared to the control group in patients under 68 years. The results of DANISH will likely change guidelines about the insertion of ICD in patients with NICM, and encourage the use of ICD in patients with NICM.

Updated Treatment of Chronic Hepatitis C

Wed, 01 Feb 2017 00:00:01 +0100

Hepatitis C virus (HCV) infection is one of the important causes of chronic liver diseases, including hepatic fibrosis, liver cirrhosis and hepatocellular carcinoma. The goals of hepatitis C treatment are to eradicate HCV and to prevent related hepatic complications, manifestations of HCV infection and death. A sustained virological response (SVR) is defined as undetectable serum HCV RNA by a sensitive assay at 12 or 24 weeks after treatment completion. The infection is cured in nearly 100% of patients who achieve an SVR. Newly introduced direct-acting antivirals act at a specific step of the viral life cycle and enable an SVR of over 90%. There are a number of unmet needs in HCV therapies that should be addressed, and are anticipated to be resolved in the near future.

The Pathological Diagnosis and Interpretation of Pathological Results: Emphasis on ...

Wed, 01 Feb 2017 00:00:01 +0100

Hematoxylin and eosin staining is simple and one of the most important techniques in pathological diagnosis. However, it cannot provide complete information about the disease of a patient. Immunohistochemical staining (IHC) is an important method for demonstrating the distribution of a certain molecule or antigen in tissues using specific antigen-antibody reactions. It is used in routine diagnostic work and research to explore biomarkers. In this review, I aim to provide an adequate interpretation of the results of IHC and pathological diagnosis for clinicians.

Diagnosis of Chronic Constipation Using Measurement of Colon Transit Time

Wed, 01 Feb 2017 00:00:01 +0100

Comparison of Peritoneal Dialysis and Hemodialysis Patients Following Extended Treatment ...

Wed, 01 Feb 2017 00:00:01 +0100

Background/Aims: Improvements in dialysis therapies and patient care are leading to more patients receiving dialysis for longer periods of time. Survival rates with peritoneal dialysis (PD) are superior to those with hemodialysis (HD) during the initial 2-3 years; however, data comparing the outcomes of these two methods are lacking. Thus, we performed a retrospective study of patients treated with dialysis for longer than 3 years to investigate patient condition according to mode of dialysis. Methods: A total of 80 patients currently being treated by dialysis for at least 36 months at the Eulji Medical Center were included in this study. Patients laboratory data and admissions histories over the prior 3 years were reviewed. Dialysis adequacy, body composition, and cytokine levels were quantified. Results: A total of 39 PD and 41 HD patients, with no difference in mean age or gender, were compared. Regarding dialysis adequacy, 97.5% of HD patients met the criterion of 1.2 Kt/V or higher, whereas only 58% of PD patients satisfied the required weekly Kt/V of 1.7. Inflammatory cytokines were significantly elevated in PD patients; however, PD patients with adequate dialysis expressed the same inflammatory cytokines as HD patients. Conclusions: The delivery of adequate dialysis to PD patients over extended periods of time is difficult. Thus, more rigorous management of PD patients is required to avoid insufficient dialysis and inflammation.

Age-related Changes in the Sirtuin1-NFE2-related Factor 2 Signaling System in the Kidney

Wed, 01 Feb 2017 00:00:01 +0100

Background/Aims: Renal aging-related changes are characterized by oxidative stress. SIRT1 regulates cellular conditions by activating Nrf2. The present study investigated the processes of renal changes by antioxidant enzymes and the relationship between SIRT1 and Nrf2. Methods: We used male 2-, 12-, and 24-month-old C57BL/6 mice. We measured renal function, histological changes, oxidative stress, and expression of SIRT1Nrf2 signaling in the kidneys. Results: 24-month-old mice exhibited increased albuminuria and serum creatinine. Creatinine clearance was decreased in 24-month-old mice compared with 12-month-old mice. There were increases in mesangial volume and tubulointerstitial fibrosis in 24-month-old mice. Moreover, oxidative stress marker, 3-Nitrotyrosine, expression and apoptosis were increased in 24-month-old mice. The 24 h urinary 8-isoprostane and 8-hydroxy-deoxyguanosine excretion increased with aging. The levels of expression of SIRT1 and nuclear Nrf2 were decreased in 24-month-old mice. The antioxidant enzymes HO-1 and NQO-1 were down-regulated in 24-month-old mice. Another antioxidant enzyme, SOD2, was decreased in 24-month-old mice. Conclusions: Our results demonstrated that SIRT1 was down-regulated with aging, and this may be related to changes in the expression of target molecules including Nrf2. As a result, oxidative stress was induced. The pharmacological targeting of these signaling molecules may reduce the pathological changes associated with aging in the kidney.

Osmotic Demyelination Syndrome Resulting from an Unexpected Response to Tolvaptan in a Patient ...

Wed, 01 Feb 2017 00:00:01 +0100

Hyponatremia is commonly encountered in patients with heart failure and has a poor prognosis. Tolvaptan, a novel selective vasopressin V2 receptor blocker, has received attention as an effective drug for treating the syndrome of inappropriate antidiuretic hormone secretion and hypervolemic hyponatremia. However, the safety of tolvaptan in the treatment of hyponatremia is not clear. We experienced a 78-year-old woman with a history of heart failure, atrial fibrillation, and hyponatremia who developed osmotic demyelination syndrome as an unexpected response to treatment with tolvaptan.

Takayasu's Arteritis Presenting with Hypertension in Pulmonary Tuberculosis

Wed, 01 Feb 2017 00:00:01 +0100

Takayasu's arteritis (TA) is an inflammatory disease involving large arteries and their branches. The etiology of TA is unknown, but infectious agents and genetic factors play a significant role in its pathogenesis. A relationship between TA and Mycobacterium tuberculosis infection has been suggested, since both diseases have similar chronic inflammatory lesions and the presence of occasional granulomas in arterial walls. Patients with TA have an increased immune response to Mycobacterium tuberculosis antigens, suggesting a role for this organism in the immunopathogenesis of the disease. Herein, we present a case of TA with active pulmonary tuberculosis in a Korean patient. A 21-year-old male presented with hypertension and active pulmonary tuberculosis. TA invading the renal artery was diagnosed while evaluating hypertension. The patient was treated with prednisolone, methotrexate, anti- hypertensive medications, and anti-tuberculosis medications.

Acute Kidney Injury Following Chemical Burns Caused by Hexavalent Chromium

Wed, 01 Feb 2017 00:00:01 +0100

The metal chromium is widely used in industry. Hexavalent chromium is a strong oxidizing agent, and exposure to some hexavalent compounds can cause serious problems, such as skin ulcers, acute gastroenteritis, acute tubular necrosis with renal failure, and hepatic necrosis. We report a case of acute kidney injury following skin exposure to hexavalent chromium, which burned a relatively small percentage of the total body surface area (TBSA). A 49-year-old man developed oliguria and acute kidney injury 3 days after burning about 5% of his TBSA with chromic acid solution, causing second- to third-degree chemical burns. His creatinine level increased to 12.5 mg/dL. The patient underwent hemodialysis with supportive care. His renal function improved and the dialysis was discontinued. The serum and urine chromium concentrations also decreased.

Peripheral T-cell Lymphoma Presenting with Chylothorax

Wed, 01 Feb 2017 00:00:01 +0100

A 72-year-old male presented with respiratory discomfort. A simple chest X-ray and abdominal computed tomography showed pleural effusion and multiple lymph node enlargement. The pleural effusion was determined by thoracentesis to be chylothorax. An inguinal lymph node biopsy showed peripheral T-cell lymphoma. Following three cycles of cyclophospamide, hydroxyl doxorubicin, vincristine, prednisolone (CHOP) chemotherapy, a partial response was observed. Chylothorax is an extremely rare complication of T-cell lymphoma. We present a case of peripheral T-cell lymphoma presenting with chylothorax. We suggest that clinicians should consider chylothorax when examining patients with lymphoma who present with atypical pleural effusion.

A Case of Myeloid Neoplasm with a PDGFRB Rearrangement and Eosinophilia

Wed, 01 Feb 2017 00:00:01 +0100

Myeloid neoplasia with eosinophilia and platelet-derived growth factor receptor beta (PDGFRB) rearrangements is an uncommon Philadelphia-negative myeloproliferative neoplasm. Their most common morphological diagnosis is chronic myelomonocytic leukemia with eosinophilia, which is associated with t(5;12)(q33;p13) and results in the formation of the ETV6-PDGFRB fusion gene.
Here, we report a 49-year-old man with a myeloid neoplasm with a PDGFRB rearrangement, who was incidentally diagnosed with hyperleukocytosis and eosinophilia during a health screening. A chromosome analysis of a bone marrow sample revealed 46, XY, t(5;12)(q33;p13), and fluorescence in situ hybridization analysis revealed the PDGFRB gene rearrangement. The patient was treated with imatinib and subsequently achieved complete hematological and molecular remission.

Vertebral Osteomyelitis Caused by Mucormycosis

Wed, 01 Feb 2017 00:00:01 +0100

Mucormycosis is a rare but fatal disease and usually affects the rhinocerebrum, lungs, traumatic wounds or surgical sites. Vertebral osteomyelitis due to mucormycosis is very rare, with only three cases caused by mucormycosis since 1970 being reported, and none in Korea. Here, we present a case of vertebral osteomyelitis caused by mucormycosis in a 67-year-old woman, having type 2 diabetes mellitus for 10 years, who was in complete remission from acute leukemia after chemotherapy 3 years previously.

Simultaneous Diagnosis of Pneumococcal Sepsis and Disseminated Mycobacterium avium Complex ...

Wed, 01 Feb 2017 00:00:01 +0100

The incidence of bacteremia in human immunodeficiency virus (HIV)-infected patients is significantly decreased by highly active antiretroviral therapy (HAART). However, bacteremia remains a major cause of morbidity and mortality in HIV-infected patients. A 43-year-old male who had fever and cough for 1 week presented to the emergency room. He was diagnosed with acquired immunodeficiency syndrome combined with atypical pneumonia and started on antibiotics plus HAART. After 3 days, Streptococcus pneumoniae was grown in blood cultures. Three weeks later, acid-fast bacilli cultures of blood and bronchoalveolar lavage fluid grew Mycobacterium avium complex (MAC); hence, the patient was treated with antimycobacterial drugs. HIV-infected patients with persistent fever despite administration of appropriate antibiotics should be examined for simultaneous infection by other organisms, such as nontuberculous mycobacteria. We report a case of simultaneous detection of MAC and S. pneumoniae in the blood of a treatment-na

A Case of Methemoglobinemia Caused by Primaquine

Wed, 01 Feb 2017 00:00:01 +0100

Primaquine is often administered for the hypnozoite stage of Plasmodium vivax and Plasmodium ovale. Primaquine (with clindamycin) is also an alternative drug for treatment of pneumocystis pneumonia when trimethoprim/sulfamethoxazole cannot be used. Primaquine may cause methemoglobinemia, an altered state of hemoglobin in which the ferrous state of heme is oxidized to the ferric state. We report a case of methemoglobinemia caused by a standard dose of primaquine plus clindamycin in a 27-year-old female recipient of a kidney transplant who was diagnosed with pneumocystis pneumonia.

Septic Arthritis Caused by Bacteroides thetaiotaomicron Bacteremia in a Patient with Multiple ...

Wed, 01 Feb 2017 00:00:01 +0100

Septic arthritis is rarely caused by anaerobic bacteria, which is mostly secondary to hematogenous dissemination among the immunocompromised host. We report a patient of septic arthritis on the right knee joint caused by Bacteroides thetaiotaomicron. To the best of knowledge, this is the first report of septic arthritis caused by Bacteroides spp. in Korea.

Co-existent Mixed Connective Tissue Disease and Papillary Thyroid Cancer in a Patient with ...

Wed, 01 Feb 2017 00:00:01 +0100

A 40-year-old female previously diagnosed with primary biliary cirrhosis was referred to the hospital complaining of muscle weakness, arthralgia, Raynauds phenomenon, and thick skin. After work-up, she was diagnosed with both mixed connective tissue disease (MCTD) and papillary thyroid cancer (PTC), based on the Alarcon-Segovia criteria and pathological examination, respectively. High-dose glucocorticoid and azathioprine were introduced to treat active myositis of MCTD, and total thyroidectomy was performed to treat PTC. This report highlights the possible association between MCTD and thyroid cancer, and suggests that MCTD is associated with PTC, similar to other autoimmune diseases including Sj

Future Development for the Board Licensing Examination of Internal Medicine

Sat, 01 Apr 2017 00:00:01 +0100

Association between a High-fat Low-carbohydrate Diet and Non-alcoholic Fatty Liver Disease: ...

Sat, 01 Apr 2017 00:00:01 +0100

Reducing caloric intake is important for weight loss and obesity; a reduction of ~500-700 kcal/day has been recommended previously. However, only a minority of individuals can successfully sustain such a reduced caloric intake. Therefore, many specialized diet programs have been proposed. Until now, many experts have recommended low-fat diets in various countries, but very-low-carbohydrate diets have recently garnered attention in Korea. The various effects of changing the dietary compositions of macro- and micronutrients have been debated. The majority of large-scale studies have demonstrated that total caloric intake, rather than the composition of macronutrients or the consumption of a specialized diet, is important for successful weight loss. While many cross-sectional studies have investigated specialized diet programs for patients with non-alcoholic liver disease, no randomized controlled studies have been performed, except for some that investigated the effect of high consumption of unsaturated fatty acids as part of the Mediterranean diet.

Acute-on-Chronic Liver Failure

Sat, 01 Apr 2017 00:00:01 +0100

Acute-on-chronic liver failure (ACLF) is increasingly recognized as a distinct disease entity associated with acute deterioration of liver function in patients with chronic liver disease. Although no widely accepted diagnostic criteria for ACLF are yet available, the definitions of the Asian-Pacific Association for the Study of the Liver (APASL) ACLF Research Consortium (AARC) and the European Association for the Study of the Liver (EASL) Chronic Liver Failure Consortium (CLIF-C) are commonly employed. However, the AARC and CLIF-C criteria are based on fundamentally different features, rendering among-study comparisons difficult. The areas of uncertainty include the definition and extent of heterogeneity of ACLF, ambiguities in terms of the underlying liver disease, and whether infection or sepsis may precipitate the condition. Although the detailed pathogenesis of ACLF remains to be elucidated, changes in host responses to injury, infection, and uncontrolled inflammation play important roles. The predisposition, infection/inflammation, response, organ failure (PIRO) concept used to evaluate sepsis may be valuable when it is sought to describe the pathophysiology and clinical features of ACLF. Currently, treatment is limited to organ support but a better understanding of the pathophysiology is likely to lead, in future, to the discovery of novel biomarkers and the development of new therapeutic strategies.

Korean Treatment Guidelines for Metastatic Prostate Cancer Developed by the Korean Association ...

Sat, 01 Apr 2017 00:00:01 +0100

The management of advanced prostate cancer has evolved rapidly. Androgen deprivation therapy, via surgical or medical castration, is the first-line therapy for hormone-na

Glucocorticoid-induced Osteoporosis

Sat, 01 Apr 2017 00:00:01 +0100

Osteoporosis is a common adverse event among patients on glucocorticoid therapy. Glucocorticoids reduce bone formation and increase cortical porosity in proportion to the dose and duration of glucocorticoid use. While the epidemiology of glucocorticoid-induced osteoporosis has been well characterized, its pathophysiology and effective management remain unclear. Several recommendations for glucocorticoid-induced osteoporosis are used to determine which patients on long-term glucocorticoid treatment to treat and when. The fracture risk can be assessed using dual-energy X-ray absorptiometry and the Fracture Risk Assessment Tool algorithm, along with other clinical factors. The management of glucocorticoid-induced osteoporosis includes anti-osteoporotic therapy and measures to prevent bone loss. Bisphosphonates are currently the first choice treatment, with teriparatide and denosumab being alternatives.

An Approach to Patients with Symptomatic Cholelithiasis Based on Degree of Probability for ...

Sat, 01 Apr 2017 00:00:01 +0100

Iron Deficiency Anemia: Diagnosis and Treatment

Sat, 01 Apr 2017 00:00:01 +0100

The Effect of Na

Sat, 01 Apr 2017 00:00:01 +0100

Background/Aims: An incomplete virological response has been observed to tenofovir dipivoxil fumarate (TDF) in nucleos(t)ide analogue (NA)-experienced chronic hepatitis B (CHB) patients. This study investigated the efficacy of TDF in NA-na

Experience of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in a Regional Hospital: ...

Sat, 01 Apr 2017 00:00:01 +0100

Background/Aims: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions that frequently result in fatal outcomes. We investigated cases of SJS and TEN in a regional hospital. Methods: From 2008 to 2014, SJS and TEN cases were enrolled retrospectively by allergy and dermatology specialists, and their clinical features and severity-of-illness score for TEN (SCORTEN) were assessed. Results: During the 7-year study period, 56 SJS and 14 TEN cases were recruited. The majority (71%) were 40-70 years of age (mean age of male and female patients, 55 and 54 years, respectively). Regarding drugs, anticonvulsants (42.8%) were the most frequently causative, followed by carbonic anhydrase inhibitors (20.0%), antimicrobials (15.7%), allopurinol (7.1%), and non-steroidal anti-inflammatory drugs (7.1%). No fatal case of SJS was seen. However, 7 of the 14 patients with TEN died (50%; mean age, 67 years; 1 of 5 [20%] males and 6 of 9 females [66.7%]). The mortality rate was reflected in the SCORTEN values. Vancomycin, allopurinol, methazolamide (two cases each) and megestrol (one case) were the causative drugs in the seven fatal TEN cases. Treatment modality did not affect the likelihood of death due to TEN. Conclusions: The causative drugs of, and frequency of mortality due to, SJS and TEN should be recognized by physicians. Elderly females with TEN are at high risk of mortality. SCORTEN values reflect the mortality rate of TEN patients. Early recognition and proper management of SJS and TEN may reduce the mortality rate.

Recurrent Spontaneous Subcapsular Hematoma of the Liver

Sat, 01 Apr 2017 00:00:01 +0100

A spontaneous subcapsular hematoma of the liver is an unusual clinical phenomenon and is usually associated with trauma, surgery, tumor or pregnancy. We report a case of a recurrent spontaneous subcapsular hematoma of the liver without an identifiable cause. A 52-year-old female presented to the emergency room with acute abdominal pain localized in the right upper quadrant area. Diagnostic workup revealed a subcapsular hematoma in the segment 8 area. The laboratory evaluation was also normal. She was managed conservatively. However, two months later another episode of abdominal pain in the right upper quadrant recurred. Diagnostic workup showed recurrence of a subcapsular hematoma in the segment 6 area. Follow-up evaluation revealed resorption of the previous subcapsular hematomas, as well as a new lesion in the segment 1 area. Herein, we discuss potential causes of this spontaneous subcapsular hematoma of the liver.

ST Elevation Myocardial Infarction in a Patient with Hereditary Hemorrhagic Telangiectasia ...

Sat, 01 Apr 2017 00:00:01 +0100

This is a case report of a 71-year-old woman with hereditary hemorrhagic telangiectasia (hereditary hemorrhagic telangiectasia [HHT], OslerWeberRendu syndrome) involving the liver who developed ST elevation myocardial infarction and died from aggressive coronary thrombosis. HHT is an autosomal dominant hereditary disease associated with mutations of genes that regulate the endothelial surface. It has characteristic muco-cutaneous telangiectasia and other common manifestations are epistaxis, gastrointestinal bleeding, and iron-deficiency anemia. In addition, arteriovenous malformations or vascular ectases commonly occur in the pulmonary, hepatic, and cerebral circulations. Hemorrhages and thrombosis can both develop from these vascular abnormalities in HHT. Most thrombotic events are forms of venous thrombosis, such as deep vein thrombosis, while arterial thrombosis occurs infrequently. We present a case of aggressive coronary thrombosis in HHT, as a rare complication of HHT.

Fulminant Type 1 Diabetes Developing during Pregnancy in Patient with Gestational Diabetes Mellitus

Sat, 01 Apr 2017 00:00:01 +0100

A 32-year-old pregnant woman (34 + 5 weeks) was admitted with dizziness, nausea, and vomiting. Previously, she was diagnosed with gestational diabetes mellitus at 28 weeks with 100 g-OGTT and insulin therapy was started. Her average fasting glucose level was 97 mg/dL and postprandial 1-hour glucose level was 130 mg/dL with basal-bolus insulin therapy (total dose of 28-30 IU/day). At 34 + 0 weeks of gestational age, polyuria and unexpected weight loss (2 kg/week) with hyperglycemia occurred, and total dose of daily insulin requirement was increased up to 50 IU/day. At admission, her serum glucose level was high (502 mg/dL), and urinalysis revealed ketonuria +3. Arterial blood gas analysis revealed pH of 6.83, pCO2 of 9 mmHg, and bicarbonate of 2 mmol/L with an anion gap of 23.5 mmol/L. The diagnosis of diabetic ketoacidosis was established and emergency caesarean section was conducted due to fetal distress. She was finally diagnosed with fulminant type 1 diabetes mellitus, and multiple daily insulin injection therapy was continued after delivery.

Cushing Syndrome Caused by ACTH-independent Macronodular Adrenal Hyperplasia

Sat, 01 Apr 2017 00:00:01 +0100

Adenocorticotropic hormone-independent macronodular adrenal hyperplasia (AIMAH) is a rare cause of Cushings syndrome. It is characterized by multinodular enlargement of the adrenal glands and hypercortisolism. Although bilateral adrenalectomy is the standard therapy, unilateral adrenalectomy is an effective alternative. Here we present a case of a 71-year-old female referred to the Endocrinology Department for further evaluation of bilateral adrenal macronodular hyperplasia. Based on dynamic hormone tests and imaging studies, she was diagnosed with AIMAH. Due to persistent hypercortisolism, she underwent completion contralateral surgery after unilateral adrenalectomy. This case demonstrates that unilateral adrenalectomy should be considered in a patient presenting with obvious symptoms of hypercotisolism and relatively asymmetric adrenal enlargement.

Pituitary Epithelioid Osteosarcoma after Gamma-knife Surgery of a Pituitary Adenoma

Sat, 01 Apr 2017 00:00:01 +0100

With the increasing use of stereotactic radiosurgery, recent reports have suggested that stereotactic radiosurgery may induce secondary malignancies. While the risk of secondary malignancy after conventional radiotherapy is well known, its development after stereotactic radiosurgery has been reported in only a few cases. Here we present the case of a 56-year-old female with visual disturbance of sudden onset. She underwent trans-sphenoidal surgery for a pituitary adenoma 13 years earlier. Imaging studies revealed a newly developed pituitary mass invading the right carvenous sinus. Gross total resection of the tumor was performed using a trans-sphenoidal and pterygopalatine fossa approach. The histological diagnosis was pituitary epithelioid osteosarcoma. Clinicians should be aware of the rare occurrence of radiation-induced pituitary sarcoma as a potentially fatal late complication of stereotactic radiosurgery.

Chordae Rupture and Acute Mitral Regurgitation Associated with Infective Endocarditis in a ...

Sat, 01 Apr 2017 00:00:01 +0100

Acute pulmonary edema in patients undergoing hemodialysis is a common cause of hospital admission and is often associated with fluid overload or congestive heart failure. Here, we report a rare case of chordae rupture and consequent severe mitral valve regurgitation due to infective endocarditis presenting as sudden onset pulmonary edema after properly conducted hemodialysis.

Quadruple Metachronous Primary Malignant Neoplasm in the Head and Neck and Digestive Tract

Sat, 01 Apr 2017 00:00:01 +0100

Multiple primary cancers, i.e., the occurrence of multiple malignant neoplasms in a single patient, were first reported by Billorth in 1889. The incidence is low but increasing gradually due to developments in cancer diagnosis, early detection, and prolongation of life. In Korea, double primary cancers are occasionally reported. However, the simultaneous presence of four primary cancers in a single patient is rare. Recently, we experienced the case of a 68-year-old male diagnosed with quadruple primary cancers involving the esophagus, tonsils, liver and buccal mucosa. Here, we report this very rare case of four metachronous primary neoplasms and provide a brief review of the related literature.

Spontaneous Remission of Pernicious Anemia

Sat, 01 Apr 2017 00:00:01 +0100

Pernicious anemia is a macrocytic anemia that is caused by vitamin B12 deficiency, itself a result of the absence of intrinsic factors due to autoimmune destruction of parietal cells. We report here the case of a 43-year-old female with spontaneous remission of pernicious anemia. The patient presented with fatigue. Her serum vitamin B12 level was low, hemoglobin level was 7.6 g/dL, and serologic tests for anti-intrinsic factor and anti-parietal cell antibodies were positive. We diagnosed her with pernicious anemia, but did not administer vitamin B12 because her hemoglobin level increased spontaneously. Since then, the patients hemoglobin and serum vitamin B12 levels have been within the normal range.

Improved Gastrointestinal Involvement in Systemic Sclerosis after Immunoglobulin Treatment

Sat, 01 Apr 2017 00:00:01 +0100

Systemic sclerosis is an intractable clinical subset characterized by diffuse fibrosis, vasculopathy, and immune abnormalities. Diffuse cutaneous systemic sclerosis has a variety of symptoms depending on the internal organs involved, such as the lungs, heart, kidneys, and gastrointestinal system. Gastrointestinal involvement is frequent and one of the major cause of morbidity and mortality. There is no sustained, effective therapy for treating the active gastrointestinal involvement of systemic sclerosis. Although immunoglobulin is commonly used in the treatment of other autoimmune diseases, its effects in the treatment of the gastrointestinal involvement in systemic sclerosis are unclear. Here, we report a patient with a severe cough caused by uncontrolled gastrointestinal involvement in diffuse cutaneous systemic sclerosis treated with immunoglobulin.

Primary Antiphospholipid Syndrome Presenting as Bell Palsy without Cerebral Arterial Thrombosis

Sat, 01 Apr 2017 00:00:01 +0100

Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by the presence of antiphospholipid antibodies with vascular thrombosis or increasing pregnancy-related morbidity. The risk of thrombotic events, including cerebral arterial thrombosis, is increased in patients who test positive for lupus anticoagulants. The presentation of neurologic symptoms without a cerebral thromboembolic event is rarely reported in APS. Here, we report a case of primary APS presenting as Bell palsy without cerebral arterial thrombosis. After administration of an anti-viral agent and high-dose steroid therapy, the patient successfully recovered without neurologic complications.

Age-related Changes in the Sirtuin1-NFE2-related Factor 2 Signaling System in the Kidney

Thu, 16 Feb 2017 00:00:01 +0100

Perspectives and Challenges for Geriatric Medicine

Thu, 01 Jun 2017 00:00:01 +0100

Korean society is aging rapidly. Overall, 13.1% of the Korean population was elderly (age ? 65 years) in 2015, and this rate is expected to reach 40.1% in 2060. To prepare for this change, the Korean government has developed a long-term care insurance service and supports regional medical centers for the aged. It has established laws about life-sustaining treatment and directives to improve end-of-life care. Although the long-term care insurance currently provides in-home service and aged care facilities, it does not cover rehabilitation hospitals, which can prevent elderly individuals from accessing certain medical services. With the changing demographics, medical care requires change. Conventional medical care must be upgraded to provide suitable care for an aged society. It is important to support the activities of daily living, rather than simply prolonging life. This will require providing homeand community-oriented medical care to improve quality of life. It will also be necessary to train more geriatricians who understand the characteristics of elderly patients, provide comprehensive geriatric assessments, and lead other physicians in team-based medicine. Internists are already engaging in multidisciplinary collaboration and end-of-life care, which are critical qualities of leading geriatricians. Further discussion and consensus is needed regarding the training of geriatric medicine specialists in Korea.

Artificial Intelligence and the Future of Internal Medicine Physicians

Thu, 01 Jun 2017 00:00:01 +0100

Artificial intelligence (AI) is now very closely related to the work of internal medicine physicians. Internal medicine physicians must actively cope with and study the weak AI that affects them. Active use of weak AI can result in a reduced frequency of medical accidents and improved work efficiency. However, the form of medical consultation designed to treat patients based on behavior and guidelines of simply looking for symptoms and prescribing medications will ultimately disappear. As the age of self-care has begun, directors of local internal medicine clinics may expand their business to include AI-based chronic diseases and healthcare service companies to treat chronic diseases.

Korean Society of Gastrointestinal Endoscopy (KSGE) Guidelines for Endoscope Reprocessing

Thu, 01 Jun 2017 00:00:01 +0100

Korean Society of Gastrointestinal Endoscopy (KSGE) issued its guidelines for endoscope reprocessing for the first time in 1995, and the version of the guidelines has been updated in August 2009, August 2012 and March 2015, respectively. Guidelines for endoscope reprocessing should be revised continuously because new disinfectants and devices are introduced. The current official version of the KSGE guidelines for endoscope reprocessing is explained herein to assist the reader in understanding of KSGE requirements for cleaning and disinfection of endoscopes.

Guidelines for the Postoperative Treatment of Thyroid Cancer: Levothyroxine and Calcium/Vitamin ...

Thu, 01 Jun 2017 00:00:01 +0100

Thyroid hormone replacement is required after surgery for thyroid cancer to manage postoperative hypothyroidism and for thyroid- stimulating hormone (TSH) suppression therapy. However, considering the increased risks of cardiovascular disease and osteoporosis as a result of excessive thyroid hormone administration, it is necessary to maintain the correct dose. This requires prescription strategies tailored to the patients individual TSH goals by assessing the risk of recurrence, response to treatment, and risk factors for thyroid hormone therapy. In addition, if hypocalcemia is observed or symptoms of hypocalcemia are detected postoperatively, calcium and vitamin D should be administered to improve the symptoms and maintain serum calcium levels within normal ranges.

Hormone Therapy for Metastatic Breast Cancer

Thu, 01 Jun 2017 00:00:01 +0100

The treatment of metastatic breast cancer depends on the patients condition, site of metastasis, and molecular subtype of cancer. Hormone receptor-positive patients, which account for 60-70% of all breast cancer patients, have the advantage of having an effective, less-toxic, hormone therapy treatment. Hormone therapy should be used actively because it is very useful in terms of the patients quality of life, by increasing the response rate and delaying the progression of cancer. Recently, studies have examined the mechanism of resistance to hormone therapy. We need to combine various target therapies to overcome resistance. The development of therapeutic agents based on molecular biological characteristics should help to improve the survival of patients with metastatic breast cancer.

Diagnostic Approach to Chest Pain

Thu, 01 Jun 2017 00:00:01 +0100

Diagnosis of Early Gastric Cancer Using Image-enhanced Endoscopy

Thu, 01 Jun 2017 00:00:01 +0100

The Impact of Arterial Micro-calcification of the Vascular Access on Coronary Artery ...

Thu, 01 Jun 2017 00:00:01 +0100

Background/Aims: The aim of this study was to explore the relationship between arterial micro-calcification (AMiC) and coronary artery calcification, and to determine the impact of AMiC on cardiovascular mortality in incident hemodialysis patients. Methods: One hundred and nineteen hemodialysis patients who received vascular access surgeries between April 2011 and May 2015 were included in this study. AMiC was diagnosed by pathologic examination of arterial specimens acquired during surgery, using von Kossa stain. All patients underwent multi-detector computed tomography imaging, and coronary artery calcium scores (CACS) were calculated. We evaluated the association between AMiC and CACS in these patients, and examined the incidence of cardiovascular death (through Febraury 2017) in patients with and without AMiC. Results: The mean age of the patient group was 64.3

Analysis of Adverse Drug Reactions in Elderly Patients Based on a Spontaneous Reporting System ...

Thu, 01 Jun 2017 00:00:01 +0100

Background/Aims: Several factors contribute to the greater propensity for adverse drug reactions (ADRs) in the elderly, including the use of multiple drugs and pharmacokinetic and pharmacodynamic alterations due to aging. We evaluated the characteristics of ADRs in elderly versus younger adults. Methods: ADRs were collected from a spontaneous reporting system at Seoul National University Hospital from February 2010 to September 2013. We analyzed causative drugs, clinical manifestations, and the severity of ADRs. Results: In total, 15,541 ADRs were reported in patients 18 years of age or older. Common causative drug categories included nervous system, anti-neoplastics, and anti-infectives. The prevalence of ADRs due to respiratory drugs and cardiovascular drugs was higher in the elderly group (? 60 years) than in other groups. The most common clinical types were gastrointestinal and skin and appendage issues. The elderly group had a tendency to show a higher proportion of psychiatric, cardiovascular, hematological, and genitourinary symptoms. The proportions of severe ADRs were higher in the elderly groups and in male patients. Conclusions: Elderly patients were susceptible to ADRs related to respiratory and cardiovascular drugs. Psychiatric, cardiovascular, hematological, and genitourinary disorders account for a higher proportion of ADR symptoms in the elderly than in other age groups. Further efforts to understand, manage, and prevent ADRs in the elderly are required.

Acute Aortic Dissection in a Patient with Pheochromocytoma

Thu, 01 Jun 2017 00:00:01 +0100

Pheochromocytomas are neoplasms of the adrenal gland that are derived from chromaffin cells. One of the most important features of this tumor is that it can synthesize and release catecholamines such as norepinephrine and epinephrine. Due to this, arterial hypertension is one of the most common manifestations of the tumor. Although arterial hypertension is a substantial risk factor for aortic dissection, aortic dissection is actually a rare manifestation of pheochromocytoma. Here, we report a patient with pheochromocytoma who presented with acute type B aortic dissection.

Successful Radiofrequency Ablation of Parathyroid Adenoma in an Older Patient with Primary ...

Thu, 01 Jun 2017 00:00:01 +0100

Primary hyperparathyroidism is one of the most common endocrine diseases and is defined as the inappropriate overproduction of parathyroid hormone, resulting in hypercalcemia. It occurs mostly as a result of parathyroid adenoma or hyperplasia. The incidence of primary hyperparathyroidism increases with advancing age. The standard treatment of symptomatic primary hyperparathyroidism is parathyroidectomy; however, in older patients with multiple comorbidities, the risks associated with surgical treatment involving general anesthesia are high. Compared with surgery, radiofrequency abalation (RFA) is a minimally invasive procedure, in which the mass is removed. We here present a case of an elderly patient with primary hyperparathyroidism associated with parathyroid adenoma who was successfully treated with ultrasonography-guided RFA. RFA is an alternative therapeutic option for treatment of primary hyperparathyroidism for high-risk elderly patients, and further evaluation of its clinical value is warranted.

Membranous Nephropathy Relapsed after 20-year of Complete Remission

Thu, 01 Jun 2017 00:00:01 +0100

Membranous nephropathy is the most common pathologic lesion in adult patients with nephrotic syndrome. The cause is idiopathic, and the pathogenesis is believed to involve the deposition of immune complexes in the subepithelial tissue of the glomerular capillaries. After a period of 5 to 10 years, one-third of patients with membranous nephropathy will develop spontaneous remission, one-third will develop sustained proteinuria, and one-third will experience progression to chronic renal disease. Proteinuria may recur in patients who are in complete remission; this has been reported in approximately 26% of patients during an average of 89 months. To date, however, recurrence of membranous nephropathy has not been reported in patients who have been in complete remission for ? 20 years. We report herein such a case. Membranous nephropathy may recur in adult patients who are currently in the remission stage. Ongoing follow-up is therefore required, even after several years of complete remission.

Hypercalcemia in a Patient with Systemic Lupus Erythematosus

Thu, 01 Jun 2017 00:00:01 +0100

Hypercalcemia is a common clinical problem. The most frequent causes of hypercalcemia include primary hyperparathyroidism and malignancy; systemic lupus erythematosus (SLE) is a very rare cause of hypercalcemia. Here we describe a case of symptomatic severe hypercalcemia, which developed during a lupus flare. After treatment with intravenous fluids, diuretics, pamidronate, and hemodialysis, calcium levels normalized and were maintained on low-dose prednisolone treatment. To the best of our knowledge, this is the first case of hypercalcemia in a patient with SLE in Korea. Clinicians should consider lupus as a differential diagnosis for patients with severe hypercalcemia.

Mediastinal Actinomycosis Mimicking Mediastinal Lymph Node Metastasis in a Patient with Locally ...

Thu, 01 Jun 2017 00:00:01 +0100

Actinomycosis is a rare chronic suppurative infectious disease caused by Actinomyces spp. Actinomyces are anaerobic Gram-positive bacteria that colonize the mouth, digestive tract, and genital tract. Thoracic actinomycosis is caused by the aspiration of oropharyngeal materials or the spread of cervicofacial infections. Therefore, poor oral hygiene, smoking, and immunodeficiency are risk factors. Actinomycoses are frequently misdiagnosed as anatomical malignancies and thus assessments of the diseases underlying malignancies are often complicated by the presence of actinomycoses. Here, we report a case of mediastinal actinomycosis presenting with clinical and radiological features of metastatic pancreatic cancer. Clinicians should consider the presence of actinomycosis when cancer patients fail to respond to anti-cancer treatments.

Pancreatic Metastasis from Invasive Ductal Carcinoma of the Breast

Thu, 01 Jun 2017 00:00:01 +0100

Pancreatic metastases from primary breast cancer are very rare. We report a case of pancreatic metastasis from invasive ductal carcinoma 13 years after the initial diagnosis of breast cancer. When the pancreatic mass was discovered, it was believed to be a primary pancreatic cancer due to the long interval from the initial diagnosis of breast cancer to metastasis. However, it was confirmed as metastatic breast cancer based on the pathology after surgical removal. Follow-up imaging has shown no recurrence.

Bevacizumab-associated Ischemic Colitis Proven by Colonoscopy

Thu, 01 Jun 2017 00:00:01 +0100

Bevacizumab is a monoclonal antibody against vascular endothelial growth factor widely used to treat several types of solid tumor. Although bevacizumab has fewer adverse effects than conventional chemotherapy agents, several serious events have been reported. Gastrointestinal perforation is an infrequent but potentially fatal side-effect of bevacizumab. The major mechanism of bevacizumab-associated gastrointestinal perforation is damage to the intestinal vasculature. However, preceding ischemic colitis is difficult to diagnose due to its non-specific symptoms. We report a case of a 56-year-old male with bevacizumab-associated ischemic colitis proven by colonoscopy and pathologic findings. The patients condition improved after general supportive care including bowel rest, intravenous fluids, and intravenous antibiotics. No similar event has been reported since he resumed chemotherapy without bevacizumab.

Systemic Sclerosis Associated with Non-small Cell Lung Cancer and Papillary Thyroid Cancer: ...

Thu, 01 Jun 2017 00:00:01 +0100

We report the case of a 52-year-old patient with rheumatic vascular disease (systemic sclerosis), non-small cell lung cancer, and papillary thyroid cancer. Malignant tumors have been described in 3-11% of systemic sclerosis cases. Several studies have demonstrated an increased frequency of cancer, especially lung and breast cancer, in patients with systemic sclerosis, but the association of systemic sclerosis with malignancy is controversial. To our knowledge, however, no case of both lung and thyroid cancer associated with systemic sclerosis has been reported. We present a rare case of double primary cancer in systemic sclerosis, with a literature review.

Severe Scrub Typhus with Hemophagocytic Lymphohistiocytosis Occurring in Summer

Thu, 01 Jun 2017 00:00:01 +0100

In Korea, scrub typhus usually occurs in October and November. Hemophagocytic lymphohistiocytosis (HLH) is a distinct clinical entity characterized by a high fever, pancytopenia, hepatosplenomegaly, histiocyte proliferation, and hemophagocytosis. We encountered a summertime case of severe scrub typhus presenting as HLH. A 49-year-old female complained of abdominal pain and fever 3 days in duration. On hospital day 3 she was transferred to the intensive care unit because of clinical deterioration accompanied by severe sepsis. As an eschar was evident on the right shoulder, we commenced doxycycline. Her condition improved dramatically and she was discharged on day 14. Although the indirect immunofluorescence antibody test (IFA) for Orientia tsutsugamushi was negative on admission, a repeat IFA test was positive; the antibody titer was 1:5,120 on hospital day 10. Scrub typhus should be considered during differential diagnosis in a patient with severe sepsis in any season except the fall.

An Atypical Case of Peripheral T Cell Lymphoma with Hemolytic Anemia and ...

Thu, 01 Jun 2017 00:00:01 +0100

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects various organs, so it is easily confused with other diseases and thus misdiagnosed. SLE is defined only by classification criteria and not by diagnostic criteria, so other diseases must be excluded before SLE can be diagnosed. We report a case of peripheral T cell lymphoma that mimicked SLE initially.

Internal Medical Doctor Should Understand Korean Medical Law

Tue, 01 Aug 2017 00:00:01 +0100

Important Points for Internists When Encountering Foreign Patients

Tue, 01 Aug 2017 00:00:01 +0100

The number of foreign visitors to South Korea is increasing, and the number of foreigners receiving medical care is also increasing. Here, I introduce basic English terms that can be useful in seeing foreigners in typical primary care settings. I also mention helpful information including patients expectations, tips for preparing medical documents, and understanding of medical costs.

Controversies Regarding the New Definition of Sepsis

Tue, 01 Aug 2017 00:00:01 +0100

The Third International Consensus Definitions for Sepsis and Septic Shock (SEPSIS-3) task force assessed the latest pathophysiological parameters associated with sepsis and septic shock and defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. This SEPSIS-3 definition may be applied using relevant clinical and biological criteria including changes in the Sequential Organ Failure Assessment score and serum lactate levels. The new definition does not include criteria for systemic inflammatory response syndrome or the concept of severe sepsis. The SEPSIS-3 definition aims to devise more precise descriptions of sepsis and to improve clinical care. However, there are important questions relating to the clinical application of the new definition. We review the main characteristics and limitations of previous definitions and discuss some of the potential controversies raised by the new framework.

Understanding the Rome IV: Background to the Rome IV Revision

Tue, 01 Aug 2017 00:00:01 +0100

Functional gastrointestinal disorders (FGIDs) are common and may be serious. As such disorders are identified principally on the basis of their symptoms, symptom-based classifications assume great importance. The Rome diagnostic criteria for FGIDs are widely used in both research and practice. Over time, the criteria have been revised as new data accumulate; the Rome IV criteria were recently released. The changes from the Rome III criteria principally reflect the data of literature reports and committee recommendations based on all available evidence. Here, we offer a historical perspective and discuss the Rome IV changes.

Understanding the Rome IV: Esophageal Disorders

Tue, 01 Aug 2017 00:00:01 +0100

The Rome IV criteria, published in 2016, encompass upper gastrointestinal lesions of functional esophageal disorders and functional gastroduodenal disorders. Functional esophageal disorders include functional chest pain, functional heartburn, reflux hypersensitivity, globus, and functional dysphagia. Patients with functional esophageal disorders typically have esophageal symptoms that are not associated with structural, inflammatory, or major esophageal motor disorders. Although the mechanisms of symptom generation in functional esophageal disorders are unclear, visceral hypersensitivity and hypervigilance may play a role. Therefore, treatment options include drugs and modalities that affect peripheral triggering and central perception. Further well-designed studies are needed to identify the mechanisms of symptom generation in, and to develop appropriate therapies for, functional esophageal disorders.

Understanding the Rome IV: Gastroduodenal Disorders

Tue, 01 Aug 2017 00:00:01 +0100

Gastroduodenal symptoms are very common in the general population. The symptoms are classified into four categories according to the newly revised Rome IV criteria: functional dyspepsia (including postprandial discomfort and epigastric pain syndrome), belching disorders (including excessive gastric and supragastric belching), chronic nausea and vomiting syndrome (including chronic nausea vomiting syndrome, cyclic vomiting syndrome, and cannabinoid hyperemesis syndrome), and rumination syndrome. Newly developed diagnostic criteria are based on recently published studies. These revised criteria will be very helpful for appropriately managing these patients in a clinical situation.

Understanding the Rome IV: Irritable Bowel Syndrome and Functional Diarrhea

Tue, 01 Aug 2017 00:00:01 +0100

Irritable bowel syndrome (IBS) is a common, chronic functional gastrointestinal disorder affecting the large intestine, and presents as abdominal pain and/or discomfort, bloating, gas retention, diarrhea, and constipation. IBS impairs quality-of-life and requires long-term management. In 2016, the Rome Foundation introduced new IBS diagnostic criteria (the Rome IV criteria), and also revised the diagnostic algorithms for, and the multidimensional clinical profile (MDCP) of, functional gastrointestinal disorders. The IBS MDCP includes clinical data, the extent to which normal daily activities are affected, and psychosocial and physiological measures. The criteria seek to aid physicians in choosing appropriate treatment for IBS patients. Herein, we seek to provide evidence-based practical information on IBS and functional diarrhea. We review the new Rome diagnostic IV criteria, the MDCP, and the various IBS treatment options. We suggest that, in clinical practice, combination therapies may be useful to treat patients with IBS of various grades.

Understanding the Rome IV: Functional Constipation and Anorectal Disorders

Tue, 01 Aug 2017 00:00:01 +0100

We used mainly the Rome diagnostic criteria to diagnose functional gastrointestinal disease (FGID). The revised Rome IV was announced in 2016. Rome IV is the recognition that a considerable overlap exists between some of the FGIDs and that they may exist as part of a spectrum, rather than discrete disorders. Based on this concept, the Rome IV criteria for functional constipation and anorectal disorders are newly revised. We review the background and content of the Rome IV diagnostic criteria and introduce the multidimensional clinical profile using clinical cases. These revised criteria will be helpful for adequately diagnosing and managing these patients in actual clinical practice.

Diagnostic Approach to Peripheral Eosinophilia

Tue, 01 Aug 2017 00:00:01 +0100

Approach to the Patient with Hypertension Accompanied by Hypokalemia

Tue, 01 Aug 2017 00:00:01 +0100

Clinical Features of Serious Adverse Drug Reactions in a Tertiary Care Hospital in Korea

Tue, 01 Aug 2017 00:00:01 +0100

Background/Aims: Several studies have reported on the clinical aspects of adverse drug reactions (ADRs). To date, no study has evaluated serious adverse drug reactions (SADRs) in Korea. The current study evaluates the clinical expression of SADRs in a Korean hospital. Methods: We reviewed a total of 3,386 cases of SADR occurring between March 2012 and November 2015 in a single tertiary care institution (Regional Pharmacovigilance Center). Results: When classified by organ system, the most common SADRs were white cell and reticuloendothelial system disorders (n = 511). Skin/appendage (n = 296) and gastrointestinal (n = 216) disorders were the fourth- and eighth-most common SADRs, respectively. The three most common single symptoms were leukopenia (n = 499 events), hypotension (n = 444) and anaphylaxis (n = 215). Leukopenia was mainly caused by anti-tumor drugs, followed by piperacilin/tazobactam (n = 28), vancomycin (n = 10) and methimazole (n = 6). Hypotension was most often caused by propacetamol injection (n = 145), while anaphylaxis was mainly caused by cefaclor (n = 19), ranitidine (n = 12), iopamidol (n = 10) and multi-vitamin infusion (n = 9). Conclusions: Significant differences were noted in the clinical aspects of ADRs and SADRs. Additional studies are warranted to further assess SADRs in response to frequently used causative drugs.

Subcapsular Hepatic Hematoma after Endoscopic Retrograde Cholangiopancreatography

Tue, 01 Aug 2017 00:00:01 +0100

Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool for the diagnosis and management of diseases of the pancreas and biliary tract. However, ERCP has a high risk of procedure-related complications compared with other endoscopic procedures performed in the upper gastrointestinal tract. The most common complications are pancreatitis, cholangitis, hemorrhage, and perforation. Extraluminal hemorrhagic complications after ERCP are relatively rare but potentially life threatening and should be identified and treated immediately. We report a case of subcapsular hepatic hematoma after guidewire injury during ERCP in a 64-year-old woman with choledocholithiasis who had undergone ERCP with guidewire-assisted papillotomy for stone extraction. Although subcapsular hepatic hematoma is a very rare complication after ERCP, it should be considered in the differential diagnosis of patients complaining of abdominal pain after ERCP.

Inflammatory Pseudotumor of the Spleen Associated with Autoimmune Thyroiditis

Tue, 01 Aug 2017 00:00:01 +0100

Inflammatory pseudotumor is a benign disease entity, which is histologically composed of inflammatory cells and fibrotic stroma. It is mainly found in the respiratory tract, but it has also been reported in the liver, central nervous system, soft tissues, urological system, and gastrointestinal tract. It is extremely rare in the spleen and there have been no cases of splenic inflammatory pseudotumor associated with autoimmune thyroiditis in Korea. The pathogenesis or etiology is unknown, but hypotheses include infection, autoimmunity, and parenchymal necrosis with hemorrhage. Because inflammatory pseudotumor may mimic malignant tumors on radiologic findings, pathologic confirmation is necessary to distinguish it from lymphoproliferative disorders of the spleen and other malignant tumors. We report a case of inflammatory pseudotumor of the spleen associated with autoimmune thyroiditis in a patient who complained of periumbilical pain.

Retroperitoneal Schwannoma Mimicking an Adrenal Mass

Tue, 01 Aug 2017 00:00:01 +0100

A schwannoma is a benign neoplasm originating from the Schwann cells of the neural sheath. The most common type of benign schwannomas is the acoustic neuroma presenting with deafness. We report a rare case of schwannoma mimicking an adrenal mass. A 66-year-old woman was diagnosed with an adrenal incidentaloma measuring 10 cm in length on a health checkup. The hormonal study revealed that the adrenal mass was non-functioning. Due to a high risk of adrenal malignancy, a retroperitoneal mass excision, distal pancreatectomy, splenectomy, wedge resection of stomach, and left adrenalectomy were conducted. The subsequent histopathologic examination revealed it to be a benign schwannoma.

Complete Remission after Pseudoprogression in Refractory Classical Hodgkin Lymphoma Treated ...

Tue, 01 Aug 2017 00:00:01 +0100

Classical Hodgkin lymphoma (cHL) is a highly curable disease, but the prognosis for relapsed/refractory cHL is grave. Pembrolizumab has recently shown impressive effects in patients with relapsed/refractory cHL in a phase Ib study (KEYNOTE-013). This report presents a case of a 17-year-old male with refractory cHL who received multiple chemotherapy regimens and radiotherapies, including brentuximab vedotin. Following both the second and fourth cycles of intravenous pembrolizumab 100 mg (2 mg/kg), positron emission tomography/computed tomography (PET/CT) scan showed progression. However, because performance status and fever improved, treatment was continued, and complete remission was confirmed by PET/CT after eight cycles of pembrolizumab. This case suggests that clinicians need to be aware of the potential for pseudoprogression in patients treated with pembrolizumab.

Community-onset Necrotizing Fasciitis Caused by Extended-spectrum Beta-lactamase-producing ...

Tue, 01 Aug 2017 00:00:01 +0100

Necrotizing fasciitis (NF) is an uncommon but fatal infectious disorder that rapidly destroys connective tissue, causing extensive necrosis, severe sepsis, multiple organ failure, and death. NF is more common in patients with comorbid medical conditions. Most NF is caused by bacteria extending from localized skin infections, or remote bacteremia. Escherichia coli (E. coli) has been isolated from polymicrobial NF, but is rarely causative of monomicrobial NF. In addition, NF attributable to community-onset, extended-spectrum beta-lactamase (ESBL)-producing E. coli has not been described previously. As ESBL-producing E. coli are becoming significant pathogens of community-acquired infections worldwide, we report an exceptional case of community-onset NF attributable to monomicrobial ESBL-producing E. coli in a patient with liver cirrhosis.

What is the Role of Korean Society of Internal Medicine to Support the Optimal Patient Care ...

Sun, 01 Oct 2017 00:00:01 +0100

Clinical Practice Guideline for Physicians on Allergic Rhinitis

Sun, 01 Oct 2017 00:00:01 +0100

Recently, the rhinitis work group of the Korean Academy of Asthma, Allergy and Clinical Immunology developed a practice guideline on allergic rhinitis. The group consisted of physicians, pediatricians, and otolaryngologists. Here, the guideline is adapted for clarity and for ease of use by physicians. To manage allergic rhinitis well, accurate diagnosis is most important. In patients with rhinitis symptoms, the first step is to perform a skin prick test to inhalant allergens, and/or to measure allergen-specific immunoglobulin E in serum. Next, allergic rhinitis should be diagnosed upon documenting the association between positive allergens and rhinitis symptoms, via patient history or allergen nasal provocation test. Allergic rhinitis should be differentiated from non-allergic rhinitis, because treatment modalities differ between the two. Allergic rhinitis should be effectively managed with allergen avoidance, pharmacotherapy, allergen immunotherapy, surgical treatment, and/or saline irrigation. Second-generation antihistamines or leukotriene modifiers may be used for mild-to-moderate forms, and intranasal steroids may be effective for moderate-to-severe forms. Allergic rhinitis is closely associated with asthma. Spirometry should be performed initially for asthma diagnosis, if asthma-like symptoms are present.

Efficacy of Endobiliary Radiofrequency Ablation for Malignant Biliary Obstruction

Sun, 01 Oct 2017 00:00:01 +0100

Malignant biliary tract obstruction (MBTO) is caused by a group of neoplasms that compromise bile duct flow, and the clinical presentation includes obstructive jaundice. The optimal treatment depends on both the type of malignancy and the stage of disease. Surgical resection may be the first choice of treatment. However, an operation is often impossible because of locally advanced disease or a high metastatic potential at the time of diagnosis. Considering the unfavorable prognosis of unresectable MBTO, endobiliary radiofrequency ablation (EB-RFA) has emerged as a palliative therapeutic modality that directly ablates malignant tissue in the bile duct. To date, some reports have suggested that EB-RFA is possibly beneficial, but it remains unclear whether EB-RFA prolongs biliary stent patency or overall survival. Nevertheless, EB-RFA is regarded as a promising loco-regional therapy for MBTO. This review focuses on the clinical application of the technique and its appropriate use, along with the benefits afforded and the complications encountered.

SGLT2 Inhibitors and Ketoacidosis: Pathophysiology and Management

Sun, 01 Oct 2017 00:00:01 +0100

Sodium-glucose cotransporter 2 inhibitors are antidiabetic drugs that increase urinary glucose excretion by inhibiting proximal tubular reabsorption of glucose in the kidney. Some sodium-glucose cotransporter 2 inhibitors have been shown to afford effective glycemic control and to decrease the risks of major adverse cardiovascular events. However, these drugs may increase the risk of diabetic ketoacidosis. This is a rare complication that occurs in less than 0.1% of treated patients with type 2 diabetes. The condition may be euglycemic, and is triggered by controllable precipitating factors such as surgery, infection, and insulin reduction or omission. It is important to understand individual patient profiles and to prevent diabetic ketoacidosis by appropriate prescribing, by withholding sodium-glucose cotransporter 2 inhibitors when indicated, and by counseling patients on sick day management.

Diagnostic Approaches for Patients with Dyspepsia

Sun, 01 Oct 2017 00:00:01 +0100

Exhaled Nitric Oxide Measurement for Asthma Management

Sun, 01 Oct 2017 00:00:01 +0100

Relationship between Bronchodilator Response, Airway Hyperresponsiveness, and Exhaled Nitric ...

Sun, 01 Oct 2017 00:00:01 +0100

Background/Aims: Exhaled nitric oxide (NO) has been extensively investigated as a marker of airway inflammation in asthma, and fractional exhaled nitric oxide (FeNO) is recognized as a useful tool for its evaluation. The aim of this study was to investigate the relationships between FeNO levels and bronchodilator response (BDR), and between FeNO and mannitol-induced airway hyperresponsiveness (AHR), in patients with suspected asthma. Methods: Clinical variables were collected from patients aged ? 13 years with suspected bronchial asthma and measured levels of FeNO. These levels were compared with patient values for forced expiratory volume in the first second (FEV1) and forced expiratory flow at 25 and 75% of the pulmonary volume (FEF_25-75%) in bronchodilator response tests under control conditions, and during bronchial provocation with mannitol. Correlations and receiver operating characteristic (ROC) curves between FeNO levels and each test were assessed. Results: A total of 259 patients were included in the analysis. The mean ages of the two test groups were 41.1 and 47.8 years, respectively. FeNO levels were strongly correlated with bronchodilator response (%) and with the mannitol dose producing a 15% fall in FEV1 (PD15). On the other hand, FeNO levels were only weakly correlated with FEF_25-75%. The optimal cut-off values for FeNO to predict a positive BDR and AHR were 38.5 and 29.5 parts per billion, respectively. Conclusions: This study suggests that FEV1 and FEF_25-75% airway responses correlate with FeNO levels in patients with suspected bronchial asthma. FeNO levels may help to predict positive responses to BDR and AHR.

Malignant Paraganglioma in the Common Hepatic Duct

Sun, 01 Oct 2017 00:00:01 +0100

Paragangliomas are rare extra-adrenal neoplasms of neural crest origin. The neoplasms may develop at various sites, but most are located in the para-aortic space along the sympathetic chain. A paraganglioma in the bile duct is very rare; only four cases of such tumors in the hepatic bile duct have been reported to date. Herein, we report on the first Korean case of a malignant paraganglioma in the common hepatic duct (with hepatic metastases) in a 75-year-old male. Computed tomography of the abdomen revealed a heterogeneously enhancing lesion in the common hepatic duct with dilatation of the intrahepatic ducts. After balloon sweeping, the mass exited spontaneously through the Ampulla of Vater. The mass was about 1.5

Adrenal Gland Metastasis of a Gastrointestinal Stromal Tumor

Sun, 01 Oct 2017 00:00:01 +0100

A 56-year-old male with a gastrointestinal stromal tumor (GIST) underwent surgical resection of the tumor. Nine months after surgery, imatinib therapy was initiated because of the discovery of metastatic tumors in the left adrenal gland and in a lymph node of the peritoneum. Seventeen months later, the patient achieved complete remission (CR) and imatinib therapy was continued. However, 48 months after initiation of imatinib therapy, computed tomography scans revealed a left adrenal gland metastasis and the patient underwent left adrenalectomy. Immunohistochemical staining indicated that the spindle-shaped cells of the resected tumor were positive for C-kit, thus confirming metastasis of the GIST. This is the first report from Korea of an adrenal gland metastasis from a GIST. Worldwide, only two such cases have been reported. Here, we describe the first case of a distant recurrence of a GIST in the left adrenal gland after CR had been achieved with the aid of surgical resection and imatinib therapy.

Bladder Malakoplakia Mimicking Bladder Cancer

Sun, 01 Oct 2017 00:00:01 +0100

Malakoplakia is an extremely rare granulomatous disease caused by infection and known to occur mostly in immune-compromised hosts. The most common site of involvement is the bladder. Patients with malakoplakia of the bladder present with multiple intravesical masses and are often misdiagnosed with bladder cancer. As a result, appropriate treatment is delayed. Here we report a case of a patient with malakoplakia of the bladder that was misdiagnosed as bladder cancer.

A Case of Acquired Factor V Deficiency after Percutaneous Coronary Intervention

Sun, 01 Oct 2017 00:00:01 +0100

Acquired factor V deficiency is extremely rare. Here we report the case of an 88-year-old female patient who presented with hematochezia 1 month after undergoing percutaneous coronary intervention. Her laboratory results showed an extremely prolonged prothrombin time and an activated partial thromboplastin time, but neither improved after fresh frozen plasma transfusion. She was finally diagnosed with acquired factor V deficiency and successfully treated with an immunosuppressant.

Eight Cases of Dengue Fever in a Volunteer Group from Sri Lanka and Its Ocular Involvement

Sun, 01 Oct 2017 00:00:01 +0100

Dengue fever is an acute febrile disease that is caused by a mosquito-borne flavivirus. It has become a major infectious disease threat in tropical and subtropical areas. In Korea, travel-associated dengue fever is increasing. Thirty-five Koreans went to Sri Lanka to do volunteer activities. Eight of the volunteers developed fever, myalgia, and rash; they were diagnosed with dengue fever. Two patients had macular hemorrhages and edema with no ophthalmic symptoms. The maculopathy caused by the dengue fever improved without specific treatment.

Hospice-Palliative Care and Law

Fri, 01 Dec 2017 00:00:01 +0100

Influenza

Fri, 01 Dec 2017 00:00:01 +0100

Influenza causes variable epidemics annually and imposes public health problems and socioeconomic burden. They cause epidemic acute respiratory disease, characterized by fever, cough and systemic symptoms. The annual epidemics of seasonal influenza can affect any age group and result in serious illness or death, particularly in high risk populations such as adults > 65 years old, children < 2 years old and those with chronic medical condition at any age. Three types (A, B, and C) are recognized as well as many subtypes within the type A. New influenza A virus subtypes sporadically emerge in humans to cause widespread disease or pandemics. Antiviral therapy with oseltamivir or zanamivir is available and shorten the duration of illness and reduce the rate of complications. Influenza vaccines are effective in the prevention of influenza illness, although improved vaccines are needed.

New Classification Criteria for Primary Sj

Fri, 01 Dec 2017 00:00:01 +0100

Primary Sj

Misunderstandings and Truth about Chronic Cough

Fri, 01 Dec 2017 00:00:01 +0100

There seem to be several pitfalls in an anatomic, diagnostic protocol for the evaluation of chronic cough. Instead, it is reasonable to propose that non-asthmatic chronic cough depends on the combined effects of an underlying, abnormally enhanced cough reflex and aggravating factors. Unexplained chronic cough is distressingly common despite a systematic diagnostic approach. It is often related to bronchial hypersensitivity and nonspecific bronchial inflammation. Inhaled corticosteroid (ICS) is effective for asthmatic cough. ICS is less effective in non-asthmatic cough than in asthma but not ineffective. It can be modestly effective in a significant portion of patients with non-asthmatic cough. Cough itself can induce upper airway mucosal inflammation, which could enhance the cough reflex and viciously aggravate cough. Therefore, an antitussive agent is not a just symptom controller but can play a major role in successful cough control. Cough can be more effectively controlled by behavioral interventions, with psychological counseling in addition to a pharmacological approach. ICS and antihistamines can reduce cough regardless of its cause, so therapeutic diagnosis is a misconception in the diagnosis of cough.

Diagnostic Approach to Refractory Constipation

Fri, 01 Dec 2017 00:00:01 +0100

Echocardiographic Evaluation of Left Ventricular Diastolic Function

Fri, 01 Dec 2017 00:00:01 +0100

Effects of Platelet Number and Platelet Indices on Platelet Reactivity in Patients Treated with ...

Fri, 01 Dec 2017 00:00:01 +0100

Background/Aims: Platelet counts and characteristics can influence platelet reactivity during antiplatelet therapy. We compared the effects of both platelet count and indices on platelet reactivity between patients who were treated with either clopodogrel or ticagrelor. Methods: Patients with coronary artery disease who underwent percutaneous coronary intervention were randomly assigned to either the clopidogrel (n = 63) or ticagrelor (n = 65) groups. Platelet count, platelet indices (including mean platelet volume, platelet distribution width, platelet large cell ratio, and immature platelet fraction), and platelet reactivity were measured before intervention, and 48 hours and 30 days post-intervention. High on-treatment platelet reactivity (HPR) was defined as ? 47 unit as assessed by multiple electrode platelet aggregometry. Results: Baseline platelet reactivity was similar between the two groups; however, at 48 hours and 30 days, platelet reactivity was significantly lower in the ticagrelor group than in the clopidogrel group. Platelet count, mean platelet volume, platelet distribution width, platelet large cell ratio, and immature platelet fraction were significantly correlated with platelet reactivity in the clopidogrel group; however, these correlations were attenuated in the ticagrelor group. The use of clopodogrel (hazard ratio [HR] 4.1, 95% confidence interval [CI] 1.4-11.9; p = 0.010) and platelet count (HR 9.7, 95% CI 2.9-32.7; p = 0.001) were independent predictors for 30 day HPR. Platelet count was an independent predictor of HPR in the clopidogrel group but not in the ticagrelor group. Conclusions: Platelet count and indices are significantly correlated with platelet reactivity. However, antiplatelet treatment with ticagrelor could overcome these associations.

Removal of Pancreatic Duct Stones by Endoscopic Ultrasonography-Guided Rendezvous ERCP

Fri, 01 Dec 2017 00:00:01 +0100

Symptomatic pancreatic ductal stones can be removed nonsurgically by endoscopic retrograde cholangiopancreatography (ERCP), either alone or in combination with extracorporeal shock-wave lithotripsy (ESWL). Here, we report a case of successful endoscopic ultrasonography (EUS)-guided rendezvous ERCP for removal of radiolucent pancreatic stones after failed ERCP and ESWL. A 79-year-old male with painful chronic pancreatitis associated with pancreatic stones and a dilated upstream duct underwent transgastric antegrade pancreatography via EUS-guided pancreatic duct access followed by rendezvous ERCP. In this patient, EUS-guided rendezvous ERCP was successful in salvaging pancreatic duct cannulation after unsuccessful ERCP due to a tight stricture at the pancreatic duct orifice and removing radiolucent pancreatic stones after ESWL, which was unsuccessful because of failure to localize the stones due to their radiolucency under x-ray fluoroscopy.

Right Coronary Artery Ostial Stenosis after Re-do Aortic Valve Replacement

Fri, 01 Dec 2017 00:00:01 +0100

Coronary ostial stenosis after aortic valve replacement (AVR) is a rare but life-threatening complication. Here, we report a case of right coronary artery ostial stenosis in a patient who had a history of re-do AVR and normal preoperative coronary angiographic findings. The patient was successfully treated with a drug-eluting stent.

Allogenic Peripheral Blood Stem Cell Transplant-Induced Membranous Glomerulonephropathy as ...

Fri, 01 Dec 2017 00:00:01 +0100

Heavy proteinuria in the nephrotic range is an uncommon, often unrecognized manifestation of graft-versus-host disease (GVHD) following hematopoietic stem cell transplantation. A few isolated case reports have been published in the Korean literature involving a small number of patients who developed membranous nephropathy as GVHD after peripheral blood stem cell transplantation (PBSCT). A 17-year-old female was diagnosed with non-Hodgkins lymphoma. Following remission, she underwent allogeneic PBSCT. Shortly thereafter, she developed acute GVHD, which was managed by medical therapy with prednisolone and cyclosporine. Approximately 13 months following PBSCT, the patient developed proteinuria without peripheral edema. Pulsed steroid therapy was initiated three times, but her condition did not improve. Twenty months after PBSCT, she developed nephrotic range proteinuria. A renal biopsy was performed, and the diagnosis was histologically consistent with membranous nephropathy. Because the response to steroids was not satisfactory, the dose of cyclosporine was increased. Approximately 3 months after renal biopsy, the proteinuria disappeared. Given the recent increase in the incidence of GVHD-mediated renal disease, in particular, renal biopsy is indispensable to the diagnosis of nephropathy and to the prevention of disease progression.

A Sporadic Case of Epstein Syndrome: A Rare Cause of Refractory Thrombocytopenia

Fri, 01 Dec 2017 00:00:01 +0100

A 37-year-old female presented to our hospital with a history of bleeding episodes (excessive bleeding after tooth extraction, gum bleeding, easy bruising, and excessive menstruation) and severe thrombocytopenia (2,000/?L). She had no family history of bleeding tendency or thrombocytopenia. No peripheral lymphadenopathy or splenomegaly was noted. The patients white blood cell count was normal; hemoglobin was 9.7 g/dL. A peripheral blood smear showed markedly decreased platelets, with occasional giant or large platelets. Bone marrow examination found increased megakaryocytes. The patient also complained of hearing difficulty; a hearing test indicated sensory-neural hearing impairment. Her thrombocytopenia was refractory to treatment with glucocorticosteroids, intravenous gamma-globulin, and danazol. In the 13 years following her initial presentation, the patient required anti- hypertensive treatment, a hearing-aid for progressive hearing loss, and started maintenance kidney dialysis. Her clinical history of refractory thrombocytopenia, progressive hearing impairment, and renal failure suggested myosin heavy chain 9 gene-related congenital syndrome (Epstein syndrome), which was confirmed by the presence of a heterozygous deletion mutation, c.221_223del, (p.Lys74del) in peripheral leukocyte deoxyribonucleic acid.

A Case of Dermatomyositis in a Patient with a Neuroendocrine Tumor at the Ampulla of Vater

Fri, 01 Dec 2017 00:00:01 +0100

Dermatomyositis is an autoimmune disease characterized by chronic muscle inflammation that results in specific dermatological signs and decreased muscle strength. It is known to have a strong association with malignancy. Most neuroendocrine tumors arise from the gastrointestinal tract, with less than 1% of cases occurring at the ampulla of Vater. While cases of dermatomyositis associated with neuroendocrine tumors have been reported internationally, to date there have been no cases reported in Korea. This case report presents a 33-year-old male who had undergone pylorus-preserving pancreaticoduodenectomy for a neuroendocrine tumor located at the ampulla of Vater, and had been followed at the hospital after his procedure. Three years post-surgery, the patient developed serious muscle weakness in his upper-right and lower-left extremities, and was subsequently diagnosed with dermatomyositis. This paper presents the first domestic case of dermatomyositis developing in the context of a neuroendocrine tumor at the ampulla of Vater. A literature review on this subject follows in the discussion.

Long Way for the Korean Journal of Internal Medicine to Be Listed in SCIE Journal

Mon, 01 Aug 2016 00:00:01 +0100

Zika Virus Infection

Mon, 01 Aug 2016 00:00:01 +0100

Zika virus was first isolated in from nonhuman primate in 1947. It is in the genus Flavivirus, closely related to other flavivirus like Dengue, West Nile, Yellow fever and Japanese encephalitis virus. Since 2007 epidemic in Yap island, zika virus infections had spread to the countries in Micronesia and South Pacific. In 2015, Zika virus outbreak occurred in Brazil and now more than 40 countries in American continents reported autochthonous infection. The virus is transmitted mainly by Ae. aegypti mosquito with many other Aedes mosquito species known as vector. Recently, Zika virus infection is known to cause severe neurological complications and congenital malformation. In this paper, we will review current knowledge on Zika virus history, biology, clinical characteristics and preventive method.

The Impact of the SPRINT Trial on Hypertension Guidelines

Mon, 01 Aug 2016 00:00:01 +0100

The most recent revision of the blood pressure guidelines adopted less aggressive blood pressure targets, particularly in patients with diabetes and chronic kidney disease, and the elderly. However, the Systolic Blood Pressure Intervention Trial (SPRINT) reported that lowering the systolic blood pressure to <120 mmHg resulted in a decreased risk of cardiovascular disease, compared with lowering the SBP to <140 mmHg, in adults with hypertension but without diabetes. This will likely lead to many changes in clinical practice. Such lowering of systolic blood pressure would benefit some categories of hypertensive patients at an increased risk of cardiovascular disease.

Chronic Refractory Cough

Mon, 01 Aug 2016 00:00:01 +0100

Chronic refractory cough is defined as a cough that persists despite guideline based treatment. It is seen in 20-46% of patients presenting to specialist cough clinics and it has a substantial impact on quality of life and healthcare utilization. Several terms have been used to describe this condition, including the recently introduced term cough hypersensitivity syndrome. Key symptoms include a dry irritated cough localized around the laryngeal region. Symptoms are not restricted to cough and can include globus, dyspnea, and dysphonia. Chronic refractory cough has factors in common with laryngeal hypersensitivity syndromes and chronic pain syndromes, and these similarities help to shed light on the pathophysiology of the condition. Its pathophysiology includes cough reflex sensitivity, central sensitization, peripheral sensitization, and paradoxical vocal fold movement. Chronic refractory cough often occurs after a viral infection. The diagnosis is made once the main disease that causes chronic cough have been excluded (or treated) and cough remains refractory to medical treatment. Treatments include speech pathology interventions using techniques adapted from the treatment of hyperfunctional voice disorders, as well as the use of centrally acting neuromodulators such as gabapentin and pregabalin. Potential new treatments in development also show promise.

Diagnostic Approach of Hyponatremia: Lessons from a Case of Hypopituitarism

Mon, 01 Aug 2016 00:00:01 +0100

Diagnostic Imaging of Gouty Arthritis

Mon, 01 Aug 2016 00:00:01 +0100

Coronary-subclavian Steal Syndrome in a Patient with Takayasu Arteritis

Mon, 01 Aug 2016 00:00:01 +0100

A 37-year-old woman who had undergone coronary artery bypass grafting (CABG) surgery for left main and right coronary ostial lesions 2 years prior presented with angina and transient visual dimness. Computed tomography angiography showed a patent left internal mammary artery (LIMA) bypass graft and concentric narrowing with perivascular thickening around the arch vessels. The patient was diagnosed with Takayasu arteritis with coronary subclavian steal syndrome (CSSS). Thoracic angiography revealed severe stenosis of the left proximal subclavian artery (SCA) and reverse flow from the coronary artery to the distal left SCA via the LIMA graft. Successful percutaneous stenting of the left SCA was performed together with stenting of the right common carotid artery (CCA). The patients symptoms were completely resolved. This case is informative since it shows that Takayasu arteritis can manifest as angina due to coronary ostial lesions and then can involve arch vessels, which can lead to CSSS in patients with CABG.

Thoracic Endovascular Repair by Chimney Technique for Aortic Dissection with Malperfusion Syndrome

Mon, 01 Aug 2016 00:00:01 +0100

A perfusion deficit of the aortic branch vessels in a patient with a type B aortic dissection is a challenging complication, as it leads to hemodynamic instability and doubles the mortality rate; however, the optimal management strategy in these cases remains controversial. Although surgical repair is still performed as the standard, endovascular approaches have been used recently as alternatives because of the high rate of perioperative complications. Herein, we report a patient with a type B aortic dissection and compromised renal and iliac arteries who was successfully treated by thoracic endovascular repair and insertion of a percutaneous stent. In addition, we adopted the chimney technique to preserve blood flow to the left subclavian artery due to the short proximal landing zone.

One-year Follow-up of Three Cases of Smoking-related Interstitial Fibrosis

Mon, 01 Aug 2016 00:00:01 +0100

Smoking-related interstitial fibrosis (SRIF) is characterized by marked alveolar septal fibrosis seen as distinct thick collagen bundles, along with emphysema and respiratory bronchiolitis. In 2010, SRIF was deemed a new entity that differed from idiopathic pulmonary fibrosis (IPF) clinically, pathologically, and radiologically. No case of SRIF has been reported in Korea and it is rare worldwide. Here, we report the 1-year follow-up of three cases of SRIF.

A Fulminant Case of Clostridium perfringens Septic Shock caused by a Liver Abscess with Massive ...

Mon, 01 Aug 2016 00:00:01 +0100

A 65-year-old female visited the emergency room for severe back pain radiating to the neck. Aortic dissection computed tomography revealed a ruptured liver abscess and large pneumoperitoneum. Although emergent percutaneous drainage of the liver abscess and aggressive resuscitation were performed, massive hemolytic anemia and disseminated intravascular hemolysis developed and she subsequently died, 11 hours after her visit to the emergency room. Clostridium perfringens was identified in a blood culture obtained at the emergency room. We report this case because refractory septic shock due to a liver abscess and massive intravascular hemolytic anemia caused by Clostridium perfringens in a healthy female is rare.

Spontaneous Thymic Cyst Hemorrhage Manifesting as a Mediastinal Mass

Mon, 01 Aug 2016 00:00:01 +0100

Thymic cysts are uncommon benign lesions in the anterior mediastinum. We here describe a 55-year-old male with spontaneous thymic cyst hemorrhage manifesting as a rapidly enlarging mediastinal mass that was resected completely with video-assisted thoracoscopic surgery. To the best of our knowledge, this is the first report of a spontaneous thymic cyst hemorrhage in Korea. In cases of rapidly enlarging mediastinal masses, spontaneous thymic cyst hemorrhage should be considered as a differential diagnosis.

Hypopituitarism Secondary to Paraclinoid Internal Carotid Artery Aneurysm

Mon, 01 Aug 2016 00:00:01 +0100

Pituitary insufficiency due to a sellar aneurysm is relatively uncommon. The prevalence of this disorder was <0.2% in a large cohort of patients with panhypopituitarism. While uncommon, a vascular sellar lesion should be included as a differential diagnosis for a sellar mass resulting in hypopituitarism. We report herein a case of hypopituitarism with hyperprolactinemia secondary to a large (1.7-cm) saccular aneurysm at the left paraclinoid internal carotid artery.

Chronic Myeloid Leukemia Following Radioactive Iodine Treatment for Thyroid Cancer: Two Case ...

Mon, 01 Aug 2016 00:00:01 +0100

The incidence of thyroid cancer has increased rapidly worldwide, although most patients can survive for a long time without developing symptoms. While most thyroid cancers are treated with thyroidectomy alone, some patients are given additional radioactive iodine (RAI) in the form of 131I to treat thyroid cancer metastasis. RAI is associated with acute and chronic complications. Secondary malignancies are the most important in long-term cancer survivors. While many studies have reported the occurrence of acute myeloid leukemia after high-dose RAI, there are few reports on chronic myeloid leukemia (CML) after low-dose RAI treatment. Moreover, previous cases of CML following thyroid cancer were reported before the tyrosine kinase inhibitor (TKI) era. Here, we describe two cases of CML following thyroid cancer that were successfully treated with second-generation TKIs.

Acute Myeloid Leukemia with the 11q23 Rearrangement in a Patient with Klinefelter Syndrome

Mon, 01 Aug 2016 00:00:01 +0100

Klinefelter syndrome is usually characterized by eunuchoidism, gynecomastia, small testes, infertility, elevated gonadotropins, mental retardation, and a constitutional extra X chromosome. Several reports have suggested an association between leukemia and Klinefelter syndrome, although two cohort studies failed to show a clear association between the two. We report the first Korean case of acute myeloid leukemia with the 11q23 rearrangement in a 27-year-old man with Klinefelter syndrome.

Hemophagocytic Lymphohistiocytosis Occurring after Induction Chemotherapy in Acute Myelocytic ...

Mon, 01 Aug 2016 00:00:01 +0100

Hemophagocytic lymphohistiocytosis (HLH), associated with acute myelocytic leukemia (AML), is a very rare disease. We here report a case of HLH occurring after induction chemotherapy for AML. AML-associated HLH can be triggered by AML itself, by chemotherapeutic agents, or by infectious complications. Our patient developed a high-grade fever of unknown cause, bilateral pulmonary infiltrates, and shock after successful treatment of AML with induction chemotherapy, and had high serum ferritin, hypertriglyceridemia, hypofibrinogenemia, hemophagocytic histiocytes in bone marrow, low natural killer cell activity, and elevated soluble interleukin-2 receptor levels. A diagnosis of HLH was made. Dexamethasone, cyclosporine, and etoposide were given and allogeneic hematopoietic stem cell transplantation was performed. Careful suspicion of HLH may be warranted if a patient experiences fever of unknown etiology, high ferritin levels, and liver dysfunction during AML treatment.

Subdural Empyema Caused by Nontyphoidal Salmonella in a Patient with a Previous Evacuation of ...

Mon, 01 Aug 2016 00:00:01 +0100

Nontyphoidal Salmonella infection often results in acute gastroenteritis, but extraintestinal infection presenting as a subdural empyema is unusual. We report a case of a 67-year-old man diagnosed with a subdural empyema caused by Salmonella group B that developed after evacuation of a subdural hematoma. To our knowledge, this is the first such case report in Korea.

Fatal Hemophagocytic Lymphohistiocytosis associated with Influenza B

Mon, 01 Aug 2016 00:00:01 +0100

Influenza infection may be complicated by various infectious or non-infectious diseases. Among them, hemophagocytic lymphohistiocytosis (HLH) is an uncommon hyperinflammatory syndrome caused by uncontrolled proliferation and activation of macrophages and lymphocytes, and it is often life threatening. A previously healthy male patient was suspected to have HLH after influenza B infection. The diagnosis was established based on clinical diagnostic criteria suggested in the HLH-2004 trial. Despite prompt antiviral therapy, the patient expired on day 19 of hospitalization. Influenza can thus be complicated by HLH. Due to the non-specific manifestations of HLH, clinical suspicion and early diagnosis are important.

Not Change, But Innovation in Training System of Internal Medicine

Sat, 01 Oct 2016 00:00:01 +0100

Health Effects of Particulate Matter

Sat, 01 Oct 2016 00:00:01 +0100

Sand dust is a source of particulate matter (PM) in Korea. Recently, an attention has been focused on the health effects of PM and fine PM. Here we examine the possible mechanisms of PM disposition and review the literature on the health effects of PM. PM can enter and accumulate in the respiratory tract via impaction, gravitational settling, diffusion, and electrostatic attractions. PM may cause oxidative stress, inflammation, direct penetration, and increased blood viscosity. This literature review revealed that PM exposure is associated with several health risks, such as mortality and respiratory and cardiovascular diseases. Furthermore, PM exposure may be linked to lung cancer. Thus, a comprehensive approach is needed to manage PM and reduce its environmental exposure and related health effects.

Guidelines for the Diagnosis and Treatment of Chronic Functional Constipation in Korea, 2015 ...

Sat, 01 Oct 2016 00:00:01 +0100

The Korean Society of Neurogastroenterology and Motility first published guidelines for chronic constipation in 2005 and was updated in 2011. Although the guidelines were updated using evidence-based process, they lacked multidisciplinary participation and did not include a diagnostic approach for chronic constipation. This study includes guidelines for diagnosis and treatment of chronic constipation to realistically fit the situation in Korea and to be applicable to clinical practice. The guideline development was based upon the adaptation method because research evidence was limited in Korea, and an organized multidisciplinary group carried out systematical literature review and series of evidence-based evaluations. Six guidelines were selected using the Appraisal of Guidelines for Research & Evaluation II process. A total 37 recommendations were adopted, including 4 concerning the definition and risk factors of chronic constipation, 8 regarding diagnoses, and 25 regarding treatments. The guidelines are intended to help primary physicians and general health professionals in clinical practice in Korea, to provide the principles of medical treatment to medical students, residents, and other healthcare professionals, and to help patients for choosing medical services based on the information. These guidelines will be updated and revised periodically to reflect new diagnostic and therapeutic methods.

Clinical Manifestations and Diagnosis of Right Ventricular Failure

Sat, 01 Oct 2016 00:00:01 +0100

Right ventricular (RV) failure is a complex clinical syndrome characterized by impaired RV filling and ejection. RV function is altered in the setting of either pressure overload or volume overload. RV failure may result from a primary reduction of myocardial contractility caused by ischemia, cardiomyopathy, or arrhythmia, but left ventricular (LV) failure remains the leading cause. As RV dysfunction progresses to RV failure, the RV chamber becomes more spherical and tricuspid regurgitation is aggravated, leading to increasing venous congestion. Ventricular interdependence may result in impaired LV filling, a decrease in LV stroke volume, and low cardiac output. The important clinical manifestations of RV failure are fluid retention, decreased systolic reserve, low cardiac output, or arrhythmias. The initial diagnosis is based on clinical history and physical examination. A chest X-ray, electrocardiogram, and biochemical tests should be routinely obtained to evaluate the underlying causes and comorbidities. Bedside echocardiography provides valuable information on cardiac structure and function. RV ejection fraction is the most commonly used index of RV function although it is a highly load-dependent index.

Clinical Implications of Functional Tricuspid Regurgitation and Optimal Surgical Timing

Sat, 01 Oct 2016 00:00:01 +0100

Optimal surgical timing is of crucial importance for the treatment of valvular heart diseases. Clinical implications of functional tricuspid regurgitation (TR) are increasingly being recognized. In contrast to the well-established treatment strategies for left-sided valve disease, optimal surgical timing of functional TR has not yet been established. Several lines of evidence have accumulated over the past 10 years, and now is the perfect time to review the data. The present article reviews the clinical implications and treatment strategies of functional TR, particularly in relation to optimal surgical timing.

Approaches to Abnormal Liver Test Results in Pregnancy

Sat, 01 Oct 2016 00:00:01 +0100

Ultrasonographic Assessment for Shoulder Pain

Sat, 01 Oct 2016 00:00:01 +0100

Impact of Age on Clinical Outcomes in Middle-aged Korean Female Patients with Acute Myocardial ...

Sat, 01 Oct 2016 00:00:01 +0100

Background/Aims: It is well known that the menopause is related to interference in lipid metabolism, obesity, and a hypercoagulable state. The aim of the present study was to examine the impact of the menopause in middle-aged Korean females with acute myocardial infarction (AMI). Methods: A total of 1,781 middle-aged females (aged < 65 years) in the Korean Acute Myocardial Infarction registry were enrolled into this study between November 2005 and December 2013. The patients were divided into two groups; the pre-menopause group (? 55 years old) and the menopause group (56-64 years old). Major adverse cardiac events (MACE) were analyzed over a one-year follow-up period. Results: The pre-menopause and menopause groups comprised 669 patients (mean age, 49.1

Bone Mineral Density Measurement Intervals for Rheumatoid Arthritis Patients Not Treated for ...

Sat, 01 Oct 2016 00:00:01 +0100

Background/Aims: Osteoporosis occurs more frequently in rheumatoid arthritis (RA) patients than in healthy individuals. This study investigated the appropriate bone mineral density (BMD) measurement interval and risk factors associated with osteoporosis for RA patients. Methods: A retrospective study was performed on 511 RA patients aged more than 40 years old who had undergone BMD testing more than once and who had normal BMD or osteopenia at the baseline BMD test and no history of any fracture of the spine or femur. The subjects were categorized into four subgroups: normal BMD (T-score > -1), mild (-1 ? T-score > -1.5), moderate (-1.5 ? T-score > -2), and advanced (-2 ? T-score > -2.5) osteopenia. The BMD testing interval was defined as the estimated time for 10% of the RA patients to make the transition to osteoporosis without osteoporotic fracture or the administration of any osteoporosis drug. Results: The observation period was 2,214 patient-years, with an average of 4.3 years. The estimated BMD testing interval was more than 10 years for normal, 4.3 years for mild, 2.5 years for moderate, and 1.5 years for advanced osteopenia in each of the RA patient groups. Conclusions: Our study indicated that in normal or osteopenic RA groups, a baseline BMD T-score is the most important factor in estimating the interval in which osteoporosis is predicted to occur. In addition, we recommend that the BMD measuring interval should be greater than 10 years in normal BMD RA patients, 4 years in mild, 2 years in moderate, and 1 year in advanced osteopenic RA patients on the basis of L-spine BMD.

Fanconi Syndrome Associated with Long-term Adefovir and Subsequent Tenofovir Therapy for ...

Sat, 01 Oct 2016 00:00:01 +0100

Adefovir dipivoxil (ADV) and tenofovir disoproxil fumarate (TDF) are nucleotide analogues used to treat chronic hepatitis B (CHB) infection. Nephrotoxicity associated with the use of these medications causes Fanconi syndrome, a rare condition involving generalized dysfunction of the proximal renal tubule causing impaired reabsorption of glucose, uric acid, and phosphate. Fanconi syndrome has been previously reported in patients with human immunodeficiency virus (HIV) or HIV-CHB coinfection treated with other antiretroviral therapies. However, it is rarely reported in patients with CHB monoinfection. We observed a case of Fanconi syndrome in a 61-year-old woman with CHB monoinfection and a history of long-term ADV therapy (42 months), followed by TDF treatment for 9 months. She presented with ankle pain and a tingling sensation in both lower extremities. Laboratory tests revealed hypokalemia, hypocalcemia, hypophosphatemia, hypouricemia, proteinuria, and glycosuria. This case illustrates the importance of recognizing Fanconi syndrome associated with nucleotide analogue treatment and the need to carefully observe symptoms and monitor renal function in these patients.

Coexistence of Myxedema Ascites and Tuberculous Peritonitis: a Case Report and Literature Review

Sat, 01 Oct 2016 00:00:01 +0100

Some patients have ascites without having liver disease, so it is important to analyze the cause of these ascites. Tuberculous peritonitis is an infectious disease characterized by lymphocyte-dominant exudative ascites. In contrast, myxedema ascites is a very rare disease characterized by a high serum/ascites albumin gradient (SAAG) with hypothyroidism. We herein report a case involving a 48-year-old woman with both diseases simultaneously. She was hospitalized because of massive ascites, generalized edema, and a puffy face. Hypothyroidism was confirmed by thyroid function tests. Her ascitic fluid had a high SAAG; no other specific findings were identified by cytology, culture, or computed tomography. Three months after initiating drug therapy for the hypothyroidism, the patients systemic edema improved but the ascites recurred. Accordingly, diagnostic laparoscopy was performed, and tuberculous peritonitis was confirmed. As seen in this case, when myxedema ascites is associated with tuberculous peritonitis, an accurate diagnosis may be challenging.

Intravenous Leiomyomatosis with Extension to the Heart Associated with Disseminated Peritoneal ...

Sat, 01 Oct 2016 00:00:01 +0100

Leiomyomatosis refers to benign smooth muscle cell tumors that often arise from unusual growth patterns and include benign metastasizing leiomyoma, disseminated peritoneal leiomyomatosis, and intravenous leiomyomatosis. Intravenous leiomyomatosis is the extension of a vascular tumor into the venous channels, whereas disseminated peritoneal leiomyomatosis is characterized by multiple leiomyomas growing along the submesothelial tissues of the abdominopelvic peritoneum. It is extremely rare for intravenous leiomyomatosis and disseminated peritoneal leiomyomatosis to occur simultaneously. A 42-year-old female presented with disseminated peritoneal leiomyomatosis and intravenous leiomyomatosis extended through the inferior vena cava into the right side of the heart. The patient underwent one-stage surgery under simultaneous sternotomy and laparotomy, and radical excision of the tumor was achieved using cardiopulmonary bypass. Here we describe a case in which complete removal of a leiomyomatosis with an unusual growth pattern was successfully performed using one-stage surgery.

17?-hydroxylase Deficiency Mimicking Hyperaldosteronism by Aldosterone-producing Adrenal Adenoma

Sat, 01 Oct 2016 00:00:01 +0100

17?-hydroxylase deficiency is a rare cause of congenital adrenal hyperplasia and is characterized by primary amenorrhea, delayed puberty and hypertension. Although 17?-hydroxylase deficiency mimics mineralocorticoid-induced hypertension, impaired sexual development can aid in the differential diagnosis of this disease. A 32-year-old woman, who had a history of testicular feminization syndrome, presented with hypertension. Her aldosterone level was elevated whereas plasma renin activity was reduced, and her computed tomography scan showed a left adrenal adenoma, which was thought to be an aldosterone producing adenoma. A left adrenalectomy was performed to treat hypertension; however, the condition did not improve. The hormonal tests revealed high levels of plasma progesterone, mineralocorticoid and adrenocorticotropic hormone, and low levels of 17a hydroxyprogesterone, cortisol and sex hormones. The patient was diagnosed with 17?-hydroxylase deficiency and commenced on prednisolone, which controlled hypertension. Here, we report a case of 17?-hydroxylase deficiency mimicking hyperaldosteronism via aldosterone-producing adrenal adenoma.

Encephalopathy Associated with Autoimmune Thyroid Disease Accompanied by Graves

Sat, 01 Oct 2016 00:00:01 +0100

A patient with encephalopathy associated with autoimmune thyroid disease (EAATD), which is one of the most important differential diagnoses of treatable dementia, presents with various neurological symptoms, such as repetitive epileptic seizures, altered mental status, and cognitive dysfunction. Steroid treatment is effective for EAATD. The incidence of EAATD increases considerably with age, particularly in female patients. Most patients with EAATD have normal thyroid function test results or mild hypothyroidism. Patients with EAATD with Graves disease are very rarely reported. Here, we report a case of a 63-year-old woman who complained of declining cognitive ability and ataxia. She was diagnosed with EAATD accompanied by Graves disease. Her neurological symptoms improved after intravenous steroid administration.

Asymptomatic Emphysematous Pyelonephritis Incidentally Detected with Computed Tomography in a ...

Sat, 01 Oct 2016 00:00:01 +0100

Emphysematous pyelonephritis (EPN) is a necrotizing infection of the kidney with gas formation that can be fatal if it is not detected and treated promptly. Typical manifestations are high fever, flank pain, and shock. It typically occurs in patients with diabetes and, although rarely reported, in hemodialysis (HD) patients with or without diabetes. Furthermore, asymptomatic EPN has not yet been reported in HD patients. Here, we report a case of asymptomatic EPN in a diabetic HD patient incidentally detected with follow-up abdominal computed tomography after resection of colon cancer.

Severe Hyponatremia with Mental Change after Ingestion of Picosulfate Sodium/Magnesium Citrate ...

Sat, 01 Oct 2016 00:00:01 +0100

Picosulfate sodium/Magnesium citrate (PS/MC) is a common bowel cleansing agent for colonoscopy. It is equally effective and better tolerated by patients with regard to taste and volume than polyethylene glycol. However, because of its osmotically active characteristics, PS/MC can cause plasma volume depletion and electrolyte disturbances, such as hyponatremia. Here, we report a case of severe hyponatremia combined with loss of consciousness in a 59-year-old woman following ingestion of PS/MC as bowel preparation for a screening colonoscopy. Upon arrival, serum sodium level was 109 mEq/L and urine osmolality and sodium levels were 393 mOms/Kg and 99 mmol/L, respectively. She was euvolemic and showed normal kidney, thyroid, and adrenal function. Based on these findings, inappropriate anti-diuretic hormone syndrome (SIADH) was diagnosed. She was treated with 3% hypertonic saline and completely recovered without any neurologic sequelae. This case shows that SIADH can be caused by PS/MC (not accompanied by dehydration), even in patients without any underlying renal, heart, or liver diseases.

HER2-Positive Gastric Hepatoid Adenocarcinoma

Sat, 01 Oct 2016 00:00:01 +0100

Gastric hepatoid adenocarcinoma is a rare adenocarcinoma that develops in the stomach. The prognosis of gastric hepatoid adenocarcinoma is poorer than that of ordinary gastric adenocarcinoma. Here, we report the first case of human epidermal growth factor receptor 2 (HER2)-positive gastric hepatoid adenocarcinoma in Korea. A 57-year-old male presented with abdominal distension and underwent endoscopic gastric biopsy and percutaneous core needle liver biopsy. The pathological findings were consistent with HER2-positive gastric hepatoid adenocarcinoma. He received six cycles of chemotherapy with cisplatin-capecitabine plus trastuzumab, which is a HER2 targeted agent. After chemotherapy, a follow-up abdominal computed tomography scan showed a partial tumor response. This case emphasizes the importance of using trastuzumab in a patient with HER2-positive gastric hepatoid adenocarcinoma.

Retroperitoneal Extramedullary Plasmacytoma

Sat, 01 Oct 2016 00:00:01 +0100

Extramedullary plasmacytoma (EMP) is a plasma cell tumor located outside of the bone marrow. It most often occurs in the upper respiratory tract (85%), as well as the head and neck, and very rarely occurs in the retroperitoneum. Here we report the case of a 57-year-old woman with retroperitoneal EMP.

Pulmonary Embolism Associated with Scrub Typhus

Sat, 01 Oct 2016 00:00:01 +0100

Acute pulmonary embolism is a cardiovascular emergency and is a major cause of morbidity and mortality. Endothelial damage secondary to invasion by Orientia tsutsugamushi can lead to focal occlusive endangiitis, causing microinfarcts in various tissues. This localized process can also cause venous thrombosis and peripheral gangrene. However, pulmonary embolism associated with scrub typhus has not been reported in Korea. Here, we report a patient diagnosed with pulmonary embolism associated with scrub typhus, the first report of its kind. The patient had an eschar with detection of anti-tsutsugamushi antibody, fever, dyspnea, and a maculopapular rash over the entire body. He was treated with doxycycline and anticoagulation therapy.

Urosepsis with Aerococcus urinae in a Patient with Complicated Urinary Tract Infection

Sat, 01 Oct 2016 00:00:01 +0100

Aerococcus urinae is a gram-positive coccus that produces alpha-hemolysis on blood agar and is negative for catalase. A. urinae can often be misidentified as a streptococcus, staphylococcus, or enterococcus by most commercial identification systems. Although A. urinae is a rarely reported human pathogen, it can be fatal in some cases. Here we report on a case of urosepsis caused by A. urinae, identified by 16S rRNA gene sequencing in a patient with ureter stones and hydronephrosis, for the first time in Korea. It is important for physicians to consider A. urinae as a potential pathogen and to prescribe the most suitable antibiotics to ensure the best outcome.

Community-acquired Methicillin-resistant Staphylococcus aureus Bacteremia Complicated by Acute ...

Sat, 01 Oct 2016 00:00:01 +0100

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) bacteremia is an uncommon infection in Korea. Typically, staphylococcal bacteremia is associated with various metastatic infections, such as multiple liver and spleen abscesses, infectious spondylitis, or infective endocarditis. Solitary cholecystitis as the only manifestation of CA-MRSA bacteremia has not been reported. Therefore, we report a case of CA-MRSA bacteremia complicated by acute cholecystitis.

Mycobacterium avium Complex Peritonitis in an Acquired Immune Deficiency Syndrome Patient

Sat, 01 Oct 2016 00:00:01 +0100

Mycobacterium avium complex (MAC) is an opportunistic bacterium that primarily infects acquired immune deficiency syndrome (AIDS) patients with low CD4⁺ T cell counts; however, peritonitis caused by MAC in AIDS patients is rare. Here, we report the first case of peritonitis caused by MAC in AIDS patients in Korea. A 41-year-old female with poor adherence to antiretroviral therapy was admitted to hospital with nonspecific symptoms; an abdominal computed tomography (CT) scan revealed substantial ascites, splenomegaly, and lymphadenopathy. Based on the CT scan and ascitic fluid cultures, MAC peritonitis was diagnosed. In addition to antiretroviral therapy, clarithromycin, rifabutin, and ethambutol were administered to treat the MAC infection, and the patients symptoms improved.

Launching the Hospitalist in Korea

Thu, 01 Dec 2016 00:00:01 +0100

Smartphone Addiction

Thu, 01 Dec 2016 00:00:01 +0100

Smartphones have significantly changed our lives and become a digital lifestyle hub. However, uncontrolled smartphone usage has created a new issue in global health, including a range of mental health concerns. Previous studies have proposed that excess use of a smartphone that interferes with daily life should be called smartphone addiction, which has similar core features to substance- related disorders (substance addiction) and known behavioral addictions. The aim of this review was to add to our understanding of smartphone addiction by presenting an overview of the research field.

New COX-2 Inhibitors

Thu, 01 Dec 2016 00:00:01 +0100

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat pain and inflammation. There are two kinds of NSAID classified according to the selectivity of COX-2 inhibition: non-selective NSAIDs and cyclooxygenase (COX)-2 inhibitors. Non-selective NSAIDs have a high incidence of gastrointestinal and bleeding-associated adverse events, while COX-2 inhibitors are safer in terms of these events. However, COX-2 inhibitors are thought to cause increased cardiovascular events. The COX-2 inhibitors rofecoxib and valdecoxib were withdrawn from the market over safety concerns. Three COX-2 inhibitors are now available in South Korea after the recent approval of etoricoxib and polmacoxib for osteoarthritis patients. After reviewing the history of and recent studies about the safety of COX-2 inhibitors, physicians should find new uses for old drugs.

Extraesophageal Manifestations of Gastroesophageal Reflux Disease

Thu, 01 Dec 2016 00:00:01 +0100

Gastroesophageal reflux disease (GERD) is prevalent in Korea. Clinical manifestations include typical symptoms which are heartburn and regurgitation and atypical symptoms that can be esophageal or extraesophageal. Various extraesophageal manifestations are associated with GERD, and the most significant of these are chronic cough, laryngitis, and asthma. The diagnosis of extraesophageal syndrome is often difficult due to the poor sensitivity and specificity of available diagnostic modalities, including endoscopy, pH monitoring, and laryngoscopy. Consequently, empirical treatment with a proton pump inhibitor (PPI) is considered to be the most cost-effective tool for the diagnosis and management of patients suspected of having extraesophageal syndrome without alarm features. Those who do not respond to PPI therapy should undergo an additional work-up that includes monitoring esophageal pH or impedance, and motility tests to evaluate the relationship between reflux and symptoms. Surgical management should cautiously be considered for very carefully selected patients.

Diagnostic Approach for Hand Arthralgia

Thu, 01 Dec 2016 00:00:01 +0100

Carpal Tunnel Syndrome

Thu, 01 Dec 2016 00:00:01 +0100

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy caused by compression of the median nerve at the wrist. Although symptoms and signs of CTS are widely known, it is often difficult to make a correct diagnosis. A clinical examination, electrophysiological studies, and ultrasonographic evaluation have similar sensitivities and specificities, and combining them improves diagnostic yield. However, evidence about the optimal treatment has not been well established. We review the clinical manifestations, diagnostic methods, and treatment options for CTS.

Interpretation of Serological Tests for Latent Syphilis

Thu, 01 Dec 2016 00:00:01 +0100

Chronic Hemorrhage from a Fistula between a Gastroduodenal Artery Aneurysm and the Duodenum

Thu, 01 Dec 2016 00:00:01 +0100

Gastroduodenal artery (GDA) aneurysm is a very rare event, but it induces life-threatening clinical manifestations upon rupture or bleeding. The causes of GDA aneurysm are atherosclerosis, infection, trauma, surgery, iatrogenic lesions, mycotic or tuberculous disease, and autoimmune disease. We report the case of a 77-year-old female who presented with melena and vomiting. Upper gastrointestinal endoscopy revealed a 4 cm pulsatile extrinsic mass with a duodenal fistula at the duodenal bulb. Abdominal computed tomography showed a large aneurysm of the GDA. We successfully conducted transcatheter embolization of the aneurysm. After the procedure, the patient did not present with melena, and her hemoglobin level was stable. Follow-up endoscopy showed that the GDA aneurysm-duodenal fistula had decreased in size and was leaking a small amount of blood. An arteriography was performed and showed no evidence of contrast filling in the aneurysmal sac.

Pulmonary Vein Thrombosis Caused by Lobar Pneumonia

Thu, 01 Dec 2016 00:00:01 +0100

Pulmonary vein thrombosis is a rare disease related to a lung malignancy or complication after lung surgery. Generally, it is caused by tumor invasion or localized stenosis of a vein anastomosis site after an operation. Here we report a case of pulmonary vein thrombosis that occurred in a patient with local thrombophlebitis due to lobar pneumonia.

Heart Retransplantation to Treat a Case of Refractory Cardiac Allograft Vasculopathy

Thu, 01 Dec 2016 00:00:01 +0100

Cardiac allograft vasculopathy is one of the most important causes of poor long-term survival after heart transplantation. The condition tends to be diffuse, usually affecting the mid-to-distal portions of the coronary artery. Reperfusion therapy is ineffective. Everolimus, an inhibitor of proliferation signaling, has been reported to prevent development of the condition; however, the efficacy thereof has not yet been fully accepted. The only definitive treatment for cardiac allograft vasculopathy is retransplantation. Herein, we describe the case of a 15-year-old boy who underwent heart retransplantation because of rapidly progressive cardiac allograft vasculopathy.

A Rapidly Expanding Ascending Aortic Aneurysm in a Patient with Relapsing Polychondritis

Thu, 01 Dec 2016 00:00:01 +0100

Here we describe a case of rapidly expanding ascending aortic aneurysm in a patient with relapsing polychondritis. To prevent aneurysm rupture, the patient underwent emergent surgical repair. Silent inflammation can progress in the aorta wall, even in asymptomatic patients with mild disease activity under immunosuppressive treatment, leading to the rapid growth of aortic aneurysms. Close monitoring with routine imaging is needed once a patient with relapsing polychondritis is diagnosed with an aortic aneurysm.

Sarcoidosis-associated Syndrome of Inappropriate Antidiuretic Hormone Secretion

Thu, 01 Dec 2016 00:00:01 +0100

Syndrome of inappropriate antidiuretic hormone secretion (SIADH), the most common cause of euvolemic hyponatremia, results from the inappropriate release of antidiuretic hormone. SIADH may be caused by a variety of malignant tumors, central nervous system (CNS) disorders, intrathoracic disorders, and pharmacological agents. We experienced a case of SIADH associated with sarcoidosis that involved the lungs and mediastinal lymph nodes. A 72-year-old male was admitted to hospital with epigastric and back pain. Laboratory tests showed hyponatremia and low serum osmolality, while the urine sodium concentration and urine osmolality were inappropriately high. A chest x-ray and computed tomography showed mediastinal lymph node enlargement, and a mediastinoscopic lymph node biopsy revealed a noncaseating granuloma. Brain magnetic resonance imaging showed no evidence of CNS sarcoidosis. Systemic corticosteroid therapy improved the observed mediastinal lymph node involvement, and tolvaptan as an SIADH treatment corrected the patients abnormal sodium level and restored the laboratory findings to normal.

Multiple Endocrine Neoplasia Type 1 Presenting with an Invasive Giant Prolactinoma

Thu, 01 Dec 2016 00:00:01 +0100

Pituitary tumors occur in 15-50% of patients with multiple endocrine neoplasia of type 1 (MEN1). To the best of our knowledge, no MEN1 case in which the initial lesion was an invasive giant prolactinoma has been reported from Korea. We describe a patient in whom a skull-base tumor involved the sellar and parasellar spaces. A 49 year-old female presented with headache and diplopia. The tumor was ultimately identified as a giant prolactinoma; the serum prolactin concentration increased from 155.6 ng/mL to 3,234.3 ng/mL after cranial irradiation. She was evaluated in terms of incidental hypercalcemia and was found to have parathyroid hyperplasia. Genetic analysis revealed a missense mutation in the MEN1 gene (c.643G>A, p.Val215Met). Two years of treatment with a dopamine agonist reduced, but did not normalize, the serum prolactin concentration. We highlight the aggressive behavior of the giant skull-base tumor, and the diagnostic delay caused by a high-dose hook effect of the MEN1-related prolactinoma.

Symptomatic Hypermagnesemia in Normal Kidney Function with a Colonic Cleansing Agent

Thu, 01 Dec 2016 00:00:01 +0100

Most reported cases of hypermagnesemia are related to laxative abuse and impaired renal function, while hypermagnesemia is uncommon without iatrogenic magnesium administration and decreased renal function. Magnesium-containing bowel-cleansing agents are widely used before colonoscopy, usually without complications. However, we experienced a case of symptomatic hypermagnesemia with normal renal function after using a bowel-cleansing agent. A 74-year-old man with normal renal function complained of lethargy and motor weakness after taking a bowel-cleansing agent containing 14 grams of magnesium before a colonoscopy for hematochezia. His magnesium level was 12 mg/dL. Fluid stasis in the gut due to colonic obstruction might have caused the hypermagnesemia. He was treated successfully with a bowel enema and intravenous calcium. We should be cautious when prescribing drugs for colonoscopy if colonic obstruction is suspected.

Complete Remission from C1q Nephropathy with Disappearance of C1q Deposition after Steroid Therapy

Thu, 01 Dec 2016 00:00:01 +0100

C1q nephropathy is a rare glomerular disease, defined by characteristic mesangial C1q immune deposition seen in immunofluorescence microscopy with no serological evidence of systemic lupus erythematosus. C1q nephropathy can be diagnosed with a subsequent biopsy, as with IgA nephropathy. There are some cases with an initial diagnosis of hematuria and proteinuria with minimal disease changes, focal segmental glomerulonephritis, and mesangial proliferative glomerulonephritis, but lacking C1q nephropathy, in which C1q deposition on immunofluorescence subsequently develops. We report a case that was diagnosed as diffuse mesangial proliferative glomerulonephritis, but a subsequent biopsy showed C1q nephropathy, with C1q deposition in both immunohistochemistry and electron microscopy (EM). We treated the C1q nephropathy with methylprednisolone and confirmed the disappearance of C1q depositions by both immunohistochemistry and EM in a follow-up biopsy.

Myelomatous Pleural Effusion with Elevated ADA Activity

Thu, 01 Dec 2016 00:00:01 +0100

Multiple myeloma is a plasma cell neoplasm mainly involving the bone marrow and skeletal system. Myelomatous pleural effusion is rare, accounting for less than 1%. In cases with high adenosine deaminase (ADA) activity, with lymphocytic exudate in the pleural fluid, tuberculous pleural effusion should be differentiated first. We report herein a rare case of a unilateral pleural effusion in a patient who was undergoing chemotherapy for multiple myeloma, with an ADA level of > 100 IU/L and lymphocytic exudate in the pleural fluid. An acid fast bacillus stain and polymerase chain reaction test for tuberculosis were negative. Consequently, the patient was diagnosed with myelomatous pleural effusion with elevated ADA activity.

The Flare Phenomenon in a Patient with Advanced Gastric Cancer with Bone Metastases

Thu, 01 Dec 2016 00:00:01 +0100

Flare phenomenon refers to increased radiotracer uptake in bones despite clinical findings showing a positive response to treatment. Flare phenomena are most often observed in patients with breast or prostate cancer. Here, we present a case of bone flare in a 54-year-old male who had advanced gastric cancer with bone metastases. After three cycles of chemotherapy, a bone scan showed increased intensity, but the patients bone pain was alleviated and abdominal computed tomography revealed a decrease in the size of the primary mass and metastatic lymph nodes. We therefore continued chemotherapy using the same regimen, and a follow- up bone scan revealed decreased intensity. A flare phenomenon after treatment is rare in cases of gastric cancer with bone metastasis. Although flare phenomena are not common, they should be considered in patients with gastric cancer when the clinical results are inconsistent with bone-scan findings.

Severe Fever with Thrombocytopenia Syndrome Accompanied by Hemophagocytic Lymphohistiocytosis

Thu, 01 Dec 2016 00:00:01 +0100

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging disease caused by the SFTS virus (family Bunyaviridae, genus Phlebovirus). A 77-year-old female farmer was bitten by a tick and developed a fever 5 days later, resulting in admittance to the emergency room. The laboratory findings showed elevated liver enzyme levels, thrombocytopenia, and leukopenia. Lymphoma was suspected based on computed tomography results. After confirming SFTS virus infection via the polymerase chain reaction, a bone marrow biopsy revealed hemophagocytic lymphohistiocytosis (HLH). HLH is rarely observed in patients with SFTS and few studies have reported the presence of SFTS in bone marrow. Here, we report a case of SFTS that was initially mistaken for a lymphoma, and was accompanied by HLH.

Development of Spinal Epidural Abscess during Treatment of Pneumococcal Meningitis

Thu, 01 Dec 2016 00:00:01 +0100

There have been a few reports of pneumococcal meningitis complicated by spinal epidural abscess. A 58-year-old female with Streptococcus pneumoniae meningitis underwent a recurrent pleocytosis without apparent clinical deterioration after appropriate antibiotic treatment. Subsequently, she developed a spinal epidural abscess. Spinal epidural abscess is a rare complication of pneumococcal meningitis, and subclinical deterioration of neutrophil-dominant pleocytosis may precede development of a spinal epidural abscess in individuals with bacterial meningitis.

Sphenoid Sinusitis with Haemophilus influenzae Septicemia

Thu, 01 Dec 2016 00:00:01 +0100

Haemophilus influenzae grows both aerobically and anaerobically and is an exclusively human pathogen. We present a case of septicemia originating from unilateral sphenoid sinusitis caused by non-typeable H. influenzae. No reports of sinusitis presenting as septicemia in a healthy young immunocompetent adult in South Korea have previously been published.

Treatment of Advanced and Metastatic Squamous Non-small Cell Lung Cancer

Fri, 01 Jan 2016 00:00:01 +0100

Lung cancer is a disease with a poor prognosis, and is the leading cause of cancer-related death in Korea as well as the USA. Unlike non-squamous non-small cell lung cancer (NSCLC), squamous NSCLC rarely harbors epidermal growth factor receptor and anaplastic lymphoma kinase mutations for which directed molecular targeted therapies are available. Traditional cytotoxic chemotherapy drugs, including cisplatin, have been approved for use in the treatment of advanced and metastatic squamous NSCLC. The second-generation regimensgemcitabine, paclitaxel, docetaxel, and vinorelbine with cisplatinare standard first-line treatments for advanced and metastatic squamous NSCLC. Docetaxel was approved for second-line treatment in 1999. Addition of the anti-angiogenic agent, ramucirumab, to docetaxel showed improved survival in squamous cell NSCLC patients in the second-line setting compared with single-agent docetaxel. The immune checkpoint inhibitor-programmed cell death-1 inhibitor, nivolumab, is currently approved for squamous cell NSCLC. Pembrolizumab also received FDA approval for treatment of NSCLC cases in which tumor tissue is positive for programmed cell death-ligand 1 expression.

Chemotherapy and Targeted Therapy beyond Adenocarcinoma of the Lung: Neuroendocrine Carcinoma

Fri, 01 Jan 2016 00:00:01 +0100

Neuroendocrine carcinoma (NEC) has been reported to comprise 25% of lung cancer cases. NEC is classified as typical carcinoid, atypical carcinoid, large-cell neuroendocrine carcinoma, and small-cell lung cancer. Carcinoid tumors are less aggressive and surgery is the mainstay of treatment; however, patients with metastatic or inoperable disease need systemic therapy to control carcinoid symptoms and improve survival. Somatostain analogues, targeted agents including everolimus, sunitinib, bevacizumab, and conventional chemotherapy have emerged as treatment options for such patients. Large-cell neuroendocrine carcinoma exhibits more aggressive behavior and has a poorer prognosis than carcinoid tumors. No standard adjuvant and palliative chemotherapeutic agents have yet been established. This review sets out the treatment options for neuroendocrine tumors.

Adequate Management of Gallbladder Wall Thickening

Fri, 01 Jan 2016 00:00:01 +0100

Thickening of the gallbladder wall is a relatively frequent finding on diagnostic imaging. Such thickening is also a common but nonspecific finding in many patients with intrinsic gallbladder disease and extracholecystic conditions. Wall thickening may be diagnostically problematic, occurring (as it does) in both symptomatic and asymptomatic patients and in those with and without indications for cholecystectomy. An important first step is to distinguish between the diffuse and focal forms of thickening. Subsequently, identification of ancillary imaging findings and the directed use of additional imaging modalities allow accurate diagnosis. This is of clinical importance. Misinterpretation of the cause of thickening can trigger unnecessary cholecystectomies in patients without intrinsic gallbladder disease. Also, misdiagnosis of patients who do in fact require cholecystectomy may delay treatment, thus increasing morbidity. Although a definitive imaging diagnosis may not be possible, the cause of gallbladder wall thickening can be determined in most instances by correlating the clinical presentation with associated imaging findings.

Heart Failure with Preserved Ejection Fraction: Current Diagnostic and Therapeutic Approach

Fri, 01 Jan 2016 00:00:01 +0100

Comparison of the Signal-averaged ECG after Primary Percutaneous Coronary Intervention ...

Fri, 01 Jan 2016 00:00:01 +0100

Background/Aims: Percutaneous coronary intervention (PCI) is the standard method of treating ST-segment elevation myocardial infarction (STEMI). There is continuing uncertainty as to whether reducing the thrombus burden through catheter aspiration improves the arrhythmogenic structure of the myocardium in STEMI. We compared the changes in electrical instability after thrombus aspiration-assisted primary PCI using conventional primary PCI. Methods: The study population included 170 consecutive patients with STEMI who underwent primary PCI. The patients were divided into 80 patients who underwent primary PCI only and 90 patients who underwent thrombus aspiration before PCI. The signal-averaged ECG (SAECG) was obtained 5

An Aggressive Natural Killer Cell Lymphoma Presenting as Acute Liver Failure with Ascites

Fri, 01 Jan 2016 00:00:01 +0100

Acute liver failure (ALF) is a medical emergency triggering an urgent need for liver transplantation. The most common causes of ALF are drug- and virus-associated hepatitis, but hematological malignancies such as an aggressive natural killer cell lymphoma (ANKL) can uncommonly cause ALF. A 50 year-old male presented with ascites, jaundice, and encephalopathy. The ascitic fluid had a serum-ascites albumin gradient of 0.3 g/L, and contained atypical lymphocytes, which were positive for CD3. Computed tomography revealed mild hepatomegaly and multiple nodules in both lobes of the liver. A liver biopsy showed that the liver parenchyma had been infiltrated by malignant lymphoid cells, and exhibited marked sinusoidal dilatation. Immunohistochemically, the lymphoid cells were positive for CD3, CD56, and Epstein-Barr virus-encoded small RNA. The patient was diagnosed with ANKL causing ALF, and died on hospital day 12. This case shows that infiltration of the liver with ANKL can (rarely) cause ALF.

Infective Endocarditis in a Patient after Percutaneous Mitral Balloon Valvuloplasty

Fri, 01 Jan 2016 00:00:01 +0100

Percutaneous mitral balloon valvuloplasty (PMBV) is the treatment of choice for mitral stenosis. Only a few reported cases have been reported in PMBV patients worldwide. In this study, a case of a 34 year-old female with infective endocarditis a year after PMBV is presented. The patient presented with fever, and peripheral vascular symptoms. Transthoracic echocardiography showed vegetation on the anterior mitral leaflets and Staphylococcus Viridans was isolated from blood cultures. The patient was successfully treated with Amoxicillin + Clavulate and Gentamicin. Further studies on the correlation between PMBV and infective endocarditis are needed.

Enterocolic Fistula caused by Acute Colitis in a Hemodialysis Patient

Fri, 01 Jan 2016 00:00:01 +0100

Enterocolic fistulas are commonly associated with previous surgery, Crohns disease, diverticulitis, radiation therapy, and malignancy. Here, we report a rare case of enterocolic fistula caused by acute colitis in a hemodialysis patient. A 62-year-old man on maintenance hemodialysis underwent a radical nephrectomy via a paramedian incision due to spontaneous right kidney rupture and was treated with prophylactic antibiotics. On the 16th day of antibiotic therapy, he complained of abdominal pain and diarrhea. Abdominal computed tomography (CT) and ascitic fluid culture revealed acute bacterial peritonitis and sigmoidoscopy showed acute colitis. After treating these diseases with adequate antibiotics, the abdominal pain and ascites were relieved, but the diarrhea persisted. Abdominal CT obtained 7 days later showed an enterocolic fistula. To our knowledge, this is the first case of enterocolic fistula due to acute colitis in Korea.

Rapid Progression of Diabetic Glomerulosclerosis with Crescents to End-stage Renal Disease in ...

Fri, 01 Jan 2016 00:00:01 +0100

Diabetic nephropathy is a chronic microvascular complication of type 2 diabetes and the leading cause of end-stage renal disease. We report the case of a 34-year-old male, newly diagnosed with type 2 diabetes mellitus, who had advanced-stage nephropathy with glomerular crescents. A moderately-to-severely decreased glomerular filtration rate with nephrotic syndrome was seen at the time of diagnosis of diabetes. Proliferative diabetic retinopathy was detected, but there was no positive finding in serology tests for glomerulonephritis. Non-necrotizing cellular crescents and nodular glomerulosclerosis were observed in a kidney biopsy, and renal function declined rapidly to the end stage. We review data on diabetic glomerulosclerosis with cellular crescents and the rapid progression of nephropathy.

Lupus-like Glomerulonephritis Associated with Extranodal Marginal Zone B-cell Lymphoma of MALT

Fri, 01 Jan 2016 00:00:01 +0100

Lupus-like glomerulonephritis is an immune complex disease with features of lupus nephritis in the absence of systemic lupus erythematosus (SLE). We report a 49-year-old man diagnosed with lupus-like glomerulonephritis associated with extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT). He was admitted to the hospital for edema. At admission, the serum creatinine was 2.2 mg/dL and the urine protein level was 3.9 mg/day. A renal biopsy showed features of lupus nephritis with no clinical or serological evidence of SLE. Extranodal marginal zone B-cell lymphoma of MALT was discovered concurrently. After successful chemotherapy, the lupus-like glomerulonephritis and lymphoma entered complete remission.

Progression of Extramedullary Plasmacytoma in a Multiple Myeloma Patient with No Increment in ...

Fri, 01 Jan 2016 00:00:01 +0100

A 76 year-old female who was diagnosed with multiple myeloma (IgG, lambda) had received bortezomib, melphalan and prednisolone as first-line treatment. After completing six cycles of chemotherapy, her serum monoclonal protein level decreased from 7.28 g/dL to 0.65 g/dL, indicating a partial response. However, at the next scheduled visit she complained of slowly progressing dyspnea. On chest X-ray, newly developed pleural effusion was found, and rapidly progressing extramedullary plasmacytoma was detected in the anterior mediastinum on chest computerized tomography. However, there was no change in her serum monoclonal protein level. In Korea, extramedullary involvement is encountered in 5% of patients with multiple myeloma. However, evaluation of treatment response using solely the serum monoclonal protein level may not accurately reflect disease status in these patients.

Incidentally Found Chronic Neutrophilic Leukemia in a Patient with Rectal Cancer

Fri, 01 Jan 2016 00:00:01 +0100

Chronic neutrophilic leukemia (CNL) is a rare myeloproliferative neoplasm characterized by sustained neutrophilia, splenomegaly, and hypercellular bone marrow without Philadelphia chromosome. Diagnosis of CNL requires exclusion of identifiable causes of reactive neutrophilia, such as infection and tumors. Our patient presented with general weakness and weight loss. Computed tomography (CT) showed a mass in the distal rectum, which was confirmed to be an adenocarcinoma by colonoscopic biopsy. Positron emission tomography-CT showed multiple liver, bone, and lymph node metastases. Liver and lymph node biopsies revealed neutrophilic infiltration with no evidence of adenocarcinoma. The pathological findings of the bone marrow were compatible with CNL. Cytogenetic analysis revealed a normal karyotype, and molecular analysis was negative for BCR/ABL. Here, we present a 73 year-old man diagnosed with concurrent CNL and rectal cancer.

Myelodysplastic Syndrome and Minimal Change Nephrotic Syndrome treated with Steroid Challenge

Fri, 01 Jan 2016 00:00:01 +0100

Glomerulonephritis associated with malignancy is deemed to be paraneoplastic glomerulonephritis. Myelodysplastic syndrome (MDS) is a group of heterogeneous clonal hematopoietic stem cell disorders characterized by impaired hematopoietic cell differentiation and cytopenia. The pathophysiology of MDS is thought to be immune-mediated in part. A few reports have documented various forms of glomerulonephritis in patients with MDS and suggested that immune dysregulation is important in the development of paraneoplastic glomerulonephritis. Here, we report a patient with MDS and refractory anemia with excess blast-2 accompanied by minimal change nephrotic syndrome. The patient was treated with prednisolone, and the nephrotic-range proteinuria and pancytopenia improved markedly.

Metastatic Thyroid Gland Tumor Presenting as an Initial Manifestation of Recurrent Uterine ...

Fri, 01 Jan 2016 00:00:01 +0100

Most patients with recurrent uterine cervical cancer have intra-pelvis metastasis with adjacent lymph node involvement, while a lone, distant metastasis is extremely rare. We report a 79-year-old woman with recurrent uterine cervical cancer that presented as thyroid mass with no intra-pelvic recurrence. Four years earlier, the patient had been diagnosed with uterine cervical cancer. She had undergone a course of concurrent chemoradiotherapy to the pelvis and had no subsequent evidence of recurrence. Several weeks before presenting, she had noticed a foreign body sensation in her throat and a palpable mass in the left side of her neck. Clinically, this was metastatic squamous cell carcinoma from the uterine cervix. Patients who present with swelling or palpable nodules in the neck with a previously diagnosed malignancy must be evaluated for metastatic disease, although metastasis from uterine cervical carcinoma to the thyroid gland is rare.

Coexistence of an EGFR Mutation and an ALK Rearrangement in a Patient with Lung Adenocarcinoma: ...

Fri, 01 Jan 2016 00:00:01 +0100

A 58 year-old woman was diagnosed with lung adenocarcinoma (cT3N1M0). We detected a point mutation in epidermal growth factor receptor (EGFR) exon 21 (L858R) and an echinoderm microtubule-associated protein-like 4- anaplastic lymphoma kinase (ALK) rearrangement. The patient was treated with preoperative neoadjuvant chemotherapy and underwent a left lower lobectomy with mediastinal lymph node dissection. However, we could not detect any mutation in EGFR or the ALK rearrangement from the tumor tissue removed. Then, 70 days after completion of adjuvant chemotherapy, she visited our outpatient clinic with diminished visual accuracy and tinnitus. A single brain metastatic lesion was seen on brain magnetic resonance imaging. She underwent surgical removal of the brain mass, which showed a mutation of EGFR, exon 21, but no ALK rearrangement. We report this unusual case of lung adenocarcinoma with a coexisting EGFR mutation and ALK rearrangement, and identify gene alterations before chemotherapy, after chemotherapy, and at recurrence.

Xanthogranulomatous Pyelonephritis Associated with Actinomycosis Misdiagnosed as a Metastatic ...

Fri, 01 Jan 2016 00:00:01 +0100

Xanthogranulomatous pyelonephritis (XP) is an uncommon, chronic, destructive, granulomatous disease of the renal parenchyma. The condition is generally associated with long-term urinary tract obstruction and infection, although the precise etiology of disease remains unknown. The condition often mimics neoplastic and inflammatory diseases, and XP associated with actinomycosis is extremely uncommon. A 60 year-old male was admitted complaining of abdominal pain and weight loss. His radiological findings were suggestive of metastatic kidney cancer, and we performed radical laparoscopic nephrectomy and mesenterectomy for diagnostic purposes. Pathologically, actinomycosis combined with XP was evident. We report here a rare case of XP associated with actinomycosis.

Compartment Syndrome followed by Inflammatory Myositis in a Patient with Urethral Cancer

Fri, 01 Jan 2016 00:00:01 +0100

Inflammatory myositis is a heterogeneous group of rare diseases characterized by inflammation of the skeletal muscle. The association between cancer and inflammatory myositis is well established, with most cancer-associated myopathies diagnosed within 2 years of initial diagnosis. However, despite this strong association, inflammatory myositis as a paraneoplastic syndrome of urethral cancer has not been reported in Korea. Furthermore, compartment syndrome in the context of inflammatory myositis is extremely rare. A 69 year-old woman presented with paresthesia and painful swelling of the right lower extremity 2 months after diagnosis with urethral cancer, which was treated by chemoradiotherapy. Painful numbness was particularly severe when extending the knee, leading to a preliminary diagnosis of myositis with compartment syndrome, which was confirmed by magnetic resonance imaging. After fascia resection, the patient was treated with high dose steroid and immunoglobulin therapy. Here, we report a case of compartment syndrome followed by inflammatory myositis in a patient with urethral cancer.

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Fri, 01 Jan 2016 00:00:01 +0100

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Diet and Nutritional Management in Functional Gastrointestinal Disorder: Gastroesophageal ...

Mon, 01 Feb 2016 00:00:01 +0100

Gastroesophageal reflux disease (GERD) is a common condition with a wide range of clinical manifestations. The clinical epidemiology of GERD is related to diet. It has been speculated that certain dietary factors may play a role in the pathogenesis or course of GERD. Physiological studies have shown a decrease in lower esophageal pressure and an increase in esophageal acid exposure in response to consuming a variety of foods. Subjects with GERD are sensitive to acidic juices, such as orange and tomato juices. Some patients are less tolerant to caffeine including coffee. Fatty foods and chocolate may weaken the lower esophageal sphincter, whereas protein may increase lower sphincter tone. Large meals distend the stomach, increase intragastric pressure, and facilitate gastroesophageal reflux. Alcohol consumption is another important risk factor for GERD. However, a wide-ranging review of the available data revealed conflicting findings regarding the impact of dietary factors on GERD.

Diet and Nutritional Management in Functional Gastrointestinal Disorder: Functional Dyspepsia

Mon, 01 Feb 2016 00:00:01 +0100

Diet play an important role in triggering symptoms in patients with functional dyspepsia. The pathophysiology of functional dyspepsia is characterized by impaired gastric accommodation and visceral hypersensitivity, and patterns of nutrient intake may affect the threshold to dyspeptic symptoms by modulating gastric motor and sensory functions. In addition, cognitive factors are likely to modulate symptom perception in patients with functional dyspepsia. Duodenal hypersensitivity to fat is regarded as an important mechanism of meal-related dyspeptic symptoms, and is associated with increased visceral hypersensitivity and decreased gastric emptying. Among a wide range of foods, fried and fatty foods are most commonly implicated in the induction of dyspeptic symptoms; however, beans, onions, wheat-containing foods, chocolates, coffee, carbonated beverages, and milk and dairy products are also frequently associated with dyspeptic symptoms. In contrast, according to the recent Asian consensus report, rice, tea, and ginger can ameliorate dyspepsia. However, evidence is lacking, as the majority of studies have been retrospective; moreover, the results are inconsistent. Further prospective studies, especially in the Korean population, are necessary to formulate reliable dietary guidelines for patients with dyspepsia.

Diet and Nutritional Management in Functional Gastrointestinal Disorder: Irritable Bowel Syndrome

Mon, 01 Feb 2016 00:00:01 +0100

Irritable bowel syndrome (IBS) is a multifactorial disorder with the pathogenesis of abnormal gastrointestinal motility, low-grade inflammation, visceral hypersensitivity, communication in the gut-brain axis, and so on. Traditionally, IBS has been treated with dietary and lifestyle modification, fiber supplementation, pharmacological and psychological therapy. Carbohydrates have a range of foods regularly consumed including grains such as rye and wheat, vegetables, fruits, and legumes. Short-chain carbohydrates poorly absorbed exert osmotic effects in the intestinal lumen increasing its water volume, and are rapidly fermented by bacteria with consequent gas production. These effects may be the basis of the beginning of gastrointestinal symptoms. This made the use of lactose-free diets in those with lactose intolerance and of fructose-reduced diets for fructose malabsorption. All dietary poorly absorbed short-chain carbohydrates have similar and additive effects in the intestine, so a concept has been developed to regard them collectively as fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and to evaluate a dietary approach that restricts them all. Based on observational and comparative studies and on randomized-controlled trials, FODMAPs trigger gastrointestinal symptoms in patients with IBS. Food choice via the low FODMAP and potentially other dietary strategies is now a realistic and efficacious therapeutic approach for symptoms of IBS. In Korea, the strategy of Korean diet for Korean patients with IBS needs apposite to the Korean cases.

Diet and Nutritional Management in Functional Gastrointestinal Disorder: Constipation

Mon, 01 Feb 2016 00:00:01 +0100

Constipation is a common functional gastrointestinal symptom, the medical treatment of which is established. However, knowledge of diet and nutritional management for constipation is lacking. Based on current studies, fiber is effective in managing chronic constipation, but care should be taken in constipated patients with gaseous bloating. Increased fluid intake is controversial but may be beneficial, especially in conjunction with a stool-bulking agent. Other diet treatments lack high-quality evidence. A well-designed study to validate the effectiveness of diet, especially Korean diet, in the treatment of chronic constipation is needed.

Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Cardiac Death

Mon, 01 Feb 2016 00:00:01 +0100

Implantable cardioverter-defibrillators (ICDs) are an effective treatment strategy for patients with aborted sudden cardiac death (SCD) and ventricular tachyarrhythmias. rimary prevention of SCD is a strategy involving the use of ICDs in patients who are at high risk for, but have not had, any previous events of ventricular arrhythmias or cardiac arrest. Several randomized clinical trials have demonstrated the efficacy of ICDs in the primary prevention of SCD. Therefore, ICD implantation is recommended as a standard of care by the guidelines in patients who have ischemic or nonischemic cardiomyopathy and a low left ventricular ejection fraction. However, the rates of ICD implantation as a primary prevention in Korea is quite low compared to western countries. In this review, we will summarize the results and efficacy of ICDs in the clinical trials about primary prevention of SCD, the current treatment guidelines, and the reimbursement policy of Korean health insurance. We hope that this review will help broaden the recognition of importance of ICD implantation for the primary prevention of SCD.

New Drugs for Obesity Treatment

Mon, 01 Feb 2016 00:00:01 +0100

There have recently been many advances in obesity treatment, including lifestyle modifications and pharmacological and surgical treatments. Specifically, pharmacological strategies have improved significantly. However, the history of the development of medications aimed at weight loss is complicated. The Federal Drug Administration (FDA) withdrew anti-obesity drugs such as fenfluramine, dexfenfluramine, and phenylpropylamine due to their unwanted side effects. Moreover, sibutramine was voluntarily withdrawn from the market and a new drug, rimonabant, has been suspended in the middle of a clinical trial due to unacceptable side effects. The FDA has approved four new anti-obesity drugs in recent years. Lorcaserin is a selective 5-hydroxytryptamine receptor 2c (5-HT2c) agonist. The pharmacological mechanism of action of this drug is similar to fenfluramine and dexfenfluramine, but lorcaserin is specific for 5-HT2c, which are located almost exclusively in the central nervous system and are not found in heart valves. Three phase 3 clinical trials for lorcaserin have been published recently; weight reduction was successful and no side effects involving the heart were found. Furthermore, the FDA has also approved phentermine/topiramate controlled-release (PHEN/TPM CR), which is composed of a combination of immediate-release phentermine and controlled-release topiramate. Weight reduction achieved with PHEN/TPM CR was demonstrated to be better than all other anti-obesity drugs. Lastly, the combination therapy bupropion/naltrexone activates proopiomelanocortin neurons and inhibits opioid-mediated negative feedback by synergism. Similar to liraglutide, a long-acting analogue of the hormone glucagon-like peptide-1, this treatment showed significant weight loss and metabolic improvements. However, in addition to its efficacy, clinicians should consider its side effects before use.

Acute Phlegmonous Gastritis Developing after Endoscopic Submucosal Dissection That Was ...

Mon, 01 Feb 2016 00:00:01 +0100

Endoscopic submucosal dissection (ESD) is widely used to treat a variety of gastric lesions including early gastric cancer and gastric adenoma. Bleeding and perforation are the most common complications of ESD. However, a rare and fatal bacterial stomach infection, termed acute phlegmonous gastritis, can also develop after ESD. We treated a patient with a high fever who complained of severe abdominal pain after ESD. Abdominal computed tomography (CT) revealed a diffuse, submucosal, minimally attenuated lesion and mucosal irregularity. The clincial presentation and the CT findings were compatible with acute phlegmonous gastritis and the patient was successfully treated with antibiotics alone. The case is worth reporting because acute phlegmonous gastritis is a very rare complication of ESD.

Paroxysmal Nocturnal Hemoglobinuria Presenting as Recurrent Jejunitis

Mon, 01 Feb 2016 00:00:01 +0100

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired hematopoietic stem cell disorder characterized by chronic complement-mediated intravascular hemolysis, nocturnal hemoglobinuria, predisposition to thrombosis and secondary bone marrow failure. Small bowel ischemia is a complication of PNH but has not been reported to date in a Korean adult. We report here a case of PNH presenting as recurrent jejunitis. Despite the uncommon etiology, PNH should be considered in the differential diagnosis of patients with unexplained recurrent jejunitis.

Simple Management of Radial Artery Perforation during Transradial Percutaneous Coronary Intervention

Mon, 01 Feb 2016 00:00:01 +0100

Radial artery perforation is one of the major complications of transradial percutaneous coronary intervention (PCI). Previous reports have suggested that sealing the perforation with a smaller guiding catheter may be possible. In one such study, the perforated segment was sealed with a 0.014- or 0.021-inch guidewire, and PCI was successfully completed. In this study, we describe a radial artery perforation that occurred after diagnostic coronary angiography and during insertion of a 6 French (FR) guiding catheter. PCI and the perforation were successfully managed through the use of a 5 Fr guiding catheter and a 0.035-inch guidewire.

Aorta-right Atrial Tunnel Accompanying Infective Endocarditis

Mon, 01 Feb 2016 00:00:01 +0100

Aorta-right atrial tunnel is a vascular anomaly that originates from the aortic sinus and terminates in either the superior vena cava or the right atrium. The patency of the tunnel can result in volume overload in both ventricles, bacterial endocarditis, aneurysm formation, and spontaneous rupture. Transesophageal echocardiography was performed in a 42-year-old male patient diagnosed with infectious endocarditis, and vegetation of the mitral and aortic valves, right atrial enlargement, and an extracardiac blood vessel connecting the aorta to the right atrium were discovered. Therefore, we were able to diagnose an aorta-right atrial tunnel leading to infectious endocarditis and proceeded with surgical treatment. Together with a review of the literature, we present a case report of a patient with aorta-right atrial tunnel accompanied by infectious endocarditis.

Pulmonary Placental Transmogrification Presenting as a Small Lung Nodule

Mon, 01 Feb 2016 00:00:01 +0100

Pulmonary placental transmogrification (PT) is a rare lung disease that takes on the histologic appearance of placental chorionic villi. We herein report a case of PT in a 66-year-old woman who presented with a single nodule on chest radiography performed during a routine health examination. She had no complaints of any symptoms. Chest radiography showed a focal ill-defined nodular opacity in the right lower lobe; chest computed tomography revealed a 17-mm lobulated, focal irregular mass with fissural retraction in the right lower lobe, suggestive of lung cancer. Pathology of a percutaneous needle aspiration biopsy revealed papillary structures resembling placental villi. These were lined by cytotrophoblast-like cells and syncytiotrophoblasts. This characteristic pathologic finding led to a diagnosis of PT. PT of the lung is found mainly in bullous or cystic lesions. However, this patient presented with a single nodule on chest radiography.

Staphylococcus-associated Glomerulonephritis

Mon, 01 Feb 2016 00:00:01 +0100

A 64-year-old woman was admitted with vertebral osteomyelitis and polyarthritis (both knees and the right shoulder). She had had no health problems before these conditions developed. Joint culture grew methicillin-resistant Staphylococcus aureus. During hospitalization, hematuria, proteinuria, azotemia, and decreased C3 were reported. The renal biopsy showed mesangial proliferative glomerulonephritis with C3 and IgA co-dominant deposits on immunofluorescence staining. Following incision and drainage of the right shoulder and right knee, and intravenous vancomycin for 15 weeks, the C-reactive protein, proteinuria, hematuria, and C3 level all normalized. Here, we report a case of Staphylococcus-associated glomerulonephritis with a brief review of the literature.

Three Types of Cancer in a Patient with Neurofibromatosis Type I: Gastrointestinal Stromal ...

Mon, 01 Feb 2016 00:00:01 +0100

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder with a prevalence of approximately 1 in 3,500 live births. NF-1 predisposes to various benign and malignant neoplasms. Neurological malignancies are most frequent, but the risks of non-nervous system tumors, such as of the esophagus, stomach, colon, liver, biliary tract, pancreas, lung, melanoma, thyroid gland, female breast and ovaries, are also increased. Malignant tumors are the most common cause of death in patients with NF-1. Cases with double primary tumors have been reported, but cases involving three or more primary cancers are rarely reported. Therefore, we present the case of a NF-1 patient diagnosed with gastrointestinal stromal tumor, breast cancer and ampulla of Vater cancer.

Chronic Myeloid Leukemia Relapsing as Isolated Extramedullary Disease Presenting as a Cardiac Mass

Mon, 01 Feb 2016 00:00:01 +0100

Allogeneic hematopoietic stem cell transplantation is the only option for chemotherapy-refractory chronic myeloid leukemia (CML). Extramedullary relapse after transplantation is rare and usually accompanies marrow relapse. Generally, the prognosis of extramedullary relapse is poor. Here, we report a man with extramedullary relapsed CML after stem cell transplantation that presented as an isolated cardiac mass, which has shown an indolent course for more than 2 years, without evolving to medullary relapse during that period. This case implies that the CML clone might contribute to the development of quiescent extramedullary relapse with a benign course.

Rare Presentation of Richter

Mon, 01 Feb 2016 00:00:01 +0100

Richters syndrome refers to the development of aggressive lymphoma in a patient with chronic lymphocytic leukemia (CLL). It occurs in about 2% to 10% of patients with CLL. The most frequent manifestation of Richters syndrome is diffuse large B cell lymphoma (DLBCL). Extranodal involvement is rare but can occur. The prognosis of Richters syndrome is very poor. We herein report a case of a rare presentation of Richters syndrome. A 42-year-old man diagnosed with CLL 2 years previously developed nodules on the bilateral thighs and buttocks. A positron emission tomography (PET)-CT scan revealed high fluorodeoxyglucose uptake in multiple lymph nodes, skeletal muscles, and the myocardium. An ultrasonography-guided biopsy confirmed Richters syndrome from CLL to DLBCL. The patient was treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy. After six cycles of chemotherapy, we performed a PET-CT scan that revealed a complete response. However, 3 months later, the syndrome recurred. The patient was undergoing salvage chemotherapy at the time of this writing.

Ramsay Hunt Syndrome in a Patient Infected with Human Immunodeficiency Virus

Mon, 01 Feb 2016 00:00:01 +0100

Ramsay Hunt syndrome is caused by reactivation of the varicella zoster virus in the geniculate ganglion of the sensory branch in the face and ears. It is characterized by peripheral facial palsy, ear pain, and vesicles in the auditory canal and auricle. We report on a first case of Ramsay Hunt syndrome in a patient with human immunodeficiency virus in Korea. The patient, a 40-year-old male, first presented with otalgia and ear fullness. On admission, he had right facial palsy of the peripheral type, otorrhea, headache, limited tongue movement, and right auricle vesicular eruptions. He had positive human immunodeficiency virus antibody and Western blot tests. His CD4 T cell count was 281/?L. The patient was treated with valacyclovir and steroid with highly active antiretroviral therapy. His symptoms and facial palsy improved with treatment.

Gas Gangrene Caused by Streptococcus anginosus

Mon, 01 Feb 2016 00:00:01 +0100

Gas gangrene, a subset of necrotizing myositis, is a bacterial infection that produces gas in tissues in gangrene. It is usually caused by Clostridium species, most commonly Clostridium perfringens. Streptococcus anginosus is a rare cause of gas gangrene, with very few cases reported. We report a rare case of traumatic gas gangrene caused by S. anginosus in a 57-year-old female with diabetes after being stabbed with scissors.

Systemic Lupus Erythematosus Presenting with Idiopathic Retroperitoneal Fibrosis

Mon, 01 Feb 2016 00:00:01 +0100

Retroperitoneal fibrosis (RPF) is a rare inflammatory fibrotic condition affecting the peri-aortic retroperitoneum in which fibrosis of the surrounding tissue can encase the ureters, resulting in obstructive uropathy. RPF is generally idiopathic in nature, but may also arise in response to other conditions, such as malignancies, infections, surgery, radiotherapy, or drugs. Idiopathic RPF is commonly seen in association with various autoimmune diseases, such as autoimmune thyroiditis, autoimmune pancreatitis, rheumatoid arthritis, and systemic lupus erythematosus (SLE). Here, we describe the first case of RPF in Korea. A 44-year-old man with SLE presenting with pain in both flanks due to RPF is discussed, along with a review of the relevant literature.

Possible Antiphospholipid Syndrome Presenting as Peripartum Cardiomyopathy and Diffuse Alveolar ...

Mon, 01 Feb 2016 00:00:01 +0100

Antiphospholipid syndrome (APS) is an autoimmune disease characterized by the presence of circulating antiphospholipid antibodies in combination with at least one other clinical manifestation, such as vascular thrombosis or recurrent pregnancy loss. APS is further characterized by the presence of vasculitis affecting multiple organ systems, resulting in a wide variety of clinical outcomes. Common cardiac manifestations of APS include valve abnormalities, occlusive arterial disease, intra-cardiac emboli, ventricular dysfunction, and pulmonary hypertension, along with rare instances of dilated cardiomyopathy. Simultaneously diffuse alveolar hemorrhage and peripartum cardiomyopathy have also been reported, though these manifestations remain extremely rare. Here, we report a case of a 34-year-old woman with possible APS who presented with peripartum cardiomyopathy and diffuse alveolar hemorrhage.

Antithrombotic Therapy for Patients with Nonvalvular Atrial Fibrillation

Tue, 01 Mar 2016 00:00:01 +0100

In patients with nonvalvular atrial fibrillation (AF), the risk of stroke is five times that of patients with a normal sinus rhythm. Antithrombotic therapy has a pivotal role for the prevention of stroke. With the advent of new oral anticoagulants (NOAC), the strategy of antithrombotic therapy has undergone significant changes due to its better efficacy, safety, and convenience when compared with warfarin or an antiplatelet regimen. Furthermore, new aspects of antithrombotic therapy in the prevention of stroke have revealed that the efficacy of antiplatelet regimens is weak while the risk of major bleeding is not significantly different to that of oral anticoagulant therapy, especially in the elderly. To reflect these pivotal changes, the previous guidelines for use of NOACs have been updated in recent years by various societies and associations. The Korean Heart Rhythm Society (KHRS) summarized the current evidence and updated its recommendations for stroke prevention in patients with nonvalvular AF. First of all, antithrombotic therapy must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient, especially with regard to balancing the benefit of stroke prevention with the risk of bleeding. They recommend using the CHA₂DS₂-VASc score rather than the CHADS₂ score to assess the risk of stroke, and suggest the HAS-BLED score be used to validate bleeding risk. In patients with truly low risks (lone AF, CHA₂DS₂-VASc score of 0), no antithrombotic therapy is recommended, whereas oral anticoagulant (OAC) therapy, including warfarin (INR 2-3) or NOACs, is recommended in patients with a CHA₂DS₂-VASc score ? 2 unless contraindicated. In patients with a CHA₂DS₂-VASc score of 1, OAC therapy should be preferentially considered. When also factoring in the bleeding risk and patient preferences, antiplatelet therapy or no therapy could be the best treatment option.

The Role of Antiarrhythmics in Atrial Fibrillation

Tue, 01 Mar 2016 00:00:01 +0100

Atrial fibrillation (Afib) is the most common arrhythmia with clinical significance, and its incidence increases with advanced age. Afib is associated with a 3- to 5-fold increased risk of stroke, a 3-fold increase in the risk of heart failure, and higher mortality than without Afib. The treatment of Afib is multifold but revolves around one essential issue: whether to attempt to restore sinus rhythm or to simply control the ventricular rate. This decision depends on symptom severity, the age of the patient, underlying heart disease, and other comorbidities that may limit therapeutic options. The management of Afib with antiarrhythmic medications was reviewed.

Radiofreqeuncy Catheter Ablation for Tachyarrhythmia

Tue, 01 Mar 2016 00:00:01 +0100

Radiofrequency (RF) refers to the portion of the electromagnetic spectrum in which electromagnetic waves can be generated by feeding an alternating current to an antenna. RF energy is electrically conducted, not radiated, during catheter ablation, and RF rarely induces rapid polymorphic arrhythmias. When using RF to measure lesion size in a steady state, the lesion size is proportional to the temperature measured at the tissue-electrode interface and the RF power amplitude. Focal ablation using RF is the treatment of choice for all supraventricular tachyarrhythmias, including AV nodal reentry, tachycardias with concealed accessory pathways, incessant automatic atrial tachycardia, isthmus dependent atrial flutter, and other macroreentrant atrial tachycardias. The isolation of pulmonary veins by RF energy has been successful for paroxysmal atrial fibrillation.

Implantable Cardioverter-Defibrillator and Cardiac Resynchronization Therapy

Tue, 01 Mar 2016 00:00:01 +0100

The use of an implantable cardioverter-defibrillator (ICD) is an effective treatment strategy for patients with aborted sudden cardiac death (SCD) and ventricular tachyarrhythmias. Primary prevention of SCD is a strategy involving the use of ICDs in patients who are at high risk for but who have not had any previous events of ventricular arrhythmias or cardiac arrest. Cardiac resynchronization therapy (CRT) improves symptoms of heart failure and left ventricular systolic function when used in patients with severe heart failure symptoms, reduced left ventricular ejection, and a wide QRS complex. CRT has also been proven to reduce the rate of hospitalization due to heart failure as well as the rate of death from any cause. In this review, we discuss the clinical trials and current clinical indications for the ICD and CRT.

Treatment Strategy of Gastric Adenoma

Tue, 01 Mar 2016 00:00:01 +0100

Gastric adenoma is a precancerous lesion. While some adenomas regress spontaneously, others progress as invasive carcinomas. Simple follow-up of gastric adenoma may be possible considering the possibility of spontaneous regression. However, several studies have reported discrepancies between the results of endoscopic forceps biopsies and post-resection biopsies. These studies showed that the pathological findings are more severe in biopsies performed after endoscopic resections. We suggest that endoscopic resections should be planned for cases of gastric adenoma. After endoscopic resection, regular endoscopic surveillance and Helicobacter pylori eradication may reduce the occurrence of gastric cancer.

Cancer Screening Guidelines in Korea

Tue, 01 Mar 2016 00:00:01 +0100

Cancer is the leading cause of death in Korea. Cancer screening has become a basic health program because of the increased incidence of cancers and heightened interest. In September 2015, experts gathered at the National Cancer Institute of Korea proposed screening guidelines for seven cancers: lung, gastric, colon, breast, cervical, and thyroid cancers and hepatoma. The Korean cancer screening guidelines recommend annual screening for lung cancer with low-dose computed tomography in adults ages 55 to 74 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. For gastric cancer, endoscopy screening is recommended once every 2 years and gastrography is recommended optionally in adults ages 40 to 74 years. For hepatoma screening, ?-fetoprotein and liver ultrasound are recommended every 6 months for patients older than 40 years old at high risk. For colon cancer screening, fecal occult blood testing is recommended with optional colonoscopy every 12 years in adults ages 40 to 80 years. For breast cancer screening, mammography is recommended every 2 years for all women ages 4069 years. For cervical cancer screening, a Pap smear is recommended every 3 years for all women older than 20 years or with sexual experience. No routine screening is recommended for thyroid cancer. The author reviews the background and practices of cancer screening guidelines for seven major cancers and prostate cancer.

Radial Arteriovenous Fistula after Coronary Angiography

Tue, 01 Mar 2016 00:00:01 +0100

A 67-year-old man underwent coronary angiography using a transradial approach. Three months after coronary angiography, the patient complained of a thrill detected in his right wrist. Localized compression was performed in the assumption of arteriovenous fistula formation. Since thrill was still detected after localized compression, surgical revision of an arteriovenous fistula was performed. Six days later, radial bruit was still reported. It was decided to perform upper extremity angiography. Upper extremity angiography revealed the remaining arteriovenous fistula from radial artery to cephalic vein, and surgical revision was performed again. This appears to be a very unusual complication related to the transradial approach for coronary angiography.

Successful Healing of the Myocardial Rupture Complicated by the Occlusion of a Single Diagonal ...

Tue, 01 Mar 2016 00:00:01 +0100

Myocardial rupture is a rare but lethal complication of myocardial infarction. Immediate conservative management is critical, but surgery should be considered if the patients hemodynamic state and degree of hemopericardium do not improve after pericardiocentesis. In this case, a 54-year old patient without underlying disease came to the emergency after experiencing chest pain for two weeks with suddenly aggravated severe dyspnea. The patient was found to have a hemopericardium with cardiac tamponade, so pericardiocentesis was immediately executed. Transthoracic echocardiogram revealed akinesia of the left ventricular muscle and focal wall thinning. The patient was diagnosed with complete occlusion of a single diagonal branch and ventricular free wall rupture using a coronary computed tomography scan. After conservative treatment, vital signs and cardiac function stabilized, and there was no definitive sequela. This case is clinically significant because myocardial rupture, a lethal complication of myocardial infarction, was successfully managed with non-surgical, conservative treatment.

A Case of Gynecomastia Induced by Use of Doxazosin

Tue, 01 Mar 2016 00:00:01 +0100

Doxazosin is an adrenergic alpha-1 receptor antagonist used to treat lower urinary tract symptoms that are common in prostatic hyperplasia. To our knowledge, few cases of gynecomastia and mastodynia, as a complication of adrenergic alpha-1 receptor antagonist, have been reported to date; no cases have been reported in Korea. We describe a case involving a 78-year-old man treated for prostatic hyperplasia with 13 months of doxazosin. He complained about unilateral gynecomstia and mastodynia. Five months after the discontinuation of doxazosin, the gynecomastia was significantly improved. This is the first reported case of gynecomastia and mastodynia associated with doxazosin use in Korea.

Acute Lymphoblastic Leukemia Diagnosed in a Patient with Acromegaly

Tue, 01 Mar 2016 00:00:01 +0100

Acromegaly is a rare disorder caused by excessive amounts of growth hormone. The incidence of colorectal, breast, and thyroid carcinomas is increased in acromegaly. However, there have been few reports on hematological malignancies in acromegaly. We describe a patient who developed acute lymphoblastic leukemia during the course of acromegaly. A 35-year-old woman presented in February 2012 with unexplained lactation and amenorrhea for 4 months. Her growth hormone level was 12.6 ?g/L, insulin-like growth factor 1 592.26 ng/mL, and prolactin 242 ?g/L. A pituitary macroadenoma secreting GH and prolactin causing acromegaly was diagnosed. Considering her fertility, the dopamine agonist cabergoline 0.5 mg was administered in March 2012. In February 2014, she presented with cytopenia (hemoglobin 12.2 g/dL, white cell count 2.69

Two Cases of Distal Renal Tubular Acidosis accompanied by Sj

Tue, 01 Mar 2016 00:00:01 +0100

Renal tubular acidosis (RTA) is a syndrome characterized by hyperchloremic metabolic acidosis and an inability to excrete highly acid urine, in which the impaired acid excretion is disproportional to the reduction in the glomerular filtration rate. Distal renal tubular acidosis (dRTA) is frequently associated with immune-mediated disease, including Sj

Huge Extramedullary Plasmacytoma of the Retroperitoneum

Tue, 01 Mar 2016 00:00:01 +0100

Extramedullary plasmacytoma (EMP) represent 3% of plasma cell neoplasms. Approximately 80-90% of EMPs involve the mucosa-associated lymphoid tissue of the upper airways and 75% of these involve the nasal and paranasal regions, while renal or retroperitoneal in?ltration is very rare. EMPs are highly radiosensitive, with excellent results. The local control rate of radiotherapy can reach 90-97% and the 5-year overall survival rate can be 57-61%. EMP has an indolent course and the prognosis is generally favorable, with 70% of the patients remaining disease free for 10 years. However, about 30% may progress to plasma cell myeloma or relapse. Here, we report a case of a huge retroperitoneal solitary extramedullary plasmacytoma that grew rapidly.

Successful Treatment of Relapsed Acquired Amegakaryocytic Thrombocytopenia with Repeat Cyclosporine

Tue, 01 Mar 2016 00:00:01 +0100

Acquired amegakaryocytic thrombocytopenia (AAMT) is an unusual disease characterized by severe thrombocytopenia resulting from a marked decrease in bone marrow megakaryocytes. Various pathogenic mechanisms have been suggested, and several treatments have been tried, with varying outcomes. In some case reports, cyclosporine and anti-thymocyte globulin have had good clinical results in the treat of AAMT. There are few reports on the treatment of relapsed AAMT with cyclosporine. We report a patient with relapsed AAMT who was treated successfully with an additional course of cyclosporine. The initial remission was achieved with cyclosporine 4 years earlier and a second remission was induced by cyclosporine. Cyclosporine may be effective for relapsed AAMT that previously responded to cyclosporine.

Chikungunya Virus Infection after Traveling to Surinam, South America

Tue, 01 Mar 2016 00:00:01 +0100

Chikungunya infection is caused by an arbovirus transmitted by the Aedes mosquito. A 19-year-old man who had traveled to the Republic of Surinam to perform volunteer work complained of a fever, arthralgia, articular stiffness, and a skin rash on both the arm and trunk. Chikungunya fever was diagnosed using a Chikungunya virus specific IgM antibody in an enzyme-linked immunosorbent assay (ELISA) using blood samples obtained during follow-up visits. In this report, we describe a case of imported Chikungunya fever that presented with arthralgia and a skin rash, with islands of normal skin, that occurred following travel to Surinam, South America.

Bordetella bronchiseptica Respiratory Infection in the Immunosuppressed Patient

Tue, 01 Mar 2016 00:00:01 +0100

Bordetella bronchiseptica is a common cause of respiratory disease in animals but is a rare cause of human infection. Furthermore, most patients with Bordetella bronchiseptica infections are immunocompromised. The Bordetella bronchiseptica organism can cause pneumonia, septicemia, and peritonitis in humans with impaired immune systems. Additionally, it can lead to a life-threatening infection patients who have an underlying debilitation or impaired immunity. The respiratory tract is the most common site of infection. Sixty-two human cases of Bordetella bronchiseptica have been published in the English literature, and 84 % hadof the cases were associated with pneumonia or bronchitis. However, only one case of Bordetella bronchiseptica has been reported in South Korea, and it was associated with peritonitis. In the current study, we report a case of Bordetella bronchiseptica pneumonia diagnosed in an immunocompromised patient.

Fibromyalgia Complicated with Dystonia Successfully Treated with Deep Brain Stimulation: a Case ...

Tue, 01 Mar 2016 00:00:01 +0100

Focal dystonia is a neurological condition affecting a muscle or group of muscles in a specific part of the body, leading to involuntary muscular contractions. This condition is often treated with medications including muscle relaxants and injections of botulinum toxin. However, some cases do not respond to normal modes of treatment. Deep brain stimulation (DBS) can be a therapeutic option for patients who are resistant to medical treatment. We report a case of fibromyalgia accompanied by focal hand dystonia, where unilateral DBS improved the patients focal dystonic movement. We also present a review of the relevant literature.

Biopsy-Proven Dermatomyositis with Normal Creatine Kinase

Tue, 01 Mar 2016 00:00:01 +0100

Dermatomyositis (DM) is an idiopathic inflammatory myopathy (IIM) characterized by skeletal muscle inflammation and typical skin manifestations. Creatine kinase (CK) has traditionally been considered to be the most useful serum enzyme for the diagnosis and assessment of adult patients with IIM. To our knowledge, there has been no reported case of biopsy-proven DM without CK elevation in Korea, to date. Panniculitis is an uncommon cutaneous manifestation in adult patients with DM. A search of the PubMed database reveals fewer than 30 reported cases of panniculitis in adult patients with DM. Here, we report a case of a 42-year-old female who was diagnosed with biopsy-proven DM with normal serum CK levels and panniculitis.

Advances in the Diagnosis of Myeloproliferative Neoplasms

Fri, 01 Apr 2016 00:00:01 +0100

Philadelphia chromosome-negative classical myeloproliferative neoplasms include polycythemia vera, essential thrombocythemia, and primary myelofibrosis. In recent years, there have been major advances in our understanding of the molecular pathophysiology of these rare subgroups of myeloproliferative neoplasms. The World Health Organization diagnostic criteria were revised in 2008, and incorporated new somatic mutations of JAK2 V617F, found in most patients with polycythemia vera, essential thrombocythemia, or primary myelofibrosis. Subsequently, other mutations (MPL W515 and CALR) were discovered and this led to substantial changes in the diagnosis and treatment guidelines. This article reviews the diagnostic criteria for Philadelphia chromosome-negative classical myeloproliferative neoplasms, and changes in the diagnostic algorithm for clinical practice in Korea.

Advances in Treatment for Polycythemia Vera and Essential Thrombocythemia

Fri, 01 Apr 2016 00:00:01 +0100

Although there have been substantial advances in confirming diagnoses and defining the molecular characteristics of polycythemia vera (PV) and essential thrombocythemia (ET), treatments for these conditions remain elementary. The main goal is still mainly focused on reducing the risk of thrombosis. The prevention of hemorrhage, leukemia transformation, and progression to myelofibrosis has yet to be established. To reduce the risk of thrombosis, risk-adapted treatment is recommended. Phlebotomy is the most important and effective treatment modality for patients with erythrocytosis, while cytoreduction using hydroxyurea, busulfan, or interferon-? is an ancillary treatment for patients at high risk for thrombosis. Anagrelide is used to decrease platelet counts in patients with thrombocytosis by inhibiting the maturation of platelets from megakaryocytes. Recent trials have shown that ruxolitinib, a Janus kinase (JAK) inhibitor, has clinical benefits in patients with polycythemia vera who show an inadequate response, or unacceptable side effects, to therapeutic doses of hydroxyurea. Theoretically, JAK inhibitors may also delay the progression of leukemia transformation and myelofibrosis but there is still no evidence of this. The cost of JAK inhibitors for the treatment of patients with PV/ET is a difficult hurdle for its use as a first-line treatment.

Evolution of Myelofibrosis Treatment

Fri, 01 Apr 2016 00:00:01 +0100

Myelofibrosis (MF) is a classical Philadelphia chromosome-negative myeloproliferative neoplasm characterized by clonal proliferation of pluripotent stem cells, dysfunctional kinase signaling, and abnormal cytokine release. MF is a heterogeneous disease, ranging from asymptomatic to being associated with one or more of the following problems: profound anemia, splenomegaly, constitutional issues, and even rapid progression to overt leukemia. Recently, important progress has been made. A Janus kinase (JAK) 2 mutation affects both pathogenesis and prognosis. Conventional treatment is primarily palliative and has only limited effects on the natural course of the disease. Allogeneic stem cell transplantation is the only curative treatment, but is presently limited to eligible intermediate-2 and high-risk patients. Ruxolitinib, the first drug approved by the Food and Drug Administration for treatment of intermediate-2 and high-risk patients, is currently the best available therapy for symptomatic MF patients. Additional JAK inhibitors are under investigation. Emerging therapies include immunomodulators and inhibitors of histone deacetylase (HDAC), mammalian target of rapamycin (mTOR), and telomerase. A better understanding of disease pathogenesis will lead to the development of better treatments modifying the disease course and, ultimately, curing the condition.

Practical Guideline of Asthma Management - Korean Guideline for Asthma 2015 -

Fri, 01 Apr 2016 00:00:01 +0100

Allergic diseases such as asthma are increasing. The prevalence of adult asthma is about 3% in Korea. However, asthma becomes more prevalent with age: 6.8-12% in the elderly. In terms of socioeconomic burden, asthma is the 6th important chronic disease in Korea. The symptoms of asthma such as dyspnea, wheezing, cough, and chest discomfort may vary according to time and season. Reversible airflow limitation and airway hypersensitivity are the characteristic features of asthma. Inhaled corticosteroid is the mainstay in the management of asthma as chronic airway inflammation is the underlying mechanism. Stepwise approach is recommended according to the severity and the control status. Physicians should be aware of the control status, lung function, and the risk factors of future risk including asthma exacerbations. Doctor-patient relationship is always important to increase the adherence and treatment outcome. Patients should learn how to use inhalers: video clips on inhalers are available at the websites such as Gyeonggi-do Atopy Asthma Education Information Center. In this review, the practical approach of asthma management was described mainly referring to the Korean guideline for asthma which has been published, revised, and updated by the Korean Academy of Asthma, Allergy, and Clinical Immunology and recently published in 2015.

Diagnosis and Management of Gastric Polyps

Fri, 01 Apr 2016 00:00:01 +0100

A gastric polyp is defined as a proliferative or neoplastic lesion from the mucosal membrane. Rates of gastric polyp detection are increasing due to widespread use of gastrointestinal endoscopy in Korea. There are many types of gastric polyps; the most common are fundic gland, hyperplastic, and adenomatous polyps. This article reviews the clinical and histologic features of these polyps and provides recommendations for management.

Removal of Anorectal Cancer by Endoscopic Submucosal Dissection

Fri, 01 Apr 2016 00:00:01 +0100

Anorectal cancer is traditionally treated via abdominoperineal resection and/or chemoradiation. Currently, endoscopic submucosal dissection (ESD) is widely used to treat early gastrointestinal epithelial neoplasias. However, the use of ESD to treat lesions of the anal canal raises concerns that do not arise when treating lesions of the stomach and colorectum. Therefore, particular care is needed when treating lesions in the anal area. We recently treated a 75-year-old woman who was scheduled for surgical resection to treat anorectal cancer. The lesion was successfully removed using ESD. This is the first report of the use of ESD to treat anorectal cancer in Korea. Here, we present our case report and review the relevant literature.

Acute Colonic Pseudo-Obstruction (Ogilvie

Fri, 01 Apr 2016 00:00:01 +0100

Acute colonic pseudo-obstruction (Ogilvies syndrome) is a very rare complication of herpes zoster. A 62-year-old female visited our hospital due to abdominal pain. Skin lesions of herpes zoster had developed after the patient experienced symptoms of colonic obstruction. The symptoms of colonic obstruction resulted in more suffering for the patient than did those of herpes zoster. In cases reported previously in Korea, these symptoms were improved by endoscopic colonic decompression. However, the symptoms of this patient were improved by conservative treatment only, which included fasting and intravenous fluid replacement. Furthermore, this case differs from previous cases in terms of the difficulty of diagnosis due to the delayed appearance of the skin lesions. We present herein the first case in Korea of Ogilvie's syndrome as a complication of herpes zoster, which was improved by conservative treatment. Clinicians should be aware of the various unusual complications of herpes zoster.

Simultaneous Multivessel Acute Stent Thrombosis in a Patient with Gastrointestinal Bleeding

Fri, 01 Apr 2016 00:00:01 +0100

Stent thrombosis is a rare, but potentially catastrophic complication of stent implantation. Dual antiplatelet therapy with aspirin and a thienopyridine (clopidogrel, prasugrel, or ticagrelor) is essential to minimize the risk of stent thrombosis in patients receiving drug-eluting stents. However, there is an ongoing debate regarding antiplatelet therapy in patients presenting with acute coronary syndrome and bleeding. Here, we report a case of a 59-year-old man with acute stent thrombosis immediately after percutaneous coronary intervention combined with acute coronary syndrome and gastrointestinal bleeding.

Acute Myocardial Infarction with Cardiogenic Shock in a Young Adult with Minimal Change Disease

Fri, 01 Apr 2016 00:00:01 +0100

Acute myocardial infarction (AMI) is very rare in young adults. Nephrotic syndrome is an uncommon cause of AMI in young adults and is characterized by excessive proteinuria, hypoalbuminemia, hyperlipidemia, and generalized edema. The hypercoagulable state and accelerated atherosclerosis in patients with nephrotic syndrome may be associated with the development of AMI in young adults. We report herein a case of ST-segment elevation myocardial infarction with sudden cardiac arrest in a young patient with minimal change disease.

Heart Failure Secondary to Pazopanib for Treatment of Metastatic Renal Cell Carcinoma

Fri, 01 Apr 2016 00:00:01 +0100

A 78-year-old man was diagnosed with renal cell carcinoma, and left nephrectomy was performed. He started pazopanib. One month later, he visited our hospital because of general weakness and dyspnea. His oxygen saturation was low. A chest X-ray showed pulmonary edema and bilateral pleural effusion. An echocardiogram showed a larger left ventricle and lower ejection fraction than observed at the previous examination. The patient discontinued pazopanib and started diuretics and digoxin. His symptoms improved and a follow-up X-ray showed improvement in the pulmonary edema with bilateral pleural effusion.

Paraganglioma Presenting as Dilated Cardiomyopathy with Cardiogenic Shock and Sepsis

Fri, 01 Apr 2016 00:00:01 +0100

Rarely, a paraganglioma can lead to disastrous cardiac complications such as heart failure, cardiomyopathy, or myocardial infarction and inflammatory complications such as sepsis. We describe a 41-year-old man who developed severe dilated cardiomyopathy with cardiogenic shock and sepsis who had a paraganglioma in the retroperitoneum. Echocardiography showed extensive global hypokinesia with severe left ventricular systolic dysfunction. In addition, leukocytosis with elevated inflammatory markers and positive blood cultures indicated sepsis. Abdominal enhanced computed tomography and magnetic resonance imaging showed a large heterogeneous mass with cystic changes in the retroperitoneum. Serum and urine samples indicated elevated levels of catecholamine and its metabolites, and a 131I-meta-iodobenzylguanidine (MIBG) scan indicated uptake of MIBG. After intensive medical treatment and surgical removal of the paraganglioma, the dilated cardiomyopathy and sepsis resolved. The diagnosis of paraganglioma should be considered in patients presenting with acute heart failure or sepsis of nonspecific origin.

Fatal Massive Hemoptysis Related to a Pulmonary Artery Pseudoaneurysm after Treatment of a Lung ...

Fri, 01 Apr 2016 00:00:01 +0100

Pulmonary artery pseudoaneurysm (PAP) is a very rare vascular abnormality and is often caused at least in part by infection. While Mycobacterium tuberculosis is a relatively common cause of PAP, it can also result from a lung abscess. Aneurysm rupture resulting in massive hemoptysis is potentially fatal, with death caused by aspiration of blood and consequent asphyxiation. We admitted a 55-year-old man with massive hemoptysis. He had been treated with intravenous antibiotics for three weeks after diagnosing a lung abscess. Contrast-enhanced chest computed tomography revealed a pseudoaneurysm inside the abscess. Diagnostic catheter pulmonary angiography confirmed the diagnosis of pseudoaneurysm of the pulmonary artery. Embolization successfully controlled the airway bleeding. However, the patient died of acute respiratory failure on the seventh hospital day. When hemoptysis is due to sustained inflammation, such as a lung abscess, bleeding from the pulmonary artery should be considered.

Diffuse Pulmonary Ossification Developing in Patients with End-stage Renal Disease

Fri, 01 Apr 2016 00:00:01 +0100

Diffuse pulmonary ossification (DPO) is a rare condition characterized by chronic metaplastic ossification of the lung parenchyma. DPO is associated with various underlying pulmonary, cardiac, and systemic diseases. However, to our knowledge, DPO has rarely been described in patients with end-stage renal disease undergoing hemodialysis. We describe two cases of DPO diagnosed in long-term hemodialysis patients. Awareness of this rare disorder is required for a better differential diagnosis of cases presenting with bilateral diffuse micronodular lesions, including calcific opacities.

Addison Disease Due to Adrenal Tuberculosis Presenting as an Abscess in a Nearby Psoas Muscle ...

Fri, 01 Apr 2016 00:00:01 +0100

An 80-year-old male with nausea and poor oral intake was referred for evaluation of hyponatremia. Primary adrenal insufficiency was diagnosed by a rapid adrenocorticotropic hormone (ACTH) stimulation test. The cause of the adrenal insufficiency was revealed to be adrenal tuberculosis presenting as a bilateral adrenal mass on computed tomography imaging. During the first few months of treatment, the size of the tuberculous mass increased and spread to an adjacent area, and further adrenal hormone replacement was needed. In addition, there was a newly developed tuberculous abscess in a nearby psoas muscle with a duodenal fistula. Thus, we report a case of a long-term clinical course of Addisons disease with changes in hormone replacement as a result of active adrenal tuberculosis, together with a review of the literature.

Good Response of a Salivary Duct Carcinoma to Androgen Deprivation Therapy

Fri, 01 Apr 2016 00:00:01 +0100

Salivary duct carcinoma (SDC) is a rare, aggressive tumor. Androgen deprivation therapy (ADT) has been shown to have beneficial effects on SDC-expressing androgen receptors (ARs). A 69-year-old male with a right neck mass presented to our clinic. Computed tomography (CT) of the neck revealed a mass (6 cm diameter) on the right parotid gland, and enlarged lymph nodes. Examination of a needle biopsy sample identified SDC-expressing ARs. We performed total parotidectomy with bilateral neck dissection and concurrent postoperative chemoradiotherapy (total 66 Gy) with cisplatin (35 mg/m²), followed by another two cycles of chemotherapy (cisplatin 60 mg/m², 5 FU 750 mg/m²). Post-treatment neck CT indicated that no residual tumor tissue remained; however, chest CT indicated recurrence in the right axilla. We initiated ADT with bicalutamide and leuprolide. Five months later, the axillar tumor tissue had almost disappeared. Our case demonstrates that ADT is effective for SDC of ARs. Therefore, clinicians should consider ADT in recurrent or metastatic SDC of ARs.

Healthcare-associated Endocarditis by PVL-negative ST 72 SCCmec Type IV MRSA

Fri, 01 Apr 2016 00:00:01 +0100

The prevalence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has been increasing worldwide. In Korea, the most common genotype of CA-MRSA is the Panton-Valentine leukocidin-negative, sequence type 72 Staphylococcal cassette chromosome (SCC) mec type IV clone. However, within Korean hospitals, this strain is still not commonly reported. In this study, we describe a case of infective endocarditis caused by Panton-Valentine leukocidin-negative MRSA (ST72-SCCmec type IV A clone). Infection occurred after open reduction and internal fixation due to a right humerus fracture with cerebral hemorrhage. Initially, the patient was treated with linezolid, but with the onset of severe thrombocytopenia, the patient was switched to vancomycin therapy.

Pneumonia Caused by Adenovirus Genotype 55 in an Army Recruit Training Center

Fri, 01 Apr 2016 00:00:01 +0100

Adenoviral pneumonia is rare in healthy adults. However, several cases were recently reported in a military training center in South Korea. Adenovirus genotype 3, 6, and 7 are predominant in South Korea. More recently, genotype 55, which emerged sporadically in China, has been reported in South Korea. In this study, we present a case of adenoviral pneumonia caused by genotype 55 in a healthy soldier from an army recruit training center in South Korea.

Cancer-associated Kidney Disease

Sun, 01 May 2016 00:00:01 +0100

Kidney disease is common in patients with cancer and includes diseases that occur in people without cancer. In addition, certain kidney disorders are related to either cancer therapy or the malignancy itself. Paraneoplastic glomerulonephritis and post-hematopoietic stem-cell transplantation kidney disease (thrombotic microangiopathy, veno-occlusive disease, and kidney injury from graft-versus-host disease) are prime examples. Newer cancer therapy has increased cancer cure rates and survival times, but nephrotoxicity remains an important complication of chemotherapy. Consequently, patients with cancer are at increased risk of developing acute kidney injury, chronic kidney disease, and fluid and electrolyte abnormalities. In patients with chronic kidney disease, therapeutic doses may need to be reduced. Therefore, it is essential that nephrologists be informed and involved in cancer care. Nephrologists must provide expertise in the evaluation and management of acute and chronic kidney disease, fluid and electrolyte disorders, and the use of various extracorporeal therapies in patients with cancer. Additionally, onco-nephrologists, who must be knowledgeable about the array of new chemotherapeutic agents and their potential effects on kidney function, are needed to provide integral care for patients with cancer.

Cardiorenal Syndrome

Sun, 01 May 2016 00:00:01 +0100

Although combined cardiac and renal dysfunction is common in hospitalized patients and portends a poor prognosis, lack of understanding of the pathogenesis and classification of the condition has hampered the development of therapeutic strategies. Interactions between the heart and kidney involve multiple hemodynamic and nonhemodynamic factors and are usually bidirectional, as acute or chronic dysfunction of the cardiac or renal systems can negatively affect one another. This review introduces a new definition and classification system of cardiorenal syndrome advocated by a consensus conference of the Acute Dialysis Quality Initiative and summarizes the current understanding of cardiorenal syndrome.

Hepatorenal Syndrome

Sun, 01 May 2016 00:00:01 +0100

Hepatorenal syndrome is a functional renal failure occurred in end-stage liver disease. It is regarded as one of the most serious complications of liver disease; commonly occur in patients with cirrhosis or acute liver failure. Pathophysiologically, portal hypertension induced vasoconstriction in the renal cortex reduces glomerular filtration rate. There are no intrinsic renal diseases or histological abnormalities. In most patients, the natural course of the renal failure leads to fatal consequences, even though various treatment options have been provided. Liver transplantation and combination therapy of albumin and vasopressin analogs can restore the damage of the blood vessel.

Bidirectional Crosstalk between Kidney and Lung

Sun, 01 May 2016 00:00:01 +0100

Data reported recently suggest that acute kidney injury (AKI) is a systemic disease that adversely affects the function of other organsincluding the heart, lung, liver, brain and immune systemwhich is related to the high mortality rate of affected patients. Kidney and lung function are closely related in both health and disease. Data support deleterious bidirectional crosstalk between the lung and kidney. AKI is a common complication in patients with acute respiratory distress syndrome, and has been reported to exert adverse effects on the lungs. Mortality rates for AKI combined with acute lung injury (ALI) can be up to 80% in critically ill patients. Although AKI-associated ALI presents clinically as increased pulmonary edema, the mechanism of AKI-associated ALI extends beyond simple volume overload. Data from animal studies suggest that AKI-induced pulmonary edema is related to both cardiogenic edema (due to elevated hydrostatic pressure) and non-cardiogenic edema (due to pulmonary endothelial and epithelial cell injury caused by inflammation, oxidative stress, and apoptosis). ALI with mechanical ventilation causes a decline in renal hemodynamic function and apoptosis. Elucidation of the mechanisms of kidneylung crosstalk would facilitate development of effective therapies and reduce the mortality rate of AKI combined with respiratory failure.

Peripheral Neuropathy

Sun, 01 May 2016 00:00:01 +0100

Peripheral neuropathies are common in neurological practice, but it is also tue that they are common in many other medical andsurgical fields. There are hundreds and thousands causes of peripheral neuropathies, and a variety of clinical manifestations. Diagnostic approach includes through history taking, neurologic examination focused on the motor and sensory system, serologic investigation with proper electrodiagnostic studies. The first and essential step is to know the clinical characteristics of peripheral neuropathies and caterogorize them to subtype for differential diagnosis. However, up to 30% of the neuropathy remains idiopathic despite of extensive evaluation. Symptomatic management with serial follow up is essential in these cryptogenic neuropathies. Herein, the clinical symptoms and signs of peripheral neuropathy and symptomatic management of neuropathic pain will be briefly reviewed.

Recent Therapies for Diabetic Nephropathy

Sun, 01 May 2016 00:00:01 +0100

Diabetes mellitus (DM) is a worldwide public issue that has increased the risks for cardiovascular morbidity and mortality. It is the most common cause of chronic kidney diseases, which necessitates renal replacement therapy. Diabetic nephropathy is one of the long-term complications of DM. Renal replacement therapy has reduced the acute complications of renal dysfunction and prolonged patient survival. However, quality of life should be considered from the patients viewpoint. Although new treatments have been developed via experimental studies, many trials failed to show beneficial effects in clinical practice in terms of long-term complications. Since there are many limitations to large clinical studies, we hope that improved approaches for individual patients will lead to new methods to increase the effectiveness of agents though big-data analysis in the future.

Ischemic Colitis Caused by Terlipressin during Treatment of Hepatorenal Syndrome

Sun, 01 May 2016 00:00:01 +0100

Terlipressin, a vasopressin agonist, is widely used to treat variceal bleeding and hepatorenal syndrome in patients with liver cirrhosis. Terlipressin increases systemic vascular resistance, particularly in the splanchnic area, thus decreasing portal pressure. Although terlipressin is associated with a lower incidence of severe cardiovascular complications than is vasopressin, terlipressin can induce serious ischemic complications including myocardial infarction, skin necrosis, and bowel ischemia in < 1% of patients. We report the case of a 79-year-old female with liver cirrhosis treated with terlipressin to control hepatorenal syndrome that developed into ischemic colitis. The patient improved upon cessation of terlipressin and provision of supportive care.

Non-operative Treatment of Gastric Ulcer Perforation with Contrast Leakage in an Elderly Patient

Sun, 01 May 2016 00:00:01 +0100

Peptic ulcer remains an important public health concern due to an aging society and the increasing use of non steroidal anti-inflammatory drugs (NSAIDs). Perforated peptic ulcer is a major life-threatening complication of peptic ulcer. While the preferred treatment is surgery, conservative treatment does not result in significantly different outcomes in young, hemodynamically stable patients. However, conservative treatment of perforated peptic ulcer is associated with high failure rates in elderly patients. We report a case of an 87-year-old patient with a perforated peptic ulcer with contrast agent leakage. The patient was treated conservatively without complications; the treatment included non per os (NPO), insertion of a Levin tube, intravenous antibiotics, and a proton pump inhibitor.

Colonic MALT Lymphoma Diagnosed 6 Months after Complete Remission of Gastric MALT Lymphoma

Sun, 01 May 2016 00:00:01 +0100

Most mucosa-associated lymphoid tissue (MALT) lymphomas are found in the gastrointestinal tract. The most common site is the stomach, whereas colon MALT lymphomas are rare. There are a few reports of simultaneously diagnosed stomach and colon MALT lymphomas. However, diagnosis of primary colonic MALT lymphoma after complete remission of gastric MALT lymphoma is extremely rare. Although the treatment protocol for gastric MALT lymphoma is well established, there is no consensus protocol for colonic MALT lymphoma owing to its rarity. Herein, we report a case of colonic MALT lymphoma incidentally diagnosed 6 months after completion of radiation therapy for gastric MALT lymphoma and treated via polypectomy, with no recurrence for 3 years.

Recurrent Upper Gastrointestinal Hemorrhage due to Hemosuccus Pancreaticus from True Splenic ...

Sun, 01 May 2016 00:00:01 +0100

Hemosuccus pancreaticus, defined as bleeding from the papilla of Vater via the pancreatic duct, is a rare cause of recurrent upper gastrointestinal bleeding. We report the case of a 67?year?old man with recurrent gastrointestinal bleeding, who was subsequently diagnosed with hemosuccus pancreaticus caused by rupture of a true splenic artery aneurysm. The patient had chronic pancreatitis after considerable delay and unnecessary surgical small bowel exploration. The patient was cured with distal pancreatectomy because concomitant arcuate ligament syndrome precluded the angiographic approach via the celiac trunk, and tortuous dilatation of the distal pancreatic duct could not exclude the main duct type of intraductal papillary mucinous neoplasm (IPMN). In the surgical specimen, the pancreatic duct contained a hematoma and was lined by normal epithelium, indicating rupture of the splenic artery aneurysm that bled into the pancreatic duct.

AKI and Takotsubo Cardiomyopathy after Bee Venom-induced Anaphylaxis

Sun, 01 May 2016 00:00:01 +0100

Bee venom-induced anaphylaxis usually causes urticaria, angioedema, respiratory distress, nausea, and vomiting. Occasionally, it leads to unusual complications such as acute myocardial infarction, takotsubo cardiomyopathy, arrhythmia, rhabdomyolysis, intravascular hemolysis, and acute kidney injury. Renal complications are rare, and there are only two cases of acute kidney injury associated with rhabdomyolysis due to multiple bee stings reported in Korea. We report a 67-year-old woman who presented at our emergency department with confusion, respiratory distress, and dizziness after multiple bee stings. She was diagnosed with anaphylactic shock. There was acute kidney injury associated with rhabdomyolysis and heart failure related to takotsubo cardiomyopathy, all of which indicated unusual and fatal complications. Her condition worsened, almost requiring intubation and mechanical ventilation. However, the patient recovered without cardiac or renal complications within 30 days of therapy with hydration and diuretics.

Type B Aortic Dissection with Malperfusion of Both Common Iliac Arteries That Underwent Stent ...

Sun, 01 May 2016 00:00:01 +0100

Malperfusion syndrome is a complication of acute descending aortic dissection (DAD) and it is associated with a poor clinical outcome. Surgical treatment for it has a high rate of mortality. Thoracic endovascular aortic repair (TEVAR) for DAD with malperfusion syndrome has resulted in good clinical outcomes. However, when both common iliac arteries are compromised by a false lumen, it is impossible to conduct TEVAR because there is no accessible artery. We successfully treated a case of DAD with malperfusion syndrome in which both common iliac arteries were compromised by placing stents in both arteries using the left brachial approach.

Development of a Complete Atrioventricular Block Associated with Intake of Evening Primrose Oil

Sun, 01 May 2016 00:00:01 +0100

A complete atrioventricular block is seen in patients due to a variety of causes, including drugs. The resolution of a drug-induced atrioventricular block is often accomplished by drug discontinuation. We report a case of a complete atrioventricular block in a 31-year-old woman following a month of treatment with evening primrose oils. After excluding all other likely causes of conduction disorders, an adverse effect of the evening primrose oils seemed to be the most likely diagnosis. After discontinuation of the oils, no associated symptoms or conduction disturbances were observed for 4 months after discharge. We stress the reconsideration of taking medicines and functional foods continuously as most patients are not aware of the hazards they pose.

Sinus Node Dysfunction with Pulmonary Edema Associated with Hyponatremia

Sun, 01 May 2016 00:00:01 +0100

Hyponatremia is the most common electrolyte abnormality in hospitalized patients and often presents no symptoms. The association between sinus node dysfunction and hyponatremia has rarely been reported. We describe a 77-year-old woman who developed reversible sinus node dysfunction accompanied by pulmonary edema that was associated with hyponatremia.

Spontaneously Regressed Immunoglobulin IgG4-related Lung Disease Presenting as Multiple ...

Sun, 01 May 2016 00:00:01 +0100

Immunoglobulin (Ig) G4-related disease was recently recognized as a systemic fibro-inflammatory disease characterized by dense lymphoplasmacytic infiltrates, storiform fibrosis, and obliterative phlebitis with IgG4-positive cells in the target tissues. This disease can localize to a single organ or be diffuse in multiple organs. Pulmonary manifestation in IgG4-related lung disease presents as various sized nodules, lung masses, patchy ground-glass opacities, consolidation, thickened bronchovascular bundles, nodular pleural lesions, and interstitial lung disease. Traditional treatment for IgG4-related lung disease includes systemic (cortico) steroids. Here, we report a case of IgG4-related lung disease presenting as multiple cavitary nodules that spontaneously regressed without systemic steroid use.

Mutation of the NF1 Gene and the Associated Clinical Features in Family Members with ...

Sun, 01 May 2016 00:00:01 +0100

With an incidence of 1 per 2,500-3,000 individuals, neurofibromatosis type 1 (NF1) is the most common autosomal dominant disorder in humans. NF1 is caused by germline mutations of the NF1 gene, but to date genotype-phenotype analyses have indicated no clear relationship between specific gene mutations and the clinical features of this disease, even among family members with the same mutation. The present study describes a case of two siblings with NF1 with the same genetic mutation but different clinical manifestations. The first patient was a female with iris Lisch nodules, an adrenal incidentaloma, Graves disease, and skin manifestations, while the second patient, the first patients younger brother, exhibited only skin neurofibromas and freckling. Further study is needed to reveal the molecular processes underlying gene expression and phenotypes. A better understanding of the genetics associated with NF1 will allow clinicians to detect complications earlier and provide better genetic counseling to NF1 families.

Myelodysplastic Syndrome (RAEB-II) Development 2 Months after Chemotherapy for a Primary ...

Sun, 01 May 2016 00:00:01 +0100

Here, we report on a 20-year-old patient with a primary nonseminomatous mediastinal germ cell tumor (MGCT) who developed myelodysplastic syndrome (MDS) 2 months following chemotherapy with cisplatin, etoposide, ifosfamide, and paclitaxel. Bone marrow examinations revealed that the MDS was a refractory anemia with excess type II blasts and complex chromosomal abnormalities. With the onset of MDS occurring rapidly following chemotherapy, it is unlikely to have been caused by the therapy. We discuss the association between primary nonseminomatous MGCTs and hematological malignancies, including the possibility of a common clonal origin.

Septic Shock with Acute Kidney Injury due to Obstructive Uropathy by Uterine Prolapse, ...

Sun, 01 May 2016 00:00:01 +0100

A 76-year-old woman with high fever and low blood pressure was admitted to the intensive care unit with a diagnosis of septic shock of unknown cause. A meticulous physical examination revealed a uterine prolapse with marked lower abdominal distention, suggesting urinary retention. After manual reduction of the uterine prolapse and insertion of a urinary catheter, the patient was managed with antibiotics for a presumed urinary tract infection. Escherichia coli was cultured on urine and blood culture media. Several days later the patient underwent a gynecological operation (anterior-posterior colporrhaphy) to correct the underlying cause of the obstructive uropathy. A preoperative and postoperative urodynamic study demonstrated marked urinary retention due to uterine prolapse. Pelvic organ prolapse including the uterus is not rare in older women. However, this common gynecological problem can cause lethal obstructive uropathy, such as uroseptic shock and acute kidney injury, if complications are present.

Update on Laboratory Testing for Diagnosing HIV Infection

Wed, 01 Jun 2016 00:00:01 +0100

Generally, laboratory testing for human immunodeficiency virus (HIV) is done for three reasons: for individual diagnosis and clinical management; to ensure the safety of blood or tissue products; and for public health surveillance. Many HIV-infected patients are unaware of their infections. The early diagnosis of infection is critical for medical and public health reasons. Its diagnosis is a two-step process that requires the sequential use of a highly sensitive screening test, followed by a highly specific confirmatory test. HIV-testing technology continues to evolve, with various tests currently available. This article reviews the current status of and recent advances in HIV testing.

Updates on Preventing HIV Infection

Wed, 01 Jun 2016 00:00:01 +0100

There are many evidence-based methods to prevent human immunodeficiency virus (HIV) transmission. This review describes recent updates on the prevention of HIV infection via sexual contact, mother-to-child transmission, and occupational exposure. The use of antiretroviral therapy to prevent HIV has been a major accomplishment. Successful strategies for preventing the sexual transmission of HIV include the implementation of treatment for prevention, pre-exposure prophylaxis, and microbicides. Mother-to-child HIV transmission can be minimized by screening and administering pre-, intra-, and postpartum prophylaxis. Adherence to universal precautions and post-exposure prophylaxis are effective preventive measures for occupational exposure. The implementation of prevention strategies based on scientific evidence should decrease the spread of this epidemic.

Recent Advances of Antiretroviral Agents

Wed, 01 Jun 2016 00:00:01 +0100

The treatment of human immunodeficiency virus is under constant development. This report reviews recent advances in antiretroviral agents.

Non-AIDS Morbidity among HIV Patients

Wed, 01 Jun 2016 00:00:01 +0100

Human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) have become a chronic condition rather than an acute life-threatening disease. Highly active antiretroviral treatment has dramatically increased the life expectancy of patients with HIV infection, who are now aging while receiving treatment. HIV patients are at higher risk for cardiovascular disease, diabetes, hypertension, bone disease, kidney disease, liver disease, psychiatric disease, and some non-AIDS-related cancers than patients in the general population. To avoid these non-AIDS morbidities, treating traditional age- and lifestyle-related conditions is important. Early treatment also reduces non-AIDS morbidity. Therefore, to reduce the risk for developing non-AIDS morbidity, it is crucial to start antiretroviral therapy (ART) early. Some ARTs are risk factors for the development of non-AIDS morbidities (e.g., nephrotoxicity with tenofovir). With the initial assessment and follow-up monitoring of non-AIDS morbidity, we have to consider switching ARTs to minimize adverse effects. Non-AIDS complications in HIV patients will become more important with advances in HIV therapy.

The Clinical Efficacy of Nailfold Capillaroscopy in Rheumatic Diseases

Wed, 01 Jun 2016 00:00:01 +0100

Nailfold capillaroscopy (NFC) is a non-invasive morphological study that routinely used to differentiate between a primary and secondary Raynauds phenomenon (RP). Secondary RP is a manifestation of an underlying rheumatic disease that occurs in 80-95% of patients with systemic sclerosis (SSc), 75% of patients with mixed connective tissue disease and in 20-25% of patients with systemic lupus erythematosus or rheumatoid arthritis. These RP frequently precedes the underlying disease by many years. The well-established roles of NFC are the early diagnosis of SSc, and potential for predicting clinical complication, as like digital ulcers. The following review will present a technique about how to perform NFC and optimal assessment with emphasis on its possible role as a reliable diagnostic tool.

Benefits of Intensive Blood Pressure Lowering

Wed, 01 Jun 2016 00:00:01 +0100

In general, each increase of 20/10 mmHg (systolic to diastolic) blood pressure (BP) above 115 mmHg and 75 mmHg results in a two-fold increased risk for cardiovascular complications. In addition, cerebrovascular events in association with hypertension are more frequent than myocardial infarctions in Asian populations. To prove the correlation between cardiovascular events and hypertension observed in the observational studies, BP-lowering studies should be performed to demonstrate the preventive effect on cardiovascular events. However, no randomized clinical studies to date have been able to prove the preventative effects of BP lowering in the blood pressure around 140/90 mmHg or mild hypertension. Despite the fact that many guidelines, including Joint National Committee-7 guidelines, recommend BP lowering for those ranges of blood pressure. In recent years, there have been many contradictory hypotheses about the asymmetry between the results from observational studies and clinical trials, which have led to the establishment of representative studies to set new target BPs. Such studies have proven the benefits of BP lowering closer to optimal blood pressure. Therefore, a discussion about applying these findings to patient care is needed.

Emergency Medical Service Use among Patients with Acute ST-segment Elevation Myocardial ...

Wed, 01 Jun 2016 00:00:01 +0100

Background/Aims: The use of emergency medical services (EMSs) at the onset of pain, and the relationship between transport type and the treatment delay for acute ST-segment elevation myocardial infarction (STEMI) were evaluated using the Jeonbuk Regional Cardiovascular Center database. Methods: In total, 527 STEMI patients who underwent primary percutaneous coronary intervention (PCI) were enrolled in this study. Basic characteristics, socioeconomic variables, and delay factors were compared between patients that contacted an EMS as first medical contact (FMC) and patients that used other forms of FMC. Results: Only 28.8% of patients used EMS as their FMC. The patients that used EMS showed significantly shorter onset-to-balloon time than those who did not (250.7

Permanent Pacemaker Implantation in a Patient with Mirror-Image Dextrocardia and Situs Inversus ...

Wed, 01 Jun 2016 00:00:01 +0100

A 68-year-old female patient with situs inversus totalis was referred for permanent pacemaker implantation to treat a symptomatic sinus pause. The initial electrocardiographic findings suggested the presence of mirror-image dextrocardia. No congenital anomalies were evident on pre-procedural examination. To explore the relevant anatomy, electrode catheters were placed at the right ventricular apex, the His bundle area, and the high right atrium under guidance via intracardiac electrography and fluoroscopy. The left and right anterior oblique views of the dextrocardia were mirror images of the right and left (respectively) anterior oblique views of a normal heart. Pacing leads were successfully positioned at the upper interventricular septum and the right atrial appendage. Dextrocardia is a rare congenital anomaly, and the accompanying anatomical distortions can render device implantation challenging. We suggest that pre-procedural fluoroscopic evaluation using electrode catheters can provide critical data on anatomical landmarks allowing effective positioning of pacing leads.

Right Coronary Artery to Left Ventricular Fistula with Giant Right Coronary Artery Aneurysm

Wed, 01 Jun 2016 00:00:01 +0100

A 35-year-old male with exertional dyspnea was transferred to our hospital for evaluation of a diastolic murmur and cardiomegaly discovered by chest X-ray. Two-dimensional and Doppler echocardiographic studies revealed an aneurysmal dilation of the right coronary artery (RCA) and diastolic inflow from the RCA to the left ventricle (LV) through a myocardial defect 11 mm in diameter in the basal inferior LV wall. Coronary computed tomography angiography (CCTA) confirmed the presence of a giant RCA to LV fistula. Due to the risks for developing overt left heart failure and spontaneous rupture of the giant RCA, the RCA was obliterated surgically. Coronary-cameral fistulas are a rare congenital coronary artery anomaly. A fistula between the coronary artery and LV, especially when combined with coronary artery aneurysm, is a rare occurrence in the literature. Here, we report a case of a giant RCA to LV fistula detected by echocardiography and CCTA.

Thrombotic Occlusion of an Inferior Vena Cava Filter during Maintenance with a Novel Anticoagulant

Wed, 01 Jun 2016 00:00:01 +0100

A 68-year-old woman presented with chest pain and dyspnea and was diagnosed with a massive pulmonary embolism. Bleeding colon cancer was detected incidentally during anticoagulation therapy. After stabilization, she underwent surgical resection of the cancer with insertion of an inferior vena cava filter and was treated with rivaroxaban as antithrombotic therapy thereafter. Unexpectedly, thrombotic obstruction of the filter was revealed on a computed tomography scan taken in preparation for removing the device. After switching to warfarin, the obstruction had resolved at the 4-week follow-up examination. We discuss what to consider when performing antithrombotic therapy in patients with an inferior vena cava filter.

Reversible Pulmonary Hypertension due to Sick Sinus Syndrome

Wed, 01 Jun 2016 00:00:01 +0100

A 60-year-old man visited the hospital after experiencing dyspnea after exertion for 2 weeks. An electrocardiogram showed sinus arrest with junctional escape rhythm at 40 beats/min. Transthoracic echocardiography showed that the right ventricular systolic pressure (RVSP) was approximately 71 mmHg and that the left ventricular ejection fraction was preserved. The ratio of peak early diastolic transmitral inflow velocity to early diastolic peak mitral annular velocity (E/E) was 29. Cardiac catheterization revealed a systolic pulmonary artery pressure (SPAP) of 63 mmHg, a mean pulmonary artery pressure of 27 mmHg, and a pulmonary capillary wedge pressure of 22 mmHg with a rhythm of 40 beats/min. The patient was diagnosed with pulmonary hypertension (group 2) due to sick sinus syndrome. SPAP decreased to 48 mmHg during atrial pacing at 60 beats/min. After permanent pacemaker insertion, RVSP decreased from 71 mmHg to 44 mmHg. In this case, passive group 2 pulmonary hypertension occurred due to sick sinus syndrome.

A Totally Occluded Long Segment Myocardial Bridge: 10-year Follow-up after Percutaneous ...

Wed, 01 Jun 2016 00:00:01 +0100

Intracoronary stent implantation can improve coronary hemodynamics and myocardial ischemia in patients with symptomatic bridging. However, percutaneous coronary intervention for this lesion is limited due to the high prevalence of restenosis and risk of complications. We present a case of a totally occluded long-segment myocardial bridge in a patient with hypertrophic cardiomyopathy who was successfully implanted with a bare metal stent under intravascular ultrasound guidance without complications. The patient has been free of ischemic symptoms with stent patency for 10 years.

Successfully Managed Aortic Aneurysm by Endovascular Treatment and Sequential Surgical ...

Wed, 01 Jun 2016 00:00:01 +0100

Aortic aneurysm-induced chronic consumptive coagulopathy is a very rare complication but can be a source of critical complications and mortality. A 72-year-old man presented with a rapidly expanding descending thoracic aortic aneurysm with a penetrating ulcer and an infrarenal abdominal aortic aneurysm complicated by chronic coagulopathy. We were aware of the bleeding risk during surgical replacement based on the patients chronic coagulopathy status and successfully performed endovascular repair of the thoracic aortic aneurysm with a penetrating ulcer. Platelet transfusion, antiplatelet agents, and proteinase inhibitors improved the coagulopathy. A delayed type Ib endoleak developed, and the coagulopathy recurred 2 months later when the patient presented with purpura of both lower legs. We successfully managed the condition by elective surgical replacement of the entire aorta after improving the coagulopathy with platelet replacement and administration of proteinase inhibitors.

Consumption of an Excessive Amount of Ionic Beverage Can Trigger Adrenal Adenoma - Induced ...

Wed, 01 Jun 2016 00:00:01 +0100

Rhabdomyolysis results from acute damage to skeletal muscles caused by various conditions, of which hypokalemia is a recognized but rare example. Although primary aldosteronism may cause severe hypokalemia leading to rhabdomyolysis, the potassium level of such patients can be within the normal range. Hypokalemia is most frequently triggered when these patients are exposed to an additional insult, such as diuretic stress. Similarly, overzealous consumption of ionic beverages with osmotic diuretic effects can cause hypokalemia. Here, we describe a patient with an aldosterone-secreting adrenal adenoma, who presented with acute rhabdomyolysis secondary to severe hypokalemia triggered by consumption of a large volume of ionic beverage for 3 weeks.

De Novo AL Amyloidosis in a Renal Allograft

Wed, 01 Jun 2016 00:00:01 +0100

Amyloidosis is characterized by the extracellular deposition of amyloid in various tissues and organs, particularly the kidney and heart. The estimated incidence of systemic amyloidosis is at least 8 per million population per year. However, few cases of systemic amyloidosis in renal allografts have been reported. A stable renal transplant recipient was admitted with proteinuria and dyspnea on exertion. The M-peak was found on serum and urine protein electrophoresis, and lambda (?) dominance was confirmed by serum and urine free-light-chain test. The patient was diagnosed with systemic amyloidosis of a renal allograft, by allograft biopsy, at 22 years after renal transplantation. We report a case of AL amyloidosis in a stable renal allograft and review the medical literature.

Acute Kidney Injury due to Rbadomyolysis Complicated with Zolpidem Overdose

Wed, 01 Jun 2016 00:00:01 +0100

Zolpidem (Stilnox

Acquired Pure Red Cell Aplasia following Autoimmune Hemolytic Anemia in Systemic Lupus Erythematosus

Wed, 01 Jun 2016 00:00:01 +0100

Pure red cell aplasia (PRCA) is a rare hematological disorder characterized by severe normochromic normocytic anemia and reticulocytopenia due to erythroid progenitor depletion in an otherwise normal bone marrow. Autoimmune hemolytic anemia (AIHA) is caused by autoantibodies directed against red blood cells with normocytic or macrocytic anemia with reticulocytosis. Both diseases can develop in conjunction with various underlying diseases, such as immunological disorders. Although rare, there have been a few cases of AIHA followed by PRCA. Here, we report a patient who developed PRCA following AIHA and was later diagnosed with systemic lupus erythematosus.

Trends of US Hospitalist and Suggestions for Introduction of Korean Hospitalist

Wed, 01 Jul 2015 00:00:01 +0100

A gap in the number of physicians caring for inpatients is expected in 2014 based on the restricted working hours for Korean medical residents. One potential solution is the use of hospitalists. The US hospitalist movement has proliferated due to high-quality care and economics. This movement has brought positive changes including a shorter length of hospital stay, increased quality of care, and greater patient satisfaction. Because the Korean government controls all suppliers and maintains a low financial compensation level for universal coverage, hospitals do not have the financial resources to introduce hospitalists. Therefore, in contrast to the US, the use of hospitalists must be developed as a cost-compensated system in Korea. Institutional strategies must be introduced to develop a hospitalist system in Korea. A hospitalist system in Korea would be distinct from that in the US. Further studies and specific strategies are needed that consider Koreas circumstances to effectively introduce a hospitalist system.

Epidemiology and Etiology of Obstructive Sleep Apnea

Wed, 01 Jul 2015 00:00:01 +0100

Obstructive sleep apnea (OSA) is one of common sleep disorders in western countries, affecting 4% of males and 2% of females. It is characterized by repeated obstruction of the upper airway during sleep, leading to intermittent hypoxemia, sympathetic activation, and sleep fragmentation. OSA is an independent risk factor for a range of medical problems, including cardiovascular disease, diabetes, depression, and cognitive dysfunctions. The etiology of OSA is complex and incompletely understood, but recent studies have shown that the development of OSA depends on the structure of the airway anatomy, the responsiveness of the upper airway dilator muscle to stimulation, and the stability of the respiratory control system. This review details the epidemiological and experimental evidence surrounding the associations between OSA and chronic diseases. Recent findings on the etiology of OSA will also be discussed.

Complications of Obstructive Sleep Apnea

Wed, 01 Jul 2015 00:00:01 +0100

While obstructive sleep apnea is a well-known sleep disorder, undiagnosed and untreated patients are an enormous burden in Korea. An episode of obstructive sleep apnea can induce dramatic changes in hemodynamics, leading to desaturation/reperfusion injury. Many complications follow episodes of obstructive sleep apnea and result in cardiovascular and other diseases, such as hypertension, heart failure, stroke, coronary artery disease, arrhythmias, pulmonary hypertension, diabetes mellitus, impotence, and even cancer mortality. Consequently, the role of physicians in detecting, treating, and educating patients about obstructive sleep apnea becomes more important.

Medical Management of Obstructive Sleep Apnea

Wed, 01 Jul 2015 00:00:01 +0100

Obstructive sleep apnea (OSA) is a prevalent disorder characterized by repeated episodes of obstructive apnea and hypopnea due to repetitive collapse of the upper airway during sleep. OSA should be suspected in patients that are obese, hypertensive, habitual snorers, and hypersomnolent. Standard overnight polysomnography is essential for proper diagnosis. OSA is a chronic disease that requires long-term multidisciplinary care. Management of this condition begins with patient education. Behavior modifications, such as weight loss, exercising, changing the sleep position, abstaining from alcohol, and avoiding certain medications, are essential for most patients with OSA. Positive airway pressure (PAP) is the mainstay therapy for OSA, and its initiation requires selection of an appropriate device and mode of PAP. The optimal pressure is determined by titration during the second polysomnography. Continuous positive airway pressure (CPAP) is the first-line therapy for moderate to severe OSA. Due to low compliance rates of CPAP, it is important to educate patients and manage complications associated with mask and pressure-related discomfort as early as possible. Bi-level PAP or auto-titrating PAP is an acceptable options for patients that cannot tolerate CPAP. In cases of mild to moderate OSA, an oral appliance can be used as a reasonable alternative therapy.

Surgical Treatment of Obstructive Sleep Apnea Syndrome

Wed, 01 Jul 2015 00:00:01 +0100

Continuous positive airway pressure (CPAP) has proven very effective in the treatment of adult obstructive sleep apnea syndrome (OSAS). However, the CPAP device must be used every day and is associated with some discomfort. As a result, many patients do not comply with physician-recommended CPAP usage. Surgical intervention for OSAS eliminates issues with patient non-compliance. Although it is less effective than CPAP, surgery represents a feasible alternative for patients who are non-compliant with CPAP usage, have mild to moderate OSAS without significant comorbidities, or suffer from simple snoring. Nasal surgery can also reduce an individuals CPAP pressure requirement and thus increase compliance. Of the various surgical procedures available, uvulopalatopharyngoplasty, which removes excess tissue from the soft palate and pharynx, is successful only in selected patients, while multilevel surgery is more effective. For example, maxillomandibular advancement is promising, although it is associated with potential morphological change in the airway. Radiofrequency ablation and palatal implants are minimally invasive interventions for simple snoring and mild OSAS. In morbidly obese patients, bariatric surgery has proven particularly effective. Finally and most recently, surgically implanted devices that stimulate the hypoglossal nerve have been investigated.

Receptor for Hepatitis B and D Virus

Wed, 01 Jul 2015 00:00:01 +0100

Chronic hepatitis B affects 400 million people worldwide and is one of the leading causes of liver-related morbidity and mortality. All clinically available hepatitis B virus (HBV) drugs are nucleoside or nucleotide analogs that inhibit viral reverse transcriptase (RT) activity. Resistance to these HBV drugs has been widely reported, and is due to specific mutations in the viral RT domain. Therefore, the development of new, non-polymerase targeting anti-HBV agents is urgently needed. A potential drug target, the HBV receptor that mediates the viral entry process, has been recently identified using human primary hepatocytes, northern tree shrew (Tupaia belangeri) hepatocytes, and HepaRG cells. A transporter of bile acids, sodium taurocholate cotransporting polypeptide (NTCP), was identified as the receptor for HBV and hepatitis D virus, and the transport function of NTCP was correlated with HBV entry. Therefore, functional inhibitors of NTCP may inhibit HBV infection, and viral entry was blocked by several NTCP receptor-targeting compounds. The HBV receptor is an attractive target for development of entry inhibitors, and serves as a model for the mechanistic study of HBV entry and infection. This review will summarize the characteristics and clinical importance of NTCP, and will discuss the potential therapeutic use of NTCP inhibitors to prevent HBV entry.

Treatment of Iron-Deficiency Anemia

Wed, 01 Jul 2015 00:00:01 +0100

Comparison of Ultrasonography and 99mTc-sestamibi Scan for Preoperative Localization of ...

Wed, 01 Jul 2015 00:00:01 +0100

Background/Aims: Primary hyperparathyroidism can be cured by minimally invasive surgery (MIS) with optimized preoperative localization. Ultrasonography (US) and ^99mTc-sestamibi (MIBI) scan are the imaging modalities most widely used for the localization of the affected glands. In this study, we defined the roles of US and MIBI scan. Methods: We retrospectively reviewed 40 patients who underwent parathyroidectomy for a single parathyroid adenoma between 2004 and 2013. US and scintigraphic findings were compared with operative findings. Results: Adenomas were accurately localized using US and MIBI scan in 38 patients (95%) and 37 patients (92.5%), respectively. Twenty-nine patients (76.3%) showed typical extrathyroidal hypoechoic nodule with central or peripheral vascularity, and, after MIS, we confirmed that they were suffering from a single parathyroid adenoma. Eight patients with atypical US findings and two patients with an undetectable lesion on US underwent MIS after localization using MIBI scan or computed tomography (CT). Only one patient showed an extrathyroidal cystic nodule evidenced by high parathyroid hormone cystic fluid on ultrasound-guided fine-needle aspiration and negative MIBI scan. All lesions not localized on US were located in the superior portion. Conclusions: US is a sensitive and accurate method for the preoperative localization of parathyroid adenoma, especially if the lesion has typical US features and is located inferiorly. We suggest that US be the first localization modality and that MIBI scan or CT be used in the limited number of cases with negative US findings.

Clinical Characteristics of Defectors from North Korea Visiting a Single Tertiary Hospital in ...

Wed, 01 Jul 2015 00:00:01 +0100

Background/Aims: There are increasing numbers of North Korean defectors, and their health status differs from that of the South Korean population. This study was performed to investigate the clinical characteristics of North Korean defectors visiting a single tertiary hospital in South Korea. Methods: The medical records of North Korean defectors who visited Dankook University Hospital, Cheonan, South Korea from 1 February 2006 to 30 April 2014 were retrospectively reviewed. Their comorbidities, main reasons for the visit, and most common diseases were investigated. Results: A total of 169 North Korean defectors (163 females, 6 males) visited our hospital. Sixty-eight patients (40.24%) had comorbidities, the most common of which was tuberculosis (13.60%), followed by chronic hepatitis B (10.06%) and chronic hepatitis C (9.47%). North Korean refugees visited the department of ophthalmology (15.71%) most frequently, followed by gastroenterology (15.18%). Cataracts, chronic hepatitis C, chronic hepatitis B, and pulmonary tuberculosis were the most common reasons for the hospital visit. Chronic hepatitis B and chronic hepatitis C were diagnosed in 19.32% and 17.58% of the patients, respectively. Sixteen patients (9.47%) were diagnosed with tuberculosis, and eight of these patients showed multidrug resistance. Of all 169 patients, 17 underwent colonofibroscopy or stool examination, and parasites (Trichuris trichiura, n = 6; Clonorchis sinensis, n = 1) were found in 7 patients (41.18%). Conclusions: Most North Korean defectors who visited this tertiary hospital in South Korea were female, and they mainly visited the departments of ophthalmology, gastroenterology, and pulmonology. Compared with South Koreans, they showed high rates of chronic hepatitis B, chronic hepatitis C, pulmonary tuberculosis with multidrug resistance, and parasite infection.

A Case of Simultaneous Primary Gastric and Duodenal Mucosa-Associated Lymphoid Tissue Lymphoma ...

Wed, 01 Jul 2015 00:00:01 +0100

Primary gastrointestinal lymphoma is the most common type of extranodal non-Hodgkins lymphoma. Most cases are defined histologically as mucosa-associated lymphoid tissue (MALT) lymphoma, while low-grade MALT lymphoma affecting the stomach and duodenum simultaneously is rare. In this case report, we describe the case of a 55-year-old female who presented to the gastroenterology clinic at our hospital for management of gastric adenoma and duodenal polyp by endoscopic mucosal resection and polypectomy. The pathology report noted MALT lymphoma with submucosal tubulovillous adenoma and hyperplastic polyps in the stomach and duodenum. She underwent eradication of Helicobacter pylori using proton pump inhibitor-based triple therapy.

A Case of Solid Variant of Serous Cystadenoma Misdiagnosed as a Neuroendocrine Tumor of the Pancreas

Wed, 01 Jul 2015 00:00:01 +0100

Rapid advancements, access to and use of imaging techniques have increased the frequency of identification of pancreatic cystic neoplasms in clinical practice. However, a diagnostic dilemma among pancreatic cystic neoplasms remains. Solid variant serous cystadenoma is extremely rare and difficult to accurately diagnose preoperatively, as they are commonly mistaken for malignant solid tumors of other types. Here, we present a case of a solid variant serous cystadenoma preoperatively misdiagnosed as a neuroendocrine tumor of the pancreas with a review of the relevant literature.

Reversible Atrioventricular Block after Electrical Injury

Wed, 01 Jul 2015 00:00:01 +0100

Here, we report a case of electrical injury-induced reversible advanced second-degree atrioventricular (AV) block. A 28-year-old male visited the emergency department for palpitations 3 days after receiving an electrical injury from 220 volt alternating current. The initial electrocardiogram (ECG) showed sinus rhythm and first-degree AV block with a prolonged PR interval of 400 ms. There was no structural heart disease or electrolyte imbalance. Follow up ECGs acquired 4-6 days after the electrical injury showed intermittent AV block with a prolonged PR interval of 400-460 ms. Exercise treadmill and atropine provocation tests performed 6 days after electrical injury induced advanced second-degree AV block. His bundle electrogram showed intermittent AH block in a Wenckebach pattern with a prolonged AH interval of 220-360 ms and a normal HV interval. Episodes of AV block decreased remarkably 4 weeks after the electrical injury, and the prolonged PR interval returned to 220 ms after 5 months.

A Case of Paroxysmal Atrial Fibrillation and Sinus Bradycardia due to Coronary Artery Spasm

Wed, 01 Jul 2015 00:00:01 +0100

Paroxysmal atrial fibrillation may be induced by coronary spasm presenting with typical angina-like pain and palpitations. It is typically treated using rate or rhythm control strategies, although sustained coronary spasm can induce sinus bradycardia with dizziness and syncope. In the present case, we reached a diagnosis of paroxysmal atrial fibrillation and sinus bradycardia due to coronary artery spasm using the methyl-ergonovine provocation test during angiography. While the treatment of coronary spasm can resolve paroxysmal atrial fibrillation, sinus bradycardia, and variant angina, the mechanism remains unclear, although it may be associated with sinus node ischemia. Similar symptoms, particularly chest discomfort, should be carefully considered in cases of paroxysmal atrial fibrillation.

A Case of Massive Pulmonary Embolism Masked by a Ventricular Septal Defect

Wed, 01 Jul 2015 00:00:01 +0100

Patients with massive pulmonary embolism may present with severe dyspnea at rest, syncope, or cardiac arrest. Early diagnosis and treatment are essential to reduce mortality; however, patient-specific factors can influence the hemodynamic effect of pulmonary embolism. Here, we present a case of massive pulmonary embolism masked by a ventricular septal defect in a 73-year-old female.

A Case of Disseminated Cryptococcosis Mimicking Lung Cancer and Prostate Cancer in an ...

Wed, 01 Jul 2015 00:00:01 +0100

Cryptococcosis can occur in immunocompetent patients; in fact, it accounts for 20% of all cryptococcal infections. In immunocompetent patients, although clinical symptoms may not be obvious, cryptococcosis should be considered in the differential diagnosis for cancer and other diseases. We recently encountered a case of disseminated cryptococcosis involving the lung and prostate. A 71-year-old male patient was referred for evaluation of a large pleural effusion. He was a 40 pack-years ex-smoker, and showed no evidence of immunodeficiency. Chest computed tomography and positron emission tomography images suggested primary lung cancer with pleural metastases and prostate cancer. Tuberculous pleurisy was suspected due to a lymphocyte-dominant exudative pleural effusion and high level of adenosine deaminase. Prostate and bronchoscopic biopsies demonstrated chronic granulomatous inflammation, and periodic acid Schiffs and Grocotts methenamine silver staining confirmed cryptococcosis in both specimens. Antifungal therapy with fluconazole was started, and follow-up images showed complete resolution of the pleural effusion.

A Case of a Coexisting Aldosterone-Producing Adrenal Adenoma and Ipsilateral Renal Artery Stenosis

Wed, 01 Jul 2015 00:00:01 +0100

The simultaneous occurrence of renovascular hypertension and an aldosterone-producing adrenal adenoma is a rare entity. Here, we report the case of a 52-year-old female who had a coexisting aldosterone-producing adrenal adenoma and ipsilateral renal artery stenosis. She was diagnosed with the aldosterone-producing adrenal adenoma and then underwent a laparoscopic left adrenalectomy. Her blood pressure was uncontrolled after the adrenalectomy. Selective renal angiography showed left renal artery stenosis; thus, she underwent balloon angioplasty at the same sitting. Subsequently, her blood pressure returned to normal after administration of a single antihypertensive drug. This case suggests that it is important to recognize the possible coexistence of renal artery stenosis in a patient with an aldosterone-producing adrenal adenoma.

Pseudo-Renal Failure with Severe Hyponatremia due to Spontaneous Bladder Rupture

Wed, 01 Jul 2015 00:00:01 +0100

Spontaneous bladder rupture is rare. Such an occurrence may appear similar to renal failure because the resulting urine leakage into the peritoneal cavity and absorption across the peritoneum increases serum creatinine although glomerular filtration rate is normal. A 46-year-old man presented with abdominal distension for 7 days after consuming a large volume of alcohol. Initial laboratory tests showed a blood urea nitrogen level of 174.3 mg/dL, serum creatinine of 11.49 mg/dL, and serum sodium of 105 mmol/L. Abdominal distension resolved after draining 5,200 mL of urine through a bladder catheter. Computed tomography cystography revealed intraperitoneal leakage of contrast dye from the left dome of the bladder, suggesting an intraperitoneal bladder rupture. Azotemia was completely normalized on the third day of hospitalization. This case shows that pseudo-renal failure should be considered when caring for a patient with unexplained azotemia and ascites.

Small Cell Lung Cancer with Mutation of Epidermal Growth Factor Receptor in Patients with Lung ...

Wed, 01 Jul 2015 00:00:01 +0100

Most epidermal growth factor receptor (EGFR) gene mutations are detected in lung adenocarcinomas. In contrast, these mutations have rarely been reported in small cell lung cancer (SCLC). We herein report two cases of EGFR-mutant SCLC transformed from and combined with lung adenocarcinoma. In one case, SCLC appeared to be transformed from EGFR mutant 19-del adenocarcinoma when the patient became resistant to gefitinib. The other patient had combined EGFR-mutant 19-del SCLC and adenocarcinoma at the initial diagnosis, which was resistant to gefitinib at multiple sites. Further comparative molecular analyses of these histologically distinct tumors would provide useful information regarding the role of EGFR mutation in the pathogenesis of SCLC. In conclusion, despite the presence of the same EGFR mutation, gefitinib was not effective in treatment of SCLC. Therefore, confirmation of SCLC cell morphology may become an important means of predicting resistance to EGFR tyrosine kinase inhibitors in addition to common secondary genetic alterations.

Treatment of a Patient with Kaposi

Wed, 01 Jul 2015 00:00:01 +0100

Kaposis sarcoma (KS) is an unusual multifocal neoplastic angioproliferative disorder. We herein report a case of classic KS that occurred in a patient receiving hemodialysis for 7 years. The patient had a history of chronic renal failure due to glomerulonephritis for 20 years. Multiple reddened violaceous patches, plaques, and nodules were found on the right knee. Biopsy revealed positivity for human herpesvirus 8 (KS-associated herpesvirus) consistent with KS. Pazopanib, a multitarget tyrosine kinase inhibitor, is an effective agent for treatment of advanced soft tissue sarcoma. The patient received pazopanib for 6 months investigate its effects on KS. The skin lesions and painful symptoms showed improvement. Further studies are required to determine the mechanism underlying the anticancer action of pazopanib and the pathogenesis of KS.

A Case of Adrenal Tuberculosis Combined with Tuberculous Peritonitis-Induced Adrenal Crisis

Wed, 01 Jul 2015 00:00:01 +0100

An adrenal crisis is a serious medical emergency. Most such crises develop in patients with Addisons disease when they are stressed. However, the clinical features of an impending adrenal crisis are nonspecific, delaying diagnosis and management. Adrenal tuberculosis is very rare among the extrapulmonary forms of tuberculosis. We herein report a case of an adrenal crisis triggered by bilateral adrenal tuberculosis. A 35-year-old man was admitted to our hospital because of drowsiness, fever, and hypotension. Abdominal computed tomography revealed bilateral adrenal enlargement, and computed tomography-guided adrenal gland biopsy allowed us to diagnose adrenal tuberculosis.

A Case of Rheumatoid Arthritis Accompanied by Thrombotic Thrombocytopenic Purpura

Wed, 01 Jul 2015 00:00:01 +0100

Thrombotic thrombocytopenic purpura (TTP) is a blood coagulation disorder that damages numerous organs, including the kidney, heart and brain. Features indicative of TTP include thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms, kidney failure and fever. Infections, toxins, pregnancy and, rarely, autoimmune diseases are all known to be associated with TTP. We encountered a rare case of rheumatoid arthritis accompanied by TTP following tympanoplasty. The patients confusion, thrombocytopenia and renal failure all improved after plasmapheresis and high-dose glucocorticoid therapy, but she eventually expired due to sepsis. We report on this case herein and also review the relevant literature.

A Case of Gastrointestinal Sarcoidosis without Pulmonary Involvement

Wed, 01 Jul 2015 00:00:01 +0100

Sarcoidosis is a multisystemic granulomatous disease of unknown etiology that is based on the presence of non-caseating granulomas. Sarcoidosis commonly involves the lungs, skin, and eyes. Gastrointestinal tract involvement in sarcoidosis is uncommon. Gastrointestinal tract sarcoidosis commonly occurs subclinically, with clinical manifestations present in only 0.1-0.9% of patients with the disease. There are rare case reports of an individual with symptomatic gastrointestinal sarcoidosis. In Korea, gastrointestinal sarcoidosis without pulmonary involvement has not been reported previously. Here, we describe a case of gastrointestinal sarcoidosis in a 37-year-old male with symptoms of weight loss, fever, and abdominal pain. He was diagnosed based on the presence of non-caseating epithelioid granulomas in the stomach, duodenum, and colon by multiple biopsies.

Epidemiology and Pathophysiology of Helicobacter Pylori Infections in Korea

Sat, 01 Aug 2015 00:00:01 +0100

Helicobacter pylori (H. pylori) commonly infects humans worldwide. However, only limited proportions of infected populations develop clinical manifestations ranging from asymptomatic gastritis to gastric cancer. A Korean nationwide survey revealed that the overall H. pylori seroprevalence was 66.9% in 1998, and significantly decreased in later years in all age groups to 59.6% in 2005 and 54.4% in 2011. In terms of geographical regions, the seroprevalence trended significantly downward in most areas over time, except in Kyungsang and Kangwon. The various outcomes of H. pylori infection are caused by imbalances between bacterial virulence factors, host factors including genetic diversity, and environmental influences. H. pylori infection triggers responses by almost all forms of innate and acquired immunity. In the present review, we describe the epidemiology and pathophysiology of H. pylori infection in Korea. A better understanding of the prevalence trend and the mechanisms of immune responses to H. pylori infection will allow public health authorities to develop novel therapeutic strategies.

Helicobacter Pylori Infection and Related Gastrointestinal Diseases

Sat, 01 Aug 2015 00:00:01 +0100

Helicobacter pylori is among the most common bacterial pathogens, but it has not yet been conquered. It is related to various gastrointestinal diseases, including chronic gastritis, peptic ulcer, gastric marginal zone B cell lymphoma, and gastric cancer. The association between Helicobacter pylori infection and functional dyspepsia or gastroesophageal reflux disease is not clear. Numerous factors determine disease course and outcome, such as bacterial virulence, genotype, host immunity, and environmental factors. The eradication of Helicobacter pylori in associated gastrointestinal diseases is important for the treatment and prevention of recurrent or severe outcomes, especially in Korea where gastric cancer is prevalent.

Diagnosis and Treatment of Helicobacter Pylori Infection

Sat, 01 Aug 2015 00:00:01 +0100

Helicobacter pylori affects nearly half of the worlds population and is a major pathogen associated with prevalent gastrointestinal disorders, including peptic ulcer and gastric cancer. Various diagnostic methods are available to detect infection, and the choice of method depends on factors such as their accessibility, advantages and disadvantages and cost. New treatment options for eradicating H. pylori have emerged as a result of the decreased efficacy of standard triple therapy due to increasing antibiotic resistance. This work reviews the main diagnostic methods used to identify H. pylori infection and to confirm the eradication of infection. We also provide a comprehensive overview of current and emerging strategies for the treatment of H. pylori infection.

Diagnosis and Treatment of Helicobacter Pylori Infection: Korean and Overseas Guidelines

Sat, 01 Aug 2015 00:00:01 +0100

The Korean College of Helicobacter and Upper Gastrointestinal Research proposed revised guidelines for the diagnosis and treatment of Helicobacter pylori infection in 2013. These new guidelines were developed using an adaptation process, and addressed the revised recommendations especially in the changes of indication and treatment of H. pylori infection in Korea. They included 19 statements: 11 on the indications for tests and treatment, four for the diagnosis, and four for the treatment. A critical difference between the new and previous guidelines was that the proposed treatment regimen was more detailed, in consideration of the increasing resistance to antibiotics in Korea. Although clarithromycin-containing triple therapy was proposed as the first-line treatment option, per the previous guidelines, a bismuth-based quadruple regimen was also proposed as an effective alternative. In the case of treatment failure following bismuth quadruple therapy, second-line treatment should be based on two or more antibiotics that had not been used previously. Several overseas guidelines from America, Europe, Canada, Japan, and the Asia-Pacific region have been published concerning H. pylori infection; they indicate regional differences in epidemiology, antibiotic susceptibility, and national health insurance systems. This review compares the guidelines for H. pylori infection among these regions.

Recent Advances in the Management of Autosomal Dominant Polycystic Kidney Disease

Sat, 01 Aug 2015 00:00:01 +0100

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease. It is characterized by the dysregulated growth of kidney cysts, resulting in end-stage kidney failure. By identifying the genes involved in ADPKD and detailing the molecular pathology of the disease, putative therapeutic agents have been developed. However, clinical trials of vasopressin receptor antagonists and somatostatin analogues have raised several concerns among researchers and clinicians. Questions regarding when and who to treat and what surrogate marker to use for describing endpoints have been raised. This review focuses on the current methods for managing ADPKD and describes recent findings from clinical trials. The main difficulties associated with implementing therapeutic agents in patients with ADPKD and considerations for clinical settings will also be discussed.

What is the FODMAP?

Sat, 01 Aug 2015 00:00:01 +0100

Outcome of Percutaneous Coronary Intervention with Intra-Aortic Balloon Pump in Patients with ...

Sat, 01 Aug 2015 00:00:01 +0100

Background/Aims: The mortality of hospitalized patients undergoing treatment with an intra-aortic balloon pump (IABP) due to cardiogenic shock is well known as quite high. The aim of this study was to evaluate the outcome of percutaneous coronary intervention (PCI) with an IABP in patients with acute coronary syndrome (ACS) and cardiogenic shock and identify the predictors of in-hospital mortality. Methods: 134 patients who underwent PCI with IABP due to ACS complicated by cardiogenic shock were consecutively enrolled. Outcomes were obtained and analyzed during hospitalization and after 1 year. Results: The incidence of all-cause mortality was 35.8% (in-hospital mortality, 34.3%; 1-year mortality, 1.5%). The nonsurvival group exhibited higher peak levels of creatine kinase MB; lower ejection fractions; and higher incidences of ST elevation myocardial infarction, ventricular arrhythmia, and use of an assistive device than did the survival group. Aging (hazard ratio 2.839; 95% confidence interval 1.408-5.723; p = 0.004), the use of a temporary pacemaker (2.035; 1.114-3.720; 0.021), the use of a mechanical ventilator (4.376; 1.852-10.341; 0.001), and the performance of cardiopulmonary resuscitation (CPR) (2.219; 1.017-4.839; 0.045) were independent predictors for in-hospital mortality. However, out-of-hospital mortality among in-hospital survivors was not affected by predictors of in-hospital mortality. Conclusions: The incidence of in-hospital mortality was high, as expected in patients undergoing PCI with IABP due to ACS with cardiogenic shock. Aging, CPR, and additional procedures such as pacemaker use and mechanical ventilation were predictors of in-hospital mortality. However, the patients who were successfully discharged after the complex procedure showed acceptable 1-year outcomes.

Comparison of Clinical Outcomes after Implantation of First- and Second-Generation Overlapping ...

Sat, 01 Aug 2015 00:00:01 +0100

Background/Aims: Despite improved revascularization techniques, the clinical outcomes of patients with diffuse coronary artery lesions after percutaneous coronary intervention are unsatisfactory. However, few studies have compared the efficacy of first- and second-generation drug-eluting stents (DES) in patients with diffuse long coronary artery lesions. Methods: Between January 2006 and July 2012, 364 patients who were treated with DES for long coronary artery stenosis (> 30 mm) were enrolled in this study and assigned to either Group I (first-generation DES, 62.3

A Primary Duodenal Angiosarcoma with Lung and Bone Metastases: A Case Report and Literature Review

Sat, 01 Aug 2015 00:00:01 +0100

An angiosarcoma is a rare soft-tissue neoplasm that develops anywhere in the body, and most commonly presents cutaneously in elderly white males, involving the head and neck, particularly the scalp. The neoplasm occurs only very rarely in the gastrointestinal tract. A patient was initially admitted to our hospital for treatment of dyspnea and hemoptysis. Both lungs contained multiple nodules, and a computed tomography (CT)-guided lung biopsy was performed. Endogastroduodenoscopy used to evaluate the anemia revealed a duodenal polypoid tumor. Microscopic examination showed that the tumor was a primary angiosarcoma of the duodenum with metastasis to the lung. In addition, positron emission tomography/CT revealed metastasis to the femur and the pelvic bone. Thus, we report a case of primary duodenal angiosarcoma with metastases to the lung and bone.

A Case of Stress-Induced Cardiomyopathy after Propofol Anesthesia

Sat, 01 Aug 2015 00:00:01 +0100

Propofol is an intravenous hypnotic agent that is generally used for sedation in the intensive care unit and for induction of anesthesia during minimally invasive surgery, endoscopy, and plastic surgery in local clinics. Low blood pressure and transient apnea might occur under propofol sedation, whereas stress-induced cardiomyopathy is a very rare complication. We herein describe a case involving a 25-year-old woman without cardiovascular risk factors who developed stress-induced cardiomyopathy after propofol injection for anesthesia and was treated with conservative treatment. This case reminds us that clinicians should consider the possible occurrence of stress-induced cardiomyopathy after anesthesia using propofol, even in patients without cardiovascular risk factors.

Two Cases of Treatment with Thrombolysis and an Extracorporeal Membrane Oxygenator in Patients ...

Sat, 01 Aug 2015 00:00:01 +0100

Massive pulmonary embolism (PE) is associated with poor prognosis and high mortality. Moreover, patients with massive PE who present with shock have mortality rates ranging from 30% to 50%. Thrombolysis should be administered to patients with massive PE unless there are absolute contraindications to its use. However, treatment failure still occurs, and there is no consensus for the management of massive PE with cardiopulmonary arrest with regard to thrombolysis. In this study, two cases of massive PE with cardiopulmonary arrest are described, both of which were successfully treated with thrombolysis and hemodynamic support, which was administered by extracorporeal membrane oxygenation (ECMO). This report suggests that ECMO may provide safe and adequate cardiopulmonary support in patients with massive PE with refractory thrombolysis and cardiopulmonary arrest.

A Case of Pheochromocytoma Presenting as Ventricular Tachycardia Storm

Sat, 01 Aug 2015 00:00:01 +0100

A 35-year-old woman was admitted for recurrent palpitations and headache with cold sweats. No structural abnormality was detected via cardiac imaging studies. A standard 12-lead electrocardiogram (ECG) revealed sustained monomorphic ventricular tachycardia (VT). Propranolol (120 mg/day) was administered; however, the frequency and duration of VT episodes increased rapidly. A 24-hr ambulatory ECG revealed frequent, successive, premature ventricular beats; accelerated idioventricular rhythms; and VTs with various cycle lengths and QRS complex morphologies. ECG findings suggested that the observed ventricular arrhythmias were driven by accelerated automaticity as their main electrophysiological mechanism. Based on clinical manifestations and ECG findings, pheochromocytoma was suspected. Solitary left adrenal pheochromocytoma was diagnosed by endocrine and imaging studies. Instead of propranolol, oral doxazosin (8 mg/day) was administered, and symptoms and VT attacks were successfully suppressed. After surgical resection of the pheochromocytoma, clinical VT was not observed in response to the high-dose isoproterenol provocation test.

A Case of Kikuchi Disease Involving an Intrapulmonary Lymph Node Mistaken for a Pulmonary Nodule

Sat, 01 Aug 2015 00:00:01 +0100

Kikuchi-Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is an uncommon idiopathic, self-limiting disease characterized by cervical lymphadenopathy. Patients with KFD may present with a wide variety of nonspecific symptoms, including fever, night sweats, and weight loss. Although KFD can affect all lymph nodes of the body, involvement of the intrathoracic lymph nodes is relatively rare. In particular, isolated involvement of the intrapulmonary lymph nodes is extremely unusual. We herein report a case involving a 45-year-old man who presented with symptoms of myalgia, fatigue, and fever. Computed tomography performed during follow-up showed a slowly growing nodule in the upper lobe of the left lung. Results of laboratory tests did not reveal any evidence of infection or autoimmune disease, including systemic lupus erythematosus. Results of excisional biopsy by video-assisted thoracoscopic surgery revealed KFD in an intrapulmonary lymph node. His symptoms improved after a trial of nonsteroidal anti-inflammatory drugs.

A Case of Graves

Sat, 01 Aug 2015 00:00:01 +0100

Graves disease following subacute thyroiditis is uncommon. Some patients in these cases showed positive for thyroid antibody only transiently in the resolving phase. However, Graves disease can rarely be caused by the presence of antibodies after subacute thyroiditis, although the pathophysiology of this is unclear. A 40-year-old woman presented with anterior neck pain and swallowing difficulty. Thyroid function testing showed reduced thyroid-stimulating hormone (TSH) and elevated free thyroxine levels. A thyroid scan revealed decreased uptake in the bilateral thyroid gland. The patient was initially diagnosed with subacute thyroiditis and treated with steroids. Five months later, thyroid function testing showed recurrent hyperthyroidism with positive conversion of TSH receptor antibody, indicating Graves disease. Since then, she needed the long-term methimazole treatment. In summary, we herein report a case of Graves disease occurring after subacute thyroiditis.

Febuxostat for the Treatment of Chronic Tophaceous Gout in a Patient on Continuous Ambulatory ...

Sat, 01 Aug 2015 00:00:01 +0100

Hyperuricemic patients with gouty arthritis or tophi, a serum uric acid concentration of 8.0 mg/dL or higher, and complications should be treated with urate-lowering drugs. Conventionally, allopurinol is used to treat hyperuricemia and gout, but it is necessary to adjust the dosage according to the degree of renal impairment. Uncommonly, allopurinol may have severe or fatal side effects. The non-purine xanthine oxidase inhibitor febuxostat undergoes hepatic metabolism and may require less dose adjustment in association with renal function. It is considered to be an alternative treatment for hyperuricemic patients with chronic kidney disease. Our experience suggests that low-dose febuxostat is a promising alternative to allopurinol for the treatment of gouty arthritis or tophi in peritoneal dialysis patients.

A Case of Primary Cardiac Osteosarcoma with Pulmonary Vein Obstruction

Sat, 01 Aug 2015 00:00:01 +0100

Primary cardiac osteosarcoma is extremely rare. We herein report a case involving a 31-year-old woman with a 2-week history of left upper trunk pain and hemoptysis. She was diagnosed with primary cardiac osteosarcoma with pulmonary vein obstruction and successfully treated via surgical resection and chemotherapy.

Recurrent Prostate Cancer Presenting as Multiple Lung Metastases with a Low Serum ...

Sat, 01 Aug 2015 00:00:01 +0100

Prostate-specific antigen (PSA) is a glycoprotein produced by prostatic duct and acinar epithelial cells and the most commonly used marker for diagnosing prostate cancer, and for monitoring its progression and recurrence. Here, we describe a 76-year-old patient with recurrent prostate cancer who developed isolated hematogenous pulmonary metastases with a normal serum PSA level 5 years after radical prostatectomy. Immunohistochemical (IHC) analysis of a transbronchial lung biopsy specimen revealed tumor cells positive for PSA and prostatic acid phosphatase. After 2 months of maximal androgen blockade, the metastatic pulmonary nodules showed near-complete regression. In conclusion, metastases of prostate adenocarcinoma may occur despite low serum PSA levels, and, if warranted clinically, IHC staining or other serological markers for prostate adenocarcinoma should be considered when evaluating metastatic carcinoma from an unknown primary lesion in males with low serum PSA levels.

Fatal PTLD Accompanied by Rapid Lymphocyte Proliferation in the Early Phase of Allogeneic HSCT

Sat, 01 Aug 2015 00:00:01 +0100

Post-transplant lymphoproliferative disorder (PTLD) is a spectrum of clinically and morphologically heterogeneous lymphoid proliferations of various clonal compositions that are observed after hematopoietic stem cell transplantation (HSCT) or solid organ transplantation. The majority of PTLD cases are associated with Epstein-Barr virus (EBV) infection, while overt peripheral blood (PB) or bone marrow (BM) involvement in PTLD is uncommon in early lesions. We report a 38-year-old woman with EBV-related PTLD, with BM and PB involvement, who presented with peripheral lymphocytosis as an early lesion 1 month after haploidentical HSCT for Philadelphia chromosome-positive acute lymphoblastic leukemia was performed during first complete remission. Although PB or BM involvement of PTLD after HSCT is uncommon in early lesions, peripheral lymphocytosis can be an initial presenting manifestation of PTLD, as in this case.

A Case of Cardiac Beh

Sat, 01 Aug 2015 00:00:01 +0100

Beh

A Case of Sj

Sat, 01 Aug 2015 00:00:01 +0100

Common variable immunodeficiency (CVID) is a heterogeneous group of primary immune deficiencies in adults characterized by hypogammaglobulinemia, recurrent bacterial infections, and a higher incidence of autoimmune diseases. More than 25% of CVID patients also have autoimmune diseases such as autoimmune hemolytic anemia, immune thrombocytopenic purpura, rheumatoid arthritis, and systemic lupus erythematosus. However, the pathogenesis of autoimmunity in CVID remains obscure. We report a 56-year-old woman with CVID and Sj

TNF-? Inhibitor Treatment in an Ankylosing Spondylitis Patient with Secondary Amyloidosis that ...

Sat, 01 Aug 2015 00:00:01 +0100

Secondary amyloidosis (Amyloid A amyloidosis) occurs when serum amyloid S accumulates in various tissues and organs. It often accompanies chronic inflammatory disease, especially rheumatoid arthritis, as well as ankylosing spondylitis (AS) and Crohns disease. Although amyloid deposits were reported in 7% of the abdominal fatty tissue samples from AS patients, most of the patients had no symptoms. In a large study, 1.1% of 730 patients with AS were diagnosed with amyloidosis. Most of them showed renal involvement, while none had gastrointestinal symptoms. In South Korea, only a few cases of gastrointestinal involvement of secondary amyloidosis have been reported in AS patients, and there is no report on the effect of a tumor necrosis factor (TNF)-? inhibitor. We report a case of secondary amyloidosis in an AS patient who improved with the TNF-? inhibitor etanercept.

Recent Update in Diabetic Nephropathy

Tue, 01 Sep 2015 00:00:01 +0100

Diabetic nephropathy is the leading cause of end-stage renal disease, and is associated with increased risk of cardiovascular disease. Optimal control of blood glucose and blood pressure based on the blockade of renin-angiotensin system is the standard of care for the prevention and treatment of diabetic nephropathy. Regardless of these therapies, the prevalence of diabetic nephropathy continues to increase, highlighting the need for additional therapies. Diabetes affects the progression of kidney disease through a variety of mechanisms; several new therapeutic agents targeting these pathways have been developed, with currently being evaluated in clinical trials.

New Modalities for the Diagnosis and Treatment of Diabetic Retinopathy

Tue, 01 Sep 2015 00:00:01 +0100

Over the past decade, significant advances have been made in both the diagnosis and treatment of diabetic retinopathy. Ultrawide field fundus photography and spectral domain optical coherence tomography have allowed more accurate, convenient, and early diagnosis of diabetic retinopathy. Numerous randomized clinical trials have demonstrated the effectiveness of anti-vascular endothelial growth factor agents for the treatment of diabetic retinopathy, although more work is necessary in terms of long-term clinical outcomes and socioeconomic costs associated with these treatments.

Management of Diabetic Peripheral Neuropathy

Tue, 01 Sep 2015 00:00:01 +0100

Diabetic peripheral neuropathy (DPN) is a common complication of diabetes mellitus. The prevalence of neuropathic pain is estimated to occur in about 30-50% of all diabetic patients. Clinical symptoms vary depending on the nerves affected, and may include both positive and negative symptoms. Many patients with DPN experience pain or discomfort, anxiety, depression, and limitations in activity, which can significantly impact their physical, emotional, and social well-being. Early diagnosis is essential for the successful management of DPN. Routine management consists of glucose and risk factor control, and symptomatic relief, along with therapies designed to target the underlying disease pathology. Pharmacological treatment of DPN includes tricyclic compounds, serotonin noradrenalin reuptake inhibitors, the antioxidant ?-lipoic acid, anticonvulsants, opiates, membrane stabilizers, topical capsaicin, and other drugs. Management of DPN must be tailored to each individual, and depends on a variety of factors, including disease severity and response to treatment.

Current Status of Coronary Stent

Tue, 01 Sep 2015 00:00:01 +0100

Coronary artery disease is one of the principal causes of mortality worldwide. Andreas Gr

Review of Sj

Tue, 01 Sep 2015 00:00:01 +0100

The Effect of Cilostazol on Arterial Stiffness in Patients Undergoing Percutaneous Coronary ...

Tue, 01 Sep 2015 00:00:01 +0100

Background/Aims: Increased arterial stiffness is a well-known risk factor for cardiovascular disease. Cilostazol, a phosphodiesterase type 3 inhibitor, is a unique antiplatelet agent with vasodilatory and vasoprotective effects. Therefore, we hypothesized that cilostazol may affect arterial stiffness. Methods: We enrolled 161 patients (112 males; mean age, 63 years) who had undergone percutaneous coronary intervention (PCI) for ischemic heart disease. The brachial-ankle pulse wave velocity (baPWV), radial augmentation index (rAI), rAI adjusted for a heart rate of 75 beats/min (rAI75), central systolic blood pressure (cSBP), and central pulse pressure (cPP), were measured at baseline and at the 30-day follow-up. Parameter changes were compared between the cilostazol group (n = 51) and the control group (n = 110). Results: In the cilostazol group, the values for rAI, cSBP, and cPP all improved after 30 days, while the control group displayed no significant interval changes in these parameters. The changes in rAI75 and baPWV did not differ significantly between the two groups. The changes in rAI, cSBP, and cPP were related to brachial systolic blood pressure, brachial diastolic blood pressure, heart rate, and the use of cilostazol and beta-blockers. In a multivariate analysis, the use of cilostazol was identified an independent factor associated with changes in rAI, cSBP, and cPP. Conclusions: The addition of cilostazol to conventional antiplatelet therapy in patients undergoing PCI may be associated with improvements in rAI, cSBP, and cPP, but not in rAI75 or baPWV. Therefore, the effects of cilostazol might be related to an increased heart rate.

Impact of Self-Efficacy on Medication Adherence among People Living with Human Immunodeficiency ...

Tue, 01 Sep 2015 00:00:01 +0100

Background/Aims: It is very important that people living with HIV (PLWH) maintain 95% medication adherence to increase health-related quality of life and prevent transmitting HIV. In this study, we analyzed factors influencing medication adherence among PLWH and used the basic data for practical interventions to increase medication adherence. Methods: A total of 190 PLWH, who were taking highly active antiretroviral therapy (HAART) from nine hospitals in South Korea, were included. The data were collected by self-administered questionnaire between April 1 and June 31, 2014. Results: About 92% of the subjects were male and 72.9% of the subjects belonged to the high compliance group. Medicationtaking self-efficacy was significantly related to compliance. Efficacy expectancy, which is a subscale of medication-taking selfefficacy, indicated that a score of 1 point higher on a 10-point scale increased compliance by 2.63 times. Conclusions: Medication adherence is associated with increased medication-taking self-efficacy. Therefore, it is necessary to promote self-efficacy to improve compliance considering the infection period and adverse reactions to HAART among PLWH.

A Case of Colitis by Giardia lamblia Infection with Atypical Presentation

Tue, 01 Sep 2015 00:00:01 +0100

Giardia lamblia infection, giardiasis, is the leading waterborne diarrhea-causing disease. It is common in most countries of the world, including South Korea and Japan. Giardia lamblia can cause asymptomatic infection but also acute abdominal discomfort with diarrhea. In addition, it may lead to chronic diarrhea associated with villous atrophy and impaired epithelial barrier in the small intestine. In the present case, a 45-year-old woman presented with lower abdominal discomfort in the absence of diarrhea. Colonoscopy showed diffuse mucosal edema, erythema, and erosions with exudate in the cecum and ascending colon. Colonoscopic biopsy and stool examination revealed trophozoites of Giardia lamblia. Colitis resolved after metronidazole therapy. Our case suggests that giardiasis should be included in the differential diagnosis of colitis, even if the patient does not present with diarrhea.

A Case of a Large, Gastric Intramural Hematoma Caused by Endoscopic Mucosal Resection, and ...

Tue, 01 Sep 2015 00:00:01 +0100

Only two cases of gastric intramural hematoma (IMH) caused by endoscopic mucosal resection (EMR) have been reported to date. This is the first reported case of gastric IMH caused by EMR, treatment of which required hemoclipping and transcatheter arterial embolization. The patient had a normal coagulation profile and no relevant medical history. About 8 h after completing the EMR, the patient vomited approximately 150 mL fresh blood and complained of abdominal pain. Endoscopy showed a 3

A Case of an Infected Aneurysm in the Thoracic Aorta Mimicking Tuberculous Lymphadenopathy

Tue, 01 Sep 2015 00:00:01 +0100

Tuberculous-infected aortic aneurysms are rare, but delayed diagnosis can lead to serious complications, including sudden aortic rupture. Here, we report a case of a tuberculous infected aneurysm in the thoracic aorta that was mistaken for lymphadenopathy. In this case, we could differentiate the lesion with the aid of contrast-enhanced computed tomography and positron emission tomography (PET). This case demonstrates the diagnostic value of PET in aortic aneurysms.

Multiple Ruptured Cerebral Aneurysms as a Presenting Feature of Pheochromocytoma in a Patient ...

Tue, 01 Sep 2015 00:00:01 +0100

Neurofibromatosis 1 (NF-1) shows an autosomal dominant pattern of inheritance with complete penetrance and variable expression. Vascular abnormalities are frequently associated with NF-1. Pheochromocytoma occurs in 0.1-5.7% of patients with NF-1. Spontaneous intracerebral hemorrhage in patients with NF-1-related pheochromocytoma is very rare. Herein, we report a case of subarachnoid hemorrhage caused by multiple ruptured cerebral aneurysms in a patient with concurrent NF-1 and pheochromocytoma. Coil embolization of the aneurysms and subsequent adrenalectomy for pheochromocytoma were successfully performed, and the patient remained normotensive thereafter. This case demonstrates the importance of a careful search for a remediable cause of episodic hypertension in patients with NF-1, who are predisposed to cerebral hemorrhage from fluctuating blood pressure.

Coarctation of the Aorta Treated with Stenting in a Patient with Turner Syndrome

Tue, 01 Sep 2015 00:00:01 +0100

Cardiovascular malformations, such as bicuspid aortic valve and coarctation of the aorta, are more prevalent in patients with Turner syndrome than in the general population. Here, we describe the case of a 35-year-old female with Turner syndrome who was admitted to our hospital with a fever caused by infective endocarditis. Aortic coarctation was diagnosed using computed tomography. The patient was treated with antibiotics and a stent was then implanted. Endovascular therapy using stents is a safe and effective treatment option for aortic coarctation in patients with Turner syndrome.

A Case of Desquamative Interstitial Pneumonia with an Increased Number of Eosinophils in ...

Tue, 01 Sep 2015 00:00:01 +0100

Here, we present a case of desquamative interstitial pneumonia (DIP) that was initially misdiagnosed as chronic eosinophilic pneumonia due to an increased number of eosinophils in the bronchoalveolar lavage fluid (BALF). A 56-year-old male smoker presented with a productive cough that had been present for 1 month. High-resolution computed tomography (HRCT) revealed multifocal patchy ground-glass and reticular opacities in the subpleural area. BALF analysis revealed an elevated level of eosinophils (37%). Thus, the patient was initially diagnosed with chronic eosinophilic pneumonia and was administered prednisolone (0.5 mg/kg/day). However, his symptoms and the diffuse infiltrative shadows on HRCT did not improve after 2 months of treatment, and a video-assisted thoracoscopic lung biopsy led to the diagnosis of DIP. Prednisolone (1 mg/kg/day) was administered again, and the patients symptoms improved. At 1 year after the end of treatment, the patient remained symptom-free.

A Case of Bilateral Adrenal Myelolipomas with Congenital Adrenal Hyperplasia

Tue, 01 Sep 2015 00:00:01 +0100

Adrenal myelolipoma (AML) is a rare, usually benign, and nonfunctioning tumor. About 7-15% of adrenal incidentalomas are AMLs, composed of normal hematopoietic elements and mature adipose tissue. AML is usually unilateral and < 4 cm. It is often discovered incidentally on abdominal computed tomography or magnetic resonance imaging. It is related to a chronic increase in adrenocorticotropic hormone, such as that observed in patients with congenital adrenal hyperplasia, Cushing disease, Conns syndrome, and pheochromocytoma. Here, we report a 28-year-old man diagnosed with non-salt-losing congenital adrenal hyperplasia with huge bilateral AMLs and a literature review.

Two Cases of Bacterial Peritonitis in Encapsulating Peritoneal Sclerosis

Tue, 01 Sep 2015 00:00:01 +0100

Encapsulating peritoneal sclerosis (EPS) is a rare complication of peritoneal dialysis associated with a high mortality rate. Bacterial peritonitis (BP), a complication of EPS treatment, is uncommon, and treatments for BP are not well known. We report two patients who had undergone steroid treatment who developed BP after hemodialysis transfer. In the first case, we treated the BP with antibiotics and performed several surgical drainage procedures; however, the fluid became too thick to drain. This patient died of malnutrition and sepsis. In the second case, antibiotics and surgical enterolysis with peritonectomy were used to treat the BP. Solid food was accepted on day 7 postoperatively, and the patient was stable after 20 months. Thus, surgical enterolysis with peritonectomy may be a good treatment modality for patients with EPS and BP.

A Case of Primary Cutaneous Anaplastic Large Cell Lymphoma with Extensive Limb Disease

Tue, 01 Sep 2015 00:00:01 +0100

Primary cutaneous anaplastic large cell lymphoma (pcALCL) is a rare subtype of malignant non-Hodgkin lymphoma, in which 40% of the cases show spontaneous regression without aggressive treatment. Surgery and focal radiation therapy are the primary forms of treatment for this disease; however, if pcALCL is accompanied by multifocal skin lesions, chemotherapy is also common. The prognosis for pcALCL is generally excellent, with a 5-year survival rate of 85-100%. However, pcALCL with extensive limb disease typically has a poor prognosis. Here, we present a case of pcALCL with extensive limb disease that resulted in the patients death, despite the use of aggressive chemotherapy.

Amylase-Producing Primary Peritoneal Carcinoma

Tue, 01 Sep 2015 00:00:01 +0100

A paraneoplastic syndrome is a disease or symptom that is the consequence of the presence of cancer in the body but is not due to the local presence of cancer cells. Thus, successful treatment of the underlying tumor often improves such syndromes. Amylase-producing lung cancer, multiple myeloma, and ovarian cancer are reported only rarely. In Korea, no cases of hyperamylasemia have been reported in patients with primary peritoneal carcinoma. We report an interesting case of hyperamylasemia suspected to have been induced by primary peritoneal carcinoma. The patients amylase isoenzyme patterns indicated salivary-type amylase. Hyperamylasemia was reduced in parallel with the response to chemotherapy. These data confirmed the diagnosis of amylase-producing primary peritoneal carcinoma.

Infected Aneurysm of the Abdominal Aorta due to Streptococcus pneumoniae

Tue, 01 Sep 2015 00:00:01 +0100

Streptococcus pneumoniae (S. pneumoniae), a bacterium that is part of the normal flora of the upper respiratory tract, can cause pneumonia, bacteremia, otitis media, and meningitis. There are few reports of infected abdominal aortic aneurysms due to S. pneumoniae, especially in Korea. We here present a 53-year-old male with an infected abdominal aortic aneurysm caused by S. pneumoniae. This patient had no previous history of atherosclerosis or infection of other organs such as the lungs, heart, or bones. He underwent resection of the abdominal aorta and iliac artery as well as bypass surgery, with maintenance of peri-operative intravenous antibiotics for 6 weeks. He has shown favorable outcomes after a 3-month follow-up.

A Case of Zonisamide-Induced Stevens-Johnson Syndrome

Tue, 01 Sep 2015 00:00:01 +0100

Stevens-Johnson syndrome (SJS) is a rare but severe disorder typically caused by medications and characterized by mucocutaneous eruptions. Zonisamide is an antiepileptic drug that is structurally different from other drugs of the same class. It is considered safe for patient use, and few cases describing severe cutaneous adverse reactions from zonisamide have been reported. We herein report a case of zonisamide-induced SJS in a 36-year-old woman. The patient presented with a widespread erythematous maculopapular rash after taking zonisamide. The symptoms of SJS improved after zonisamide was discontinued and systemic steroids and intravenous immunoglobulins were administered. This is the first case of zonisamide-induced SJS in Korea. Although this drug is generally considered safe, we suggest that clinicians be aware of potential adverse reactions, including SJS.

Refractory Macrophage Activation Syndrome in a Patient with Systemic Lupus Erythematosus ...

Tue, 01 Sep 2015 00:00:01 +0100

Macrophage activation syndrome (MAS) is a secondary hemophagocytic lymphohistiocytosis caused by autoimmune diseases, such as systemic lupus erythematosus (SLE). It is characterized by fever, cytopenia, coagulopathy, hepatosplenomegaly, elevated liver enzyme, and high ferritin, typically combined with hemophagocytic histiocyte proliferation in the bone marrow. Here, we report a case of MAS in a patient with SLE treated successfully by tocilizumab. She was transferred to our hospital due to persistent fever of unknown origin. Initial blood tests revealed cytopenia, elevated liver enzyme, and high ferritin. Bone marrow histology revealed the presence of hemophagocytic histiocytes. The patient was initially treated with high dose corticosteroids; however, fever and cytopenia were not controlled. Additional treatments with cyclosporine, intravenous immunoglobulin, and rituximab were applied consecutively, but the fever and cytopenia persisted. Symptom resolution was finally achieved following treatment with tocilizumab, resulting in rapid improved of fever, and resolution of pancytopenia within 2 months.

Periodic Surveillance and Medical Management of Thoracic Aortic Aneurysm

Thu, 01 Oct 2015 00:00:01 +0100

Thoracic aortic enlargement is a silent, but deadly, disease that is often diagnosed on imaging studies performed for unrelated indications and result in life threatening event such as aortic rupture and dissection. The etiologies underlying thoracic aortic enlargement are diverse and can range from degenerative or hypertensive aortic enlargement to more rare genetic disorders including Marfan syndrome and Loeys-Dietz syndrome. Therefore, the diagnosis and management of this disease can be complex. This review focuses on the periodic surveillance using imaging modality before surgical intervention and medical management of asymptomatic patients with thoracic aortic aneurysm.

Endovascular Therapy for Thoracic Aortic Aneurysm

Thu, 01 Oct 2015 00:00:01 +0100

Endovascular therapy, proposed as an alternative to surgery, is considered a therapeutic innovation because of its low degree of invasiveness, allowing for the treatment of high-risk surgical patients and outcomes of limited complications and mortality. The combination of endovascular exclusion with cerebral branch revascularization for the treatment of thoracic aortic aneurysms involving arch has also been attempted. With improved capability to recognize proper anatomy and select clinical candidates, endovascular therapy may offer a strategy to optimize management and improve prognosis for thoracic aortic aneurysm patients.

Non-Interventional and Interventional Treatment of Aortic Dissection

Thu, 01 Oct 2015 00:00:01 +0100

A new appraisal of the management of acute aortic dissection is timely because of recent developments in diagnostic strategies (including biomarkers and imaging), endograft design, and surgical treatment. These have led to a better understanding of the epidemiology, risk factors, and molecular nature of aortic dissection. Although open surgery is the main treatment for proximal aortic repair, the use of endovascular management is now established for complicated distal dissection and distal arch repair and has recently been discussed as a pre-emptive measure to avoid late complications by inducing aortic remodeling.

Optimal Management of Abdominal Aortic Aneurysm and Regular Surveillance

Thu, 01 Oct 2015 00:00:01 +0100

An abdominal aorta with a maximal diameter of > 3.0 cm is considered aneurysmal. Abdominal aortic aneurysm (AAA) most often affects the segment of aorta between the renal arteries. Patients with aneurysms under observation should undergo periodic imaging to assess for aortic expansion, but the optimal surveillance schedule has not been defined clearly. Generally, surveillance is every 6 to 12 months by ultrasound or computed tomography for medium-sized aneurysms (4.0 to 5.4 cm in diameter), but less frequent intervals (every 2 to 3 years) are recommended for smaller aneurysms. The primary goals of aneurysm repair are to prevent rupture while minimizing morbidity and mortality associated with repair. Two methods of aneurysm repair are currently available: traditional open surgery and endovascular aneurysm repair (EVAR). In randomized trials, EVAR is associated with lower perioperative morbidity and mortality compared with open AAA repair but does not completely eliminate the future risk of AAA rupture, whereas open repair is associated with higher perioperative morbidity and mortality than EVAR but provides a more definitive repair. Physicians must choose an individualized approach for AAA repair, taking into account the patients age, aortic anatomy, life expectancy, and risk factors for perioperative morbidity and mortality.

Extrapancreatic Effect of Glucagon like Peptide-1

Thu, 01 Oct 2015 00:00:01 +0100

Glucagon like peptide-1 (GLP-1) is an intestinal L cell derived incretin hormone which stimulates insulin secretion of beta cell and inhibits glucagon secretion of alpha cell of pancreatic islets. GLP-1 receptors are located in pancreas as well as in a wide variety of tissue such as gastrointestinal tract, heart, blood vessel, lung, brain, kidney, and bone. Therefore GLP-1 and GLP-1 based treatment have multiple extrapancreatic effects which are inhibition of gastrointestinal motility, reduction of appetite, weight loss, increase of cardiac output, cardiovascular protection, neuroprotection, renoprotection, and increase of bone mineral density. Recently, besides GLP-1 receptor dependent pathway, GLP-1 receptor independent pathway has been identified in the extrapancreatic effect of GLP-1 in liver, adipose tissue, muscle, cardiovascular system. This review provides an overview of the pleiotropic effect of GLP-1 in the extrapancreatic organ through review of animal and clinical research.

Management of Anaphylaxis

Thu, 01 Oct 2015 00:00:01 +0100

Anaphylaxis is a life-threatening systemic hypersensitivity reaction with a rapid onset. All healthcare professionals should be familiar with its recognition and management. The clinical diagnosis is important. It involves the sudden onset of characteristic symptoms and signs within minutes to hours after exposure to a known or potential trigger, often followed by rapid progression over hours. Symptoms usually involve two or more body systems, including the skin and mucous membranes, and respiratory, gastrointestinal, cardiovascular, and central nervous systems. Prompt initial basic treatment with intramuscular epinephrine in the mid-anterolateral thigh can be life-saving. Simultaneously, it is important to place the patient in a supine position, call for help when indicated, provide supplemental oxygen, start intravenous fluid, and provide cardiopulmonary resuscitation as required, while monitoring the patients vital signs and oxygenation status. Antihistamines and glucocorticoids are not initial treatments of choice. For self-management, patients at risk of anaphylaxis should carry epinephrine auto-injectors, have personalized emergency action plans, and follow-up with a physician about preventing anaphylaxis recurrence. Patient and caregiver training and education are essential in the management of anaphylaxis.

Clinical Outcome Comparison of Everolimus- and Biolimus-eluting Stents in Patients with Acute ...

Thu, 01 Oct 2015 00:00:01 +0100

Background/Aims: We compared the efficacy and safety of the second-generation everolimus-eluting stent (EES) and the third generation biolimus-eluting stent (BES) in patients with acute myocardial infarction (AMI). Methods: We analyzed 629 consecutive patients (mean age 65.1

A Case of Afferent Loop Syndrome Treated by Endoscopic Metal Stent Insertion Using Two Endoscopes

Thu, 01 Oct 2015 00:00:01 +0100

Afferent loop syndrome is a rare complication of pancreaticoduodenectomy, and the endoscopic approach is difficult due to the surgically altered anatomy. Herein, we report a case of afferent loop obstruction treated by endoscopic metal stent insertion using two endoscopes. A 57-year-old male who had undergone the Whipple operation 7 months prior for pancreatic head cancer presented with abdominal pain and jaundice. Abdominal computed tomography showed afferent loop obstruction due to recurrent metastatic pancreatic cancer. First, we attempted to insert the stent using percutaneous transhepatic approaches following percutaneous transhepatic biliary drainage, but these failed. We therefore accessed the obstruction site using a relatively thin endoscope and then exchanged this endoscope for another with a large working channel, through which the self-expandable metal stent was passed. The stent was inserted successfully. This method will increase the success rate of endoscopic treatment.

A Case of Noonan Syndrome Presenting with Malignant Hypertension in an Adult

Thu, 01 Oct 2015 00:00:01 +0100

Noonan syndrome is an autosomal dominant disorder characterized by dysmorphic facial features, congenital heart defects and short stature. To date, renal artery stenosis has not been associated with Noonan syndrome. We report the case of a 27-year old male who presented with malignant hypertension associated with renal artery stenosis, dysmorphic facial features, pectus excavatum, pulmonary stenosis and hypertrophic cardiomyopathy who was diagnosed with Noonan syndrome.

How Long Should We Wait for Recovery from Acute Fulminant Myocarditis?

Thu, 01 Oct 2015 00:00:01 +0100

A 54-year-old diabetic man presented to the hospital with shock and bradycardia. His initial estimated left ventricular ejection fraction (LVEF) was 15% and the electrocardiogram showed a junctional escape rhythm with a wide QRS complex and no P wave. Intensive supportive therapy was initiated after inserting a pacemaker and starting extracorporeal membrane oxygenation. A myocardial biopsy confirmed acute lymphocytic myocarditis with extensive myocyte necrosis, and cardiac transplantation was planned. However, the patient survived without transplantation after vigorous hemodynamic support for 2 weeks. After discharge, he had limited activity for 4 months due to dyspnea caused by a reduced systolic heart function (LVEF, 21%) with a junctional escaped beat. His systolic function recovered markedly 6 months after stopping the hemodynamic support, with the presence of a P wave and narrowed QRS complex.

A Coronary Intramural Hematoma Presenting with ST-Elevation Myocardial Infarction in an Elderly Man

Thu, 01 Oct 2015 00:00:01 +0100

An intramural hematoma is a rare, challenging cause of myocardial infarction generally seen in middle-aged females with no atherosclerotic risk factors. Intravascular ultrasound is useful in diagnosing and managing intramural hematomas. Here, we present anintramural hematoma presenting with ST-elevation myocardial infarction without definite intimal dissection in an elderly man who was diagnosed using intravascular ultrasound and managed accordingly.

Acute Myocardial Infarction Occurring at a Preexisting Intermediate Coronary Artery Stenosis

Thu, 01 Oct 2015 00:00:01 +0100

Acute myocardial infarction often evolves from a mild coronary lesion. Therefore, the evaluation and management of intermediate coronary stenosis are important to prevent cardiac events. However, the decision on how to treat these lesions is challenging. Here, we report acute myocardial infarction occurring at a preexisting intermediate coronary stenosis based on invasive coronary angiography performed 10 days before the event.

A Case of Mycobacterium gordonae Pulmonary Disease in a Patient with Ulcerative Colitis Treated ...

Thu, 01 Oct 2015 00:00:01 +0100

Tumor necrosis factor-? (TNF-?) is a key component of the host defense against mycobacterial infection. Mycobacterium gordonae (M. gordonae) is one of the least virulent mycobacteria, and is generally considered non-pathogenic if detected from a clinical specimen. Here, we report a rare case of pulmonary M. gordonae infection in a patient with ulcerative colitis who had been treated with infliximab, a TNF-? antagonist. M. gordonae infection was treated successfully with clarithromycin, rifampin, and ethambutol. We believe this to be the first report of M. gordonae pulmonary disease associated with TNF-? antagonist treatment.

A Case of Salicylate-Intoxication-Induced Pseudohyperchloremia

Thu, 01 Oct 2015 00:00:01 +0100

Despite the increasing use of alternative analgesic agents, salicylate overdose remains a not-uncommon problem. Severe poisoning is life threatening, so prompt treatment and supportive measures are required to reduce mortality. Generally, salicylate intoxication results in the development of high-anion-gap metabolic acidosis. However, outside of Korea, normal-anion-gap or negative-anion-gap metabolic acidosis with hyperchloremia is rarely reported. We report herein the case of an 83-year-old female patient with chronic aspirin intake who presented with hyperchloremia and a negative anion gap. The patients symptoms improved with conservative treatment and hemodialysis; notably, her chloride levels decreased as her blood salicylate concentrations decreased. Salicylate may cause hyperchloremia, demonstrating the importance of careful documentation of patient medication histories.

A Case of Rhabdomyolysis Presenting with Acute Kidney Injury Complicating Carbon Monoxide Poisoning

Thu, 01 Oct 2015 00:00:01 +0100

Carbon monoxide (CO) poisoning has increased rapidly in South Korea and may cause a variety of clinical effects. The most common complications are neurologic and neuropsychological disturbances. However, in rare cases, CO poisoning may also be associated with acute kidney injury and non-traumatic rhabdomyolysis. Here, we report a case of acute kidney injury and rhabdomyolysis complicating CO poisoning. A 32-year-old woman was admitted to our emergency department with dyspnea and confused consciousness after exposure to CO during a suicide attempt involving charcoal briquettes. Laboratory findings revealed a carboxyhemoglobin (COHb) level of 44.8%, a blood urea nitrogen level of 20.5 mg/dL, a serum creatinine level of 1.4 mg/dL, and a creatine phosphokinase level of 8,688.3 IU/L. Acute kidney injury and rhabdomyolysis complicating CO poisoning were diagnosed. This case was managed with normobaric oxygen therapy and hydration. The patient recovered completely with respect to renal function and muscle enzyme level, and COHb level returned to 0%.

A Case of Clear-Cell Sarcoma in the Stomach

Thu, 01 Oct 2015 00:00:01 +0100

Clear-cell sarcoma (CCS) is a rare soft tissue sarcoma that usually develops in the lower extremities of young adults. CCS of the gastrointestinal tract is extremely rare. We report here the first case of CCS of the stomach in Korea. A 28-year-old female developed a large tumor of the stomach that was initially considered Ewing sarcoma, based on the results of a needle biopsy. She had paraneoplastic syndrome; fever, anemia, and hyperglycemia. Follow-up abdominal computed tomography after four-cycles of chemotherapy with vincristinedoxorubicincyclophosphamide or ifosfamideetoposide showed no tumor shrinkage and revealed a fistula between the tumor and the gastric lumen. The infected tumor prompted debulking surgery, which resulted in improvement of her symptoms. The pathologic findings were consistent with CCS, and fluorescence in situ hybridization for EWS gene rearrangement was positive, confirming the diagnosis. This case highlights the importance of clinical suspicion for CCS in chemotherapy-refractory Ewing sarcoma.

A Case of Sparganosis that Mimicked Recurrence of Contralateral Breast Cancer

Thu, 01 Oct 2015 00:00:01 +0100

Sparganosis is a rare parasitic infection caused by plerocercoid tapeworm larvae of the genus Spirometra. While initially asymptomatic, the migrating larvae initially appear as subcutaneous nodules, which can be mistaken for cancer because all parts of the body can be affected, including the abdominal cavity, genitourinary tract, gastrointestinal tract, musculoskeletal system, central nervous system, and even the breasts. Therefore, we report here a case of sparganosis that was differentially diagnosed from recurrence of breast cancer.

Pseudoxanthoma Elasticum-Like Disorder with Multiple Coagulation Factor Deficiency in a Patient ...

Thu, 01 Oct 2015 00:00:01 +0100

Pseudoxanthoma elasticum (PXE)-like disorder with multiple coagulation factor deficiency is a genetic disease characterized by dystrophic mineralization of the connective tissue in multiple organs such as the skin, arteries, and retina. Patients with this disorder have excessive folding and sagging of the skin with loss of recoil, as well as coagulopathy. Crohns disease is a chronic inflammatory condition of the gastrointestinal tract, which primary affects the small intestine, often leading to malnutrition. Here, we describe the case of a 25-year-old woman who presented with these diseases. We found that nutrient deficiency due to long-term Crohns disease aggravated the coagulopathy associated with PXE-like disorder.

Distal Renal Tubular Acidosis Caused by Tacrolimus in a Systemic Lupus Erythematosus Patient: A ...

Thu, 01 Oct 2015 00:00:01 +0100

Renal tubular acidosis (RTA) refers to a group of disorders involving transport defects in bicarbonate reabsorption or hydrogen excretion. Features like metabolic acidosis with a normal anion gap, neurological symptoms, and electrolyte imbalances indicate RTA. Kidney transplantation, cirrhosis, sickle cell anemia, medications, and autoimmune diseases, particularly Sj

Adult-Onset Still

Thu, 01 Oct 2015 00:00:01 +0100

Adult-onset Stills disease (AOSD) is a rare systemic inflammatory disorder that affects multiple organs and is fatal in some cases. Thrombotic thrombocytopenic purpura (TTP), another rare disease, is characterized by multiple organ failure and microangiopathic hemolytic anemia. TTP is an extremely rare complication of AOSD. We report a 59-year-old woman who presented with TTP that manifested after she was diagnosed with AOSD. Initially, her clinical manifestations improved with glucocorticoid therapy. However, her disease worsened and was accompanied by acute kidney injury, thrombocytopenia, hemolytic anemia, petechiae, and impaired consciousness. These clinical findings led to a diagnosis of TTP. This is the first report of AOSD complicated by TTP in Korea. Awareness of the possible development of TTP as a complication of AOSD is important for early diagnosis and treatment.

The Endoscopic Management of Common Bile Duct Stones

Sun, 01 Nov 2015 00:00:01 +0100

Gallbladder stone, or gallstone, is an endemic condition that affects up to 20% of the general population. Of patients with gallstones, 11-21% also have concomitant common bile duct (CBD) stones. Moreover, in East Asia-including Korea, Taiwan, and Japan-the prevalence of primary CBD stones without gallbladder stones is higher than that in Western countries. CBD stones may be associated with various symptoms and conditions. Therefore, CBD stones must be managed for the prevention of potentially life-threatening complications, such as ascending cholangitis, liver abscess, and acute pancreatitis. During the past 40 years, endoscopic retrograde cholangiopancreatography has become a widely available and routine procedure for the management of CBD stones. Other interventions include intraoperative bile duct exploration and percutaneous transhepatic stone removal. As a consequence, clinicians are now faced with a number of potentially valid options for managing patients with suspected CBD stones.

Diagnosis and Treatment of Acute Pancreatitis

Sun, 01 Nov 2015 00:00:01 +0100

Acute pancreatitis is common, and is sometimes associated with significant morbidity and mortality. Early diagnosis and assessment of the severity of the condition are important when decisions must be made on appropriate early-stage treatment and/or patient transfer to medical facilities familiar with the condition. Initial intensive management of acute pancreatitis is important to minimize complications and mortality. In the present review, we discuss initial diagnosis of the condition, severity assessment, and the adequacy of early treatments, with reference to recently updated Korean guidelines.

Endoscopic Ultrasound Guided Intervention

Sun, 01 Nov 2015 00:00:01 +0100

Endoscopic ultrasound (EUS) has recently become widely used for the diagnosis and treatment of gastrointestinal disease. With applications of linear EUS and EUS-guided fine needle aspiration, many EUS-guided interventions are now emerging as feasible treatment options for patients with pancreatobiliary disease. EUS-guided drainage from pseudocyst, bile duct, pancreatic duct, and the gallbladder are becoming routine procedure. EUS-guided celiac plexus neurolysis and block can relieve intractable pancreatic pain. Moreover, EUS-guided local tumor therapy (ethanol ablation and radiofrequency ablation) may be feasible in selected patients. Safe EUS-guided intervention requires a good deal of experience but is becoming widely used to treat pancreatobiliary disease.

Systemic Treatment for Metastatic Bladder Cancer

Sun, 01 Nov 2015 00:00:01 +0100

Metastatic bladder cancer is generally incurable, with a median survival of 14 to 15 months under a modern chemotherapy regimen. Cisplatin-based chemotherapy, including the combination regimens methotrexate-vinblastine-doxorubicin-cisplatin and gemcitabine-cisplatin, are the standard first-line therapy. Despite response rates of 40% to 60% achieved, most patients cancers progress after about 8 months. Second-line single agents have only marginal efficacy after cisplatin-based treatment failure, with objective response rates of 5% to 20% and a median progression-free survival of only 3 to 4 months. Moreover, there is little evidence that second-line systemic treatment can substantially improve overall survival or quality of life. Agents targeting growth, survival, and proliferation pathways have been added to cytotoxic therapy with limited added benefits to date. Drugs that modulate the host immune response to cancer-associated antigens, including immunologic checkpoint blockade by antibodies against programmed cell death protein-1 or its ligands, appear promising, and multiple new therapeutic approaches are being pursued. In addition, the receptor tyrosine kinase/Ras pathway and the phosphatidylinositol 3-kinase/protein kinase B/mammalian target of the rapamycin pathway represent potential therapeutic targets for advanced disease, and novel agents are in development.

Mesenchymal Stem Cell Therapy in Pulmonary Disease

Sun, 01 Nov 2015 00:00:01 +0100

Stem cells are undifferentiated cells that are clonal, self-renewing, and can differentiate into multiple cell types (known as potency). Among stem cells, there are embryonal stem cells, induced pluripotent stem cells, mesenchymal stem cells (MSCs), and hematopoietic stem cells. MSCs are fibroblast-like non-hematopoietic stem cells that can differentiate into various tissue types, including bone, muscle, liver, lung, and cartilage. MSCs can be isolated from bone marrow, adipose tissue, placenta, or umbilical cord blood, among other tissues. MSCs are adherent under tissue culture conditions and express several cell surface markers, including CD105, CD73, and CD90. However, MSCs show negative expression for CD45, CD34, CD14, CD11b, CD79?, CD19, and HLA-DR. This article aims to explain the current definition of MSCs, describe therapies for which MSCs may be used, and review recent lung disease clinical trials.

Entecavir Resistance at rtS202, rtM250 May Cause Poor Viral Response to Tenofovir-based Rescue ...

Sun, 01 Nov 2015 00:00:01 +0100

Background/Aims: Long-term use of nucleos(t)ide analogues (NA) may lead to genotypic and/or phenotypic resistance of the hepatitis B virus (HBV). We investigated the efficacy of tenofovir-based rescue therapy in chronic hepatitis B (CHB) patients with newly developed genotypic resistance to prior NAs or partial virologic response to sequential rescue therapies. Methods: Fifty-four CHB patients were included retrospectively. The patients were treated with tenofovir alone or combined with lamivudine or entecavir. Results: There were 26 forms of genotypic resistance at enrollment. The median amount of serum HBV-DNA was 18,438 IU/mL and 83% of samples were positive for hepatitis B e antigen (HBeAg). Serum HBV-DNA was undetectable in 50%, 61%, and 76% of the patients at 3, 6, and 12 months, respectively. In multivariate analysis, HBV-DNA < 20,000 IU/mL and negative HBeAg at baseline were independent predictors of negativity for serum HBV-DNA. Interestingly, the rtS202 mutation tended to be associated with an unfavorable response. Other clinical variables and viral resistance genotypes showed non-significant viral response. Conclusions: Lower serum HBV-DNA, negative HBeAg and lack of rtS202G mutations at baseline may predict a favorable response to tenofovir-based rescue therapies in CHB patients with newly developed genotypic resistance to prior NAs or a partial virologic response to sequential rescue therapies.

Risk Factors for Severe Complications in Patients with Esophageal Foreign Bodies

Sun, 01 Nov 2015 00:00:01 +0100

Background/Aims: Complications by ingested foreign bodies are uncommon, since successful removal by endoscopy occurs in most cases. However, severe complications, such as perforation, can result in death. The aim of this study was to determine the risk factors associated with severe complications in patients with esophageal foreign bodies. Methods: This study involved 298 patients who underwent successful removal of an esophageal foreign body between January 2001 and December 2014 at Dankook University Hospital. Medical records were reviewed retrospectively. Severe complications were defined as laceration, unstoppable bleeding with simple irrigation, or perforation. Risk factors for severe complications were analyzed using multivariate logistic regression. Results: The most common foreign bodies in adults and pediatrics were fish bones (52.0%) and coins (61.0%). Complications included erosion, ulcer, laceration, bleeding, and perforation. Using multivariate analysis, the type (fish bone, odds ratio [OR] = 2.306, p = 0.004) and size (> 25 mm, OR = 2.614, p = 0.001) of the obstruction and duration of impaction (> 24 hours, OR = 1.887, p = 0.035) were risk factors for severe complications including laceration, bleeding, and perforation. For perforation, duration of impaction (> 24 hours, OR = 41.700, p = 0.005) was a statistically significant risk factor. In two patients, delayed perforation occurred despite successful endoscopic removal of the foreign body. Conclusions: Patients with esophageal fish bone foreign bodies, foreign bodies larger than 25 mm, and a duration of impaction longer than 24 hours should be treated carefully considering the possibility of severe complications. Specifically, patients with a duration of impaction longer than 24 hours should be closely observed due to increased risk of perforation and potential delayed perforation even after successful endoscopic removal.

Asymptomatic Perforated Appendicitis Presenting as a Subepithelial Sigmoid Colon Lesion at ...

Sun, 01 Nov 2015 00:00:01 +0100

Acute appendicitis is common in all age groups. Although many patients with acuteappendicitis present with migrating abdominal pain, the initial presentation can be atypical and nonspecific. Unusual manifestations can lead to diagnostic delay, which is associated with increased morbidity and mortality. Colonoscopic findings suggestinga diagnosis of asymptomatic appendicitis include hyperemia and bulging at the appendiceal orifice area with surrounding mucosal edema, and drainage of pus from the appendiceal orifice. We report a case of asymptomatic perforated appendicitis and periappendiceal abscess that presented as a subepithelial sigmoid colon lesion at screening colonoscopy. On colonoscopy, a subepithelial lesion with pustular drainage surrounded by hyperemic mucosa was seen at the sigmoid colon. Computed tomography revealed appendicitis and a periappendiceal abscess with adjacent sigmoid colon wall thickening. The patient underwent an appendectomy, with a final diagnosis of a perforated appendicitis with a periappendiceal abscess.

Successful Retrieval of a Fractured Guidewire during Extracorporeal Membrane Oxygenator Insertion

Sun, 01 Nov 2015 00:00:01 +0100

Recently, the use of extracorporeal membrane oxygenation has evolved rapidly and there is potential for expanding its use. There are many complications associated with extracorporeal membrane oxygenation, but the fracture of a guidewire has been reported to be very rare during extracorporeal membrane oxygenation insertion. We describe our experience of successfully removing a fractured 0.038-inch guidewire using a catheter wedge with balloon inflation following a fracture that occurred during insertion of extracorporeal membrane oxygenation through the left femoral vein.

Sick Sinus Syndrome Following Severe Hyponatremia Associated with Desmopressin Therapy

Sun, 01 Nov 2015 00:00:01 +0100

Desmopressin diacetate arginine vasopressin (DDAVP) is a synthetic analogue of the arginine vasopressin that is widely used in the treatment of diabetes insipidus, nocturnal enuresis, and polyuria. Although it is generally well-tolerated, DDAVP can cause hyponatremia, especially in elderly patients. There are many reports of DDAVP-induced hyponatremia, but there has been only one case report in which sinus node dysfunction was caused by severe hyponatremia. Here we report a case of sick sinus syndrome that occurred during an episode of severe hyponatremia induced by chronic use of desmopressin in a 91-year-old man who had nocturnal enuresis.

A Case of Acute Lung Injury due to Mercury Vapor Inhalation

Sun, 01 Nov 2015 00:00:01 +0100

Mercury is traditionally used as a dye for making amulets in Korea. Inhaling the vapor produced by burning mercury damages major organs, such as the lungs, kidneys, and brain. We herein present a case of a 41-year-old man who complained of abdominal pain and dyspnea. A chest X-ray and computed tomography scan showed infiltration in both upper lung lobes. A thorough medical history revealed that the patient had made amulets prior to developing symptoms, and blood and urine tests confirmed elevated levels of mercury. Dimercaptosuccinic acid was used to chelate the mercury, and methylprednisolone was used to treat the acute lung injury. No kidney or nervous system complications were detected during follow-up. Inhalation of mercury vapor should be suspected in patients with acute lung injury involving both upper lobes.

A Case of Incidentally Detected Asymptomatic Emphysematous Pyelonephritis

Sun, 01 Nov 2015 00:00:01 +0100

Emphysematous pyelonephritis (EPN) is a severe gas-forming infection of the renal parenchyma and surrounding tissues. Patients with EPN commonly present with high fever, chills, and flank pain. These symptoms mimic a simple urinary tract infection, such that diagnosis is often delayed. Because of its life-threatening fulminant course, the early detection of EPN and its prompt treatment with intravenous antibiotics with or without percutaneous drainage are critical. Here we describe a case of a 63-year-old Korean female with diabetes mellitus who had no specific symptoms or signs of EPN. A chest computed tomography (CT) scan to assess a right pleural effusion incidentally detected an abnormal gas shadow in the renal parenchyma. An abdominal CT scan performed 5 days later showed increased gas within the kidney parenchyma, but the patient still had no symptoms of EPN. She was treated with intravenous antibiotics alone. A follow-up abdominal CT scan revealed the complete disappearance of the features of EPN.

Two Cases of Fabry Disease in Women with Proteinuria Diagnosed by Molecular Analysis of the ...

Sun, 01 Nov 2015 00:00:01 +0100

Fabry disease is an X-linked lysosomal storage disorder caused by ?-galactosidase A deficiency, which results in the intracellular accumulation of globotriaosylceramide and leads to severe painful neuropathy with progressive renal, cardiovascular, and cerebrovascular dysfunction and early death. We report 52- and 55-year-old women with proteinuria and hematuria that were proven to be due to Fabry disease. A gene analysis using PCR direct sequencing confirmed a missense mutation of the GLA (?-galactosidase A) gene. Electron microscopy of a kidney biopsy showed lamella inclusion bodies, which are typical findings of Fabry disease. The patients were treated with enzyme replacement therapy as outpatients. They had a reduction in proteinuria and normal renal function.

A Case of Primary Lung Cancer Mistaken for Pulmonary Metastasis of Renal Cell Carcinoma

Sun, 01 Nov 2015 00:00:01 +0100

Renal cell carcinoma (RCC) is rare relative to other urological cancers, but relatively common overall among males. Even when primary tumors are successfully removed by surgery, metastases are often noted within a few years. On the other hand, masses found at other sites in patients with RCC may represent different primary cancers. We present the case of a 63-year-old man with a right lung mass and a left lung nodule who underwent radical right nephrectomy for RCC. We found no local recurrence of RCC in the abdomen. Despite treatment for RCC, the right lung mass increased in size. We performed a lung needle biopsy and diagnosed primary lung cancer. Postoperatively, the remaining left lung nodule also increased in size. It was diagnosed as an RCC metastasis upon biopsy and removed by wedge resection. The patient was treated with everolimus after the second surgery.

Myeloid Sarcoma of Peritoneum in Acute Myeloid Leukemia Patient with Inversion of Chromosome 16

Sun, 01 Nov 2015 00:00:01 +0100

Myeloid sarcoma is an extramedullary myeloid neoplasm that usually involves the skin, soft tissues, and lymph nodes. Myeloid sarcoma is found in 2.5-9.1% of acute myeloid leukemia patients, usually those with t(8;21), while inv (16) is rarely associated with myeloid sarcoma. Consequently, little is known of the characteristics and incidence of inv (16) in myeloid sarcoma. Myeloid sarcoma in acute myeloid leukemia patients with inv (16) is most often found in the abdominal lesions; the intestinal tract is involved most commonly, in the form of a mass. Here, we report an unusual myeloid sarcoma presenting as peritoneal carcinomatosis in acute myeloid leukemia with inv (16) that appeared to be ascites.

Successful Transcatheter Embolization of Spontaneous Splenic Rupture in a Patient with Chronic ...

Sun, 01 Nov 2015 00:00:01 +0100

We report a rare case of a patient who presented with pathological splenic rupture as the initial manifestation of chronic myeloid leukemia (CML) and was treated successfully by transcatheter arterial embolization. A 36-year-old man presented to the emergency department with a 1-day history of abdominal pain. Computed tomography showed gross hemoperitoneum with marked splenomegaly, with suspected focal rupture at the lower portion of the spleen and the extravasation of contrast material indicating active bleeding. Given the patients hemodynamic stability, he was treated with partial splenic embolization by an interventional radiologist, and transfused with red blood cells. Examination of a bone marrow aspiration and biopsy led to a diagnosis of chronic phase CML. He was discharged from the hospital on day 13 post-embolization. Transcatheter arterial embolization should be considered as the initial treatment of spontaneous splenic rupture, especially in patients with hematological malignancies.

A First Case of Solid Pseudopapillary Tumor of the Pancreas in an Old Man in South Korea

Sun, 01 Nov 2015 00:00:01 +0100

Solid pseudopapillary tumor (SPT) of the pancreas is a rare tumor that typically affects young women without causing significant clinical symptoms. No case of SPT in an old man has been reported in South Korea, and such cases are very rare worldwide. We report a 70-year-old man with SPT of the pancreas with multiple organ metastasis. Although surgical resection is the treatment of choice for SPT, we decided not to treat, considering his age and the disease severity.

A Case of Tuberculous Peritonitis in a Patient with Ankylosing Spondylitis during Infliximab Therapy

Sun, 01 Nov 2015 00:00:01 +0100

Infliximab is a chimeric monoclonal antibody against tumor necrosis factor-alpha (TNF-?) that is used to treat chronic inflammatory diseases such as ankylosing spondylitis (AS). Side effects include greater susceptibility to severe infections, such as tuberculosis. Positive diagnosis of tuberculous infections, such as tuberculous peritonitis, are often difficult due to the nonspecific nature of symptoms and the rarity of the infection, with definitive diagnoses requiring either a positive culture or histological biopsy. Here, we describe a case of tuberculous peritonitis during infliximab therapy in a 71-year-old man with AS; the disease was confirmed via histopathological examination.

Antiphospholipid Syndrome Presenting as Recurrent Pancreatitis and Renal Thrombotic Microangiopathy

Sun, 01 Nov 2015 00:00:01 +0100

Antiphospholipid syndrome (APS) is characterized by vascular thrombosis or recurrent fetal loss in the presence of antiphospholipid antibodies. APS has various manifestations because it can involve any vessel in most organs and tissues. There are a few reports of acute pancreatitis or renal thrombotic microangiopathy accompanying APS, but none on concurrent acute pancreatitis and renal thrombotic microangiopathy in Korea. The clinical consequences can be devastating, so a high index of suspicion is necessary for early diagnosis and treatment. We report an unusual case of APS-associated recurrent pancreatitis and renal thrombotic microangiopathy. A 33-year-old woman was admitted for severe epigastric pain attributed to acute pancreatitis. She subsequently developed an acute kidney injury and the histology revealed thrombotic microangiopathy. Four weeks later, she was readmitted with recurrent pancreatitis. After treatment with anticoagulation and low-dose steroid, her abdominal pain subsided and the amylase and lipase levels normalized.

Acute Transverse Myelitis in a Patient with Rheumatoid Arthritis Treated with Intravenous ...

Sun, 01 Nov 2015 00:00:01 +0100

Acute transverse myelitis (ATM) is a heterogeneous syndrome characterized by acute spinal cord dysfunction resulting in paresis and sensory and autonomic impairment below the level of the lesion. The etiology of ATM includes parainfectious, paraneoplastic, drug-induced, systemic autoimmune disorders, and acquired demyelinating diseases. ATM is very rare in patients with rheumatoid arthritis (RA). A 79-year-old woman with RA, a recurring peptic ulcer, and congestive heart failure presented with acute weakness of both upper and lower extremities. She was diagnosed with ATM based on the results of laboratory and radiological tests. ATM is usually treated with high-dose glucocorticoid. However, we treated her with intravenous immunoglobulin (IVIG) considering the adverse events of high-dose glucocorticoid, and she improved. We report a case of ATM in a patient with RA successfully treated with IVIG.

Ultrasonographic Findings in Rheumatoid Arthritis