A Case of Treatment with Steroid and Hydrochloroquine of Thrombocytopenia in Primary Sjögren's Syndrome / 고신대학교의과대학학술지

Sjögren's syndrome is a systemic autoimmune disease characterized by sicca symptoms and extraglandular manifestations. Anemia, leukopenia, thrombocytopenia and lymphoproliferative disorders are well-known extraglandular, hematological complications of Sjögren's syndrome. These hematologic alterations are usually mild and respond well with steroid therapy. We report a case of a 52-year-old female patient who was initially presented with thrombocytopenia. The patient was then diagnosed with primary Sjögren's syndrome and initially treated with steroid. The patient's platelet count was decreased when steroid was tapered. The dose of steroid could be effectively reduced after combined medication with hydroxychloroquine.

Comparison of Recurrence Rate Based on the Frequency of Preceding Symptoms in Patients With Neurocardiogenic Syncope or Presyncope

BACKGROUND AND OBJECTIVES: In patients with neurocardiogenic syncope or presyncope, symptoms developed unpredictably and intermittently. The purpose of this study was to determine whether there was any significant difference in the recurrence rate of symptoms during the follow-up period between patients with many episodes of symptoms and those with fewer episodes of symptoms before diagnosis, as well as to assess the clinical significance of previous episodes of symptoms during treatment. SUBJECTS AND METHODS: A total of 100 patients with neurocardiogenic syncope or presyncope were divided in two groups (high episode group, n=54; low episode group, n=46) according to the frequency of symptoms before the head-up tilt test. We retrospectively analyzed the recurrence of symptoms using telephone interviews and medical record reviews. RESULTS: The clinical characteristics were not significantly different between the two groups. However, the recurrence rate was significantly lower in the high episode group than in the low episode group (5.6% vs. 19.6%, p=0.001). In the high episode group, patients treated with medication showed higher recurrence of symptoms than those without medication. In the lower episode group, a similar result was observed. CONCLUSION: The frequency of previous symptoms at the diagnosis of neurocardiogenic syncope or presyncope did not predict the occurrence of symptoms during the follow-up period. Therefore, to continue drug treatment based on the frequency of symptoms in patients with neurocardiogenic syncope or presyncope may not be the best option.

Correlation Between Levels of N-terminal Pro-B-Type Natriuretic Peptide and Degrees of Heart Failure

BACKGROUND: The N-terminal fragment of pro Brain Natriuretic Peptide (NT-pro BNP) is a neuro-hormone synthesized in the cardiac ventricles in response to increased wall tension. The purpose of this study was to assess the correlation between the NT-pro BNP levels and the New York Heart Association function class (NYHA Fc) of dyspnea and echocardiographic findings for the patients who visited our cardiology departments. METHODS: From October, 2002 to April, 2003, serum NT-pro BNP levels were measured in 348 patients who visited the Samsung Medical Center and the Jong Koo Lee Heart Clinic. RESULTS: The NT-pro BNP levels were increased with the progression of NYHA Fc of dyspnea (p< 0.001 by ANOVA), the increase in the systolic left ventricular internal dimension (p< 0.05), and the decrease in the ejection fraction (p< 0.01). For the NYHA Fc I patients, the NT-pro BNP levels were positively correlated with age (p< 0.001) and left atrial size (p< 0.001). For the patients with ischemic heart disease, the NT-pro BNP levels were also positively correlated with the NYHA Fc (p< 0.001 by ANOVA). The NT-pro BNP levels were increased with the increase in the systolic (p< 0.001) and diastolic pressure (p=0.017), the left ventricular internal dimension as well as the decrease in the ejection fraction (p< 0.001). The area under the receiver operating characteristic (ROC) curve for the NT-pro BNP levels was 0.994 (95% confidence interval, 0.979-0.999), and the most reliable cut-off level for the NT-pro BNP was 293.6 pg/mL. CONCLUSION: The NT-pro BNP levels were positively correlated with the NYHA Fc of dyspnea and the systolic dysfunction for the patients who visited our cardiology departments. A 300 pg/mL value for the NT-pro BNP cut-off point appears to be a sensitive level to differentiate dyspnea originating from an ailing heart or not for the patients who visited our cardiology departments.

Correlation between levels of n-terminal pro-b-type natriuretic peptide and degrees of heart failure / 대한내과학회지

BACKGROUND: N-terminal fragment of pro Brain Natriuretic Peptide (NT-pro BNP) is a neuro-hormone synthesized from the cardiac ventricles in response to increased wall tension. The purpose of this study was to assess the correlation between NT-pro BNP levels and New York Heart Association function class (NYHA Fc) and echocardiographic findings in patients, who visited cardiology department. METHODS: From October, 2002 to April, 2003, serum NT-pro BNP levels were measured in 348 patients, who visited Samsung Medical Center and Jong Koo Lee Heart Clinic. RESULTS: NT-pro BNP levels were increased with the progression of NYHA Fc of dyspnea (p<0.001 by ANOVA) as well as with the increase in systolic left ventricular internal dimension (p<0.05) and the decrease in ejection fraction (p<0.01). In NYHA Fc I patients, NT-pro BNP levels were positively correlated with age (p<0.001) and left atrial size (p<0.001). In patients with ischemic heart disease, NT-pro BNP levels were also positively correlated with NYHA Fc (p<0.001 by ANOVA). NT-pro BNP levels were increased with the increase in systolic (p<0.001) and diastolic (p=0.017) left ventricular internal dimension as well as the decrease in ejection fraction (p<0.001). The area under the receiver operating characteristic (ROC) curve for NT-pro BNP levels was 0.994 (95% confidence interval, 0.979-0.999), and the most reliable cut-off level of NT-pro BNP was 293.6 pg/mL. CONCLUSION: NT-pro BNP levels were positively correlated with NYHA Fc of dyspnea and systolic dysfunction in patients, who visited cardiology department. A 300 pg/mL of NT-pro BNP level appears to be a sensitive level to differentiate dyspnea of heart origin or not in patients, who visited cardiology department.

Predictors of Sinus Rhythm Restoration after Maze Operation and Relationship between Pre- and Post-operative Left Atrial Volume

BACKGROUND AND OBJECTIVES: The Maze operation is known to be an effective measure for restoring sinus rhythm in patients with atrial fibrillation (AF). The purpose of this study was to identify the relationship of pre- and post-operative left atrial volume (LAV) and diameter (LAD) with successful restoration of sinus rhythm in the Maze operation. SUBJECTS AND METHODS: The subjects for this study were 28 patients who underwent open-heart surgery in conjunction with the Maze-III operation for chronic AF from October, 2002, to April, 2003. Electrocardiographic and transthoracic echocardiographic studies were done pre-operatively and three months post-operatively. LAV and LAD were assessed and corrected for body surface area (LAV index=LAV/BSA, LAD index=LAD/BSA). RESULTS: Sinus rhythm was restored and maintained in 22 of the 28 patients (78.6%). Between the group with successful restoration of sinus rhythm (Group A;n=22) and the group with unsuccessful restoration (Group B;n=6), there was no difference in age, gender, and NYHA functional class. The duration of AF in group A was significantly shorter than that of B (3.6+/-2.7 years versus 15.8+/-7.5 years, p=0.003). Group A and B did not show any difference in pre-operative left ventricular ejection fraction. However, pre-operative LAV index in group A was significantly smaller than that of group B (80.7+/-22.4 mL/m2 versus 118.1+/-42.5 mL/m2, p=0.048). In group A, the LAV index (80.7+/-22.4 mL/m2 versus 52.8+/-14.7 mL/m2, p<0.001) and LAD index (35.4+/-5.3 mm/m2 versus 31.7+/-4.7 mm/m2, p=0.001) decreased significantly three months after the operation. In group B, however, no significant changes are found in the LAV index (118.1+/-42.5 mL/m2 versus 89.2+/-38.9 mL/m2, p=0.116) and LAD index (39.1+/-7.9 mm/m2 versus 36.2+/-9.2 mm/m2, p=0.144). CONCLUSION: Pre-operative LAV index measured by echocardiography and the duration of AF were significant predictors of successful sinus rhythm restoration after the Maze operation. Significant reduction of the LAV index after the Maze operation was found in patients whose rhythm was successfully restored and maintained.

Effect of Cardiac Rehabilitation on Physiologic and Inflammatory Markers in Patients with Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: here are several reports of cardiac rehabilitation (CR) having beneficial effects on the reduction of cardiovascular mortality and in the prevention of recurrent coronary events in patient with myocardial infarction (MI). An 8-week CR program was investigated to see if it affected the prognostic factors, such as inflammatory markers, after acute MI. SUBJECTS AND METHODS: 33 male and 5 female patients, with a mean age of 55+/-10 yrs, were consecutively assigned to the CR (n=19) and the control (n=19) groups three weeks after acute MI. The 8-week CR program consisted of life style modification and aerobic exercise training. At the baseline, and after 8 weeks, the symptom limited exercise test and peripheral blood sampling were performed to measure the physiologic capacity, the serum levels of high sensitive C-reactive protein (hs-CRP) and the plasma levels of interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha. The interval changes of each parameter were compared between the two groups. RESULTS: The interval increments of the maximal oxygen uptake (14.3% vs. 10.6%, CR vs. control group, p=0.014), anaerobic threshold (18.8% vs. 7.0%, CR vs. control group, p=0.044) and exercise duration (9.4% vs. 3.1%, CR vs. control group, p=0.009) were larger in the CR than in the control group. The magnitudes of the interval changes in hs-CRP, IL-6 and TNF-alpha, as inflammatory markers, did not differ between the two groups (p>0.05). CONCLUSION: This 8-week CR program demonstrated an improved exercise capacity for MI patients, but a larger clinical trial, with modified exercise intensity and duration, will be necessary to detect any possible effect on the inflammatory markers.

Safety of One-Day Admission Transradial Coronary Intervention

BACKGROUND: Recent advances of percutaneous coronary intervention (PCI) and transradial coronary intervention (TRI) have made it possible to reduce the local complication rate and the time until a return to ambulation. The aim of this study is to assess the safety and the patient satisfaction of the TRI-based one-day admission program for PCI. METHODS: Total 230 consecutive patients underwent TRI on the day of admission, according to pre-determined inclusion criteria, from May 2001 to October 2003. The subjects were examined for clinical and angiographic characteristics. The patients having a same-day discharge were telephone-interviewed one day and seven days after discharge to assess late complications and the patients' satisfaction. RESULTS: The mean age of the subjects was 59+/-9 years and 77.4% were male patients. 169 (73.4%) had stable angina and 37 (16.1%) had unstable angina. Stents were implanted in 178 cases (69.3%). Of the 230 patients who underwent TRI, 206 patients (89.6%) could discharge on the same day after the procedure. The procedure was successful in 98.5%. The average hospital stay for them was 9.4+/-1.4 hours. Two subjects reported hematoma near the puncture site within 24 hours after discharge, and one reported this problem 7 days after discharge. During the follow-up, there were no cases reporting chest pain needing rehospitalization or such complications as subacute vessel closure. No deaths, myocardial infarctions or revascularization were noted during the follow-up period. The majority of the patients (n=197, 95.6%) were satisfied with the same-day admission and discharge. CONCLUSIONS: Same day admission and discharge after TRI seems to be safe as well as satisfactory for not low-risk patients.

Clinical Usefulness of the Second Derivative of a Photoplethysmogram Waveform(SDPTG)

BACKGROUND AND OBJECTIVES: The second derivative of a photoplethysmogram (SDPTG) is a simple, convenient and non-invasive technique for pulse wave analysis. The SDPTG index correlates with age and other risk factors of atherosclerosis in the Japanese population, but has not yet been described in the Korean population. The purposes of this study were to analyze the age-related changes in the SDPTG of healthy subjects (study 1), and investigate the differences in the SDPTG of patients with hypertension, compared with those of normotensive subjects (study 2). We also compared the differences in the SDPTG between coronary artery disease (CAD) patients and normal subjects (study 3), to test the clinical usefulness of SDPTG in the evaluation of atherosclerosis. SUBJECTS AND METHODS: We consecutively studied 235 healthy adults, 40 with essential hypertension and 42 with CAD. Their SDPTG were recorded in the sitting position using a Fukuda FCP-3166. RESULTS: In study 1, the b/a ratio increased with age, whereas the c/a, d/a and e/a ratios decreased. The SDPTG aging index (AGI)(y) increased with age (x)(r=0.71, p=0.000;y=22.731x+54.571). In study 2, the patients with hypertension showed a lower average d/a ratio (-0.47+/-0.15 vs. -0.38+/-0.15, p=0.02) and higher average SDPTG AGI (-0.09+/-0.34 vs. -0.26+/-0.37, p=0.011) than the normotensive subjects. In study 3, the patients with CAD had higher average b/a ratio (-0.47+/-0.19 vs. -0.59+/-0.17, p=0.001) and SDPTG AGI (-0.01+/-0.41 vs. -0.23+/-0.40, p=0.004) than the normal subjects. In a logistic regression analysis, the SDPTG AGI was a significant determinant of CAD (p=0.046). CONCLUSION: The SDPTG aging index may be useful in the evaluation of vascular aging and damage due to hypertension and atherosclerosis.

Clinical Characteristics of Ventricular Premature Beats Originating from Right Ventricular Outflow Tract

BACKGROUND AND OBJECTIVES: Ventricular premature beat (VPB) with a left bundle branch block morphology and an inferior axis usually originates from the right ventricular outflow tract (RVOT) and is a frequent clinical problem. Although some investigators have suggested that RVOT VPBs are associated with RVOT ventricular tachycardia, few data are available on patients with RVOT VPBs. The purpose of this study was to determine the clinical characteristics and prognosis of RVOT VPB. SUBJECTS AND METHODS: The study subjects were 161 consecutive patients with frequent RVOT VPBs on standard electrocardiography. All patients underwent clinical examinations, echocardiography and 24-hour ambulatory electrocardiography. Among these patients, 50 were followed up for a period averaging 28.5+/-18.1 months. RESULTS: No structural cardiac abnormalities were found in 149 (92.5%) of the 161 patients with frequent RVOT VPBs. The prevalence of complex VPBs was relatively high (101 of 161 patients: 62.7%) on initial 24-hour electrocardiography. In the case of the 50 follow-up patients, there was no significant difference in mean frequency of RVOT VPBs between baseline and follow-up study (636+/-482/hour vs. 569+/-502/hour, p=NS). Furthermore, VPBs tended to persist over the follow-up period in the majority (92%) of patients with frequent RVOT VPBs. Five patients (10%) developed nonsustained ventricular tachycardia, 2 (4%) sustained ventricular tachycardia and 1 (2%) died suddenly. Antiarrhythmic drugs are effective in decreasing the frequency of VPBs, and beta-blockers especially seem to be effective in decreasing the severity of VPBs. CONCLUSION: In the patients with frequent RVOT VPBs, sustained ventricular tachycardia or sudden death could develop. Therefore, careful observation is required in patients with frequent RVOT VPBs.

A Case of Metastatic Tracheal Tumor From Ovarian Carcinoma / 결핵

Tracheal tumors are uncommon comprising less than 0.1% of all malignancies. Metastatic tracheal tumors, especially form the extrathoracic sites, are exceedingly rare. Ovarian cancer tends to metastasize to the serous cavities and the lymph nodes. One large autopsy study reported tracheal involvement in 1% of patients who had died from ovarian cancer. Other studies have not mentioned tracheal involvement at all. Since the main symptoms of cough, hemoptysis, or wheezing are nonspecific, patients may be initially treated for other conditions including asthma or bronchitis. Here we describe a metastatic tracheal tumor from an overain carcinoma that was initally treated for bronchial asthma.

A Case of Bleomycin Induced Bronchiolitis Obliterans Orgnizing Pneumonia / 결핵

There are numerous agents with potential toxic effects on the lung. In particular, cytotoxic drugs constitute the largest and most imprtant group of agents associated with lung toxicity. Bleomycin is commonly used, either alone or in combination with other chemotherapeutic agents, in the treatment of squamous cell carcinoma(head and neck, esophagus, and genitourinary tract), lymphoma, and germ cell tumor. One of the therapeutic advantages of bleomycin is its minimal bone marrow toxicity. However, pulmonary toxicity is one of the most serous adverse side effect. Classically, pulmonary toxicity manifests as a diffuse interstitial process or less commonly as a hypersensitivity reaction. This pulmonary toxicity is generally considered to be dose related and can progress to a fatal fibrosis. It is also possible that bronchiolitis obliterans organizing pneumonia(BOOP) is another manifestation of bleomycin induced toxicity. Bleomycin induced BOOP is less common and has a favorable response to steriod therapy. Here we present a case that demonstrates a BOOP, secondary to a relatively small cumulative dose of bleomycin(225mg/??, may be reversible.

Efficacy of Sotalol and Amiodarone for Atrial Fibrillation

BACKGROUND AND OBJECTIVES: Atrial fibrillation(AF) is the most frequently encountered arrhythmia in clinical practice. Pharmacologic therapy has been advocated for both immediate restoration of sinus rhythm and prevention of recurrent AF. Because conventional antiarrhythmic therapy is often ineffective in maintaining sinus rhythm or is associated with adverse side effects in patients with AF, recent interest has focused on the use of class III antiarrhythmic agents. This study investigated the efficacy and safety of sotalol and amiodarone for conversion of chronic AF and prevention of recurrent AF. MATERIALS AND METHOD: Thirty six patients with AF were firstly received sotalol by prospective study protocol. The patients were classified as having paroxysmal AF(PAF, N=2) or chronic AF(CAF, N=4) based on AF pattern. If the patients with CAF did not convert to sinus rhythm or the patients with PAF recurred in AF, the patients were received second agents(amiodarone). Patients were followed up for one year. RESULTS: Among the 12 patients with PAF receiving sotalol, 10(83.3%) patients remained in normal sinus rhythm for average 9.4+/-3.6 months. Sotalol was replaced by amiodarone in the remaing 2 patients with arrhythmia recurrence and 1 of the 2 patients remained in sinus rhythm during the follow-up period. In the case of 24 patients with CAF, conversion to sinus rhythm was achieved in 5(20.8%) patients with sotalol. Among the patients with CAF who were not respond to sotalol, 17 patients received amiodarone subsquently and 3 patients successfully converted to sinus rhythm. There were no proarrhythmic effects related to both agents during the study period. CONCLUSION: Both sotalol and amiodarone appear to be less effective in the termination of CAF, but sequential use of these two agents seem to be very effective for the prevention of recurrence of PAF.

Two cases of honey poisoning with syncope / 대한내과학회지

Intoxifications caused by toxic honey were occurred recently in Korea. Honey poisoning is known to be induced by grayanotoxins, that appear in flowers of different species of Rhododendron. These toxic compounds cause depolarization of membranes that contain fast Na channel by increasing in Na permeability. After ingestion of toxic honey patients may present with neurological, cardiovascular, gastrointestinal sign and symptoms. Two cases of honey poisoning are described here. Both patients experienced syncope and severe arterial hypotension after ingestion of honey which was brought from Nepal and Brazil. Conservative treatement was fully successful in both patients within 24 hours. We report the first case of honey poisoning in Korea.