A case of renal cell carcinoma with mediastinal lymph node metastasis diagnosed by EBUS-TBNA / 대한내과학회지

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a new method of sampling mediastinal lymph nodes to aid in diagnosing lymphadenopathy and in staging metastatic cancers. This paper describes a case of renal cell carcinoma with mediastinal and hilar lymph nodes metastasis that was diagnosed using EBUS-TBNA. A 17-year-old woman who had mediastinal lymphadenopathy and a right renal mass underwent imaging studies. The results of a first EBUS-TBNA suggested malignancy, but the type of tumor and exact site of the primary tumor were uncertain. Therefore, we repeated EBUS-TBNA with a lower pressure on the vacuum syringe. We successfully diagnosed the mediastinal lymph node metastasis from renal cell carcinoma.

A Comparison of Adaptive Support Ventilation (ASV) and Conventional Volume-Controlled Ventilation on Respiratory Mechanics in Acute Lung Injury/ARDS / 대한구급학회지

BACKGROUND: ASV is a closed-loop ventilation system that guarantees a user-set minimum per-minute volume in intubated patients, whether paralyzed or with spontaneous breathing. Here, we tested the effects of ASV onrespiratory mechanics and compared them with volume-controlled ventilation (VCV). METHODS: Thirteen patients meeting the criteria for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) were enrolled. All patients were paralyzed to eliminate spontaneous breathing. We started with VCV (VCV1), then used ASV followed by VCV modes (VCV2), maintaining minute volume as much as that of VCV1. RESULTS: During ASV, compared with VCV1, the inspiratory and expiratory tidal volumes and expiratory resistance increased. Conversely, the total respiratory rate and maximum pressure decreased. No changes in the arterial blood gases, heart rate, or mean systemic pressure were noted during the trial. CONCLUSIONS: In ALI/ARDS patients, although no differences were observed in the arterial blood gas analysis between the two modes, ASV provided better respiratory mechanics in terms of peak airway pressure and tidal volume than VCV.

The 3 years Prognosis of Patients with Long Term Mechanical Ventilation in Medical Intensive Care Unit at a University Hospital / 결핵및호흡기질환

BACKGROUND: There is little data on the 3 year prognosis and quality of life of patients on long-term (>72 hour) mechanical ventilation in a medical intensive care unit (MICU). METHODS: Patients with long-term mechanical ventilation from May 2003 through July 2003 in MICU of Asan Medical Center, Seoul were enrolled in this studay. The survival rates were observed prospectively at 1, 3, 6, 12, 24, 36 months, and the quality of life of survivor was measured at 12 months by using Short Form 36 (SF-36). RESULTS: The survival rate at 1, 3, 6, 12, 24 and 36 months was 54.8% (40/73), 39.7% (29/73), 30.1% (22/73), 20.5% (15/73), 18.3% (13/71) and 16.9% (12/71), respectively. There was a similar survival rate regardless of the diseases that required mechanical ventilation. A neoplasm or chronic liver disease had a worse survival rate than chronic lung or kidney disease (p>0.05). Each SF-36 domain except for the Role-emotional was inferior to the general population. CONCLUSIONS: The survival rate of patients with mechanical ventilation more than 72 hours is decreases continuously until 12 months but is relatively constant from 12 to 36 months. In these patients quality of life is also decrased.

Hepatotoxicity of Rifampicin and Pyrazinamide Treatment Excluding Isoniazid / 결핵및호흡기질환

BACKGROUND: Even though two-month rifampicin (RMP, R) and pyrazinamide (PZA, P) treatment has some advantages over isoniazid (INH, H) treatment for latent tuberculosis infection (LTBI), it was withdrawn from the list of treatment regimens for LTBI because of reported cases of severe hepatotoxicity. The purpose of this study was to estimate the frequency of hepatotoxicity of RMP and PZA treatment excluding INH in a Korean population. METHOD: TIn order to recruit patients who were prescribed RMP and PZA excluding INH, 256 INH-resistant tuberculosis patients were investigated through retrospective medical record analysis. A standard four-drug regimen was changed to a RMP/PZA-containing regimen excluding INH in 64 patients (RZ+ group). In the same study period, 146 patients who were prescribed an INH/RMP/PZA-containing standard regimen were randomly selected as a control (HRZ+ group). Clinical characteristics including liver diseases and the frequency of drug-induced hepatitis were compared between the RZ+ and HRZ+ groups. RESULT: The mean age of patients in the RZ+ group was 50.2 (+/-16.2) and the male-to-female ratio was 36:28. The frequency of underlying liver diseases was 10.9% (7/64), which was not significantly different from that of the HRZ+ group (4.1%, 6/146). Even though the treatment duration of RZ+ (5.5 +/- 4.8 months) was longer that than that of HRZ+ (2.7 +/- 2.3 months), the frequency of toxic hepatitis was not significantly different between RZ+ and HRZ+ groups, 3.5% (2/57) and 7.1% (10/140), respectively. CONCLUSION: Hepatotoxicity was mild and occurred in a minor proportion of patients in a Korean population prescribed an RMP/PZA-containing regimen. A future prospective study including more patients is needed.

Hepatotoxicity of Rifampicin and Pyrazinamide Treatment Excluding Isoniazid / 결핵및호흡기질환

BACKGROUND: Even though two-month rifampicin (RMP, R) and pyrazinamide (PZA, P) treatment has some advantages over isoniazid (INH, H) treatment for latent tuberculosis infection (LTBI), it was withdrawn from the list of treatment regimens for LTBI because of reported cases of severe hepatotoxicity. The purpose of this study was to estimate the frequency of hepatotoxicity of RMP and PZA treatment excluding INH in a Korean population. METHOD: TIn order to recruit patients who were prescribed RMP and PZA excluding INH, 256 INH-resistant tuberculosis patients were investigated through retrospective medical record analysis. A standard four-drug regimen was changed to a RMP/PZA-containing regimen excluding INH in 64 patients (RZ+ group). In the same study period, 146 patients who were prescribed an INH/RMP/PZA-containing standard regimen were randomly selected as a control (HRZ+ group). Clinical characteristics including liver diseases and the frequency of drug-induced hepatitis were compared between the RZ+ and HRZ+ groups. RESULT: The mean age of patients in the RZ+ group was 50.2 (+/-16.2) and the male-to-female ratio was 36:28. The frequency of underlying liver diseases was 10.9% (7/64), which was not significantly different from that of the HRZ+ group (4.1%, 6/146). Even though the treatment duration of RZ+ (5.5 +/- 4.8 months) was longer that than that of HRZ+ (2.7 +/- 2.3 months), the frequency of toxic hepatitis was not significantly different between RZ+ and HRZ+ groups, 3.5% (2/57) and 7.1% (10/140), respectively. CONCLUSION: Hepatotoxicity was mild and occurred in a minor proportion of patients in a Korean population prescribed an RMP/PZA-containing regimen. A future prospective study including more patients is needed.

The Expressions of Hypoxia-Inducible Factor-1 and Vascular Endothelial Growth Factor in Osteosarcoma and Chondrosarcoma / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to investigate the impact of the vascular endothelial growth factor (VEGF) and the hypoxia-inducible factor-1 (HIF-1) expression on clinicopathologic factors in osteosarcomas and chondrosarcomas. MATERIALS AND METHODS: Thirty-five osteosarcomas and 9 chondrosarcomas were assessed for HIF-1 and VEGF expressions with monoclonal antibodies using immunohistochemistry. The pathologic tumor grades are followed the WHO classification. RESULTS: Nineteen out of 35 osteosarcomas (54.3%) and 8 out of 9 chondrosarcomas (88.9%) showed HIF-1 expressions. The HIF-1 expressions increased with the pulmonary metastasis (p=0.020) and the tumor grades (p=0.016) in only osteosarcomas. Twenty-four out of 35 osteosarcomas (68.6%) and 6 out of 9 chondrosarcomas (66.7%) showed VEGF expressions. The extents of VEGF expression in only osteosarcomas showed positive correlation with the pulmonary metastasis (p=0.024). CONCLUSION: The HIF-1 and VEGF appear to be an important role for the development and progression of these two tumors. The HIF-1 expression in osteosarcomas seems to be poor prognostic value including aggressive tumor grades and pulmonary metastasis. The extents of VEGF immunostaining might indicate the possibility of pulmonary metastasis in osteosarcomas. However, the two gene expressions could not indicate the significant prognostic value in chondrosarcomas.

The Expressions of CD117 (c-kit) and Her-2/neu in Malignant Bone and Soft Tissue Tumors / 대한정형외과학회잡지

PURPOSE: The aim of this study was to determine the prevalence of c-kit (CD117) and Her-2/neu expressions in malignant bone and soft tissue tumors and to identify a possible predictive role in patients with these malignancies. MATERIALS AND METHODS: A retrospective study was conducted on 40 archival paraffin-embedded tissue specimens of patients with 32 malignant bone tumors (23 osteosarcomas, 9 chondrosarcomas) and 8 synovial sarcomas. The gene expressions levels were evaluated by immunohistochemistry. RESULTS: C-kit expression was observed in 13 out of 23 osteosarcoma patients (56.5%), 4 out of 9 chondrosarcoma patients (44.4%) and 4 of 8 synovial sarcoma patients (50.0%). In particular, the relationship between c-kit expression and gender (p=0.044), a pulmonary metastasis (p=0.044), and the tumor cell grade (p=0.023) in osteosarcoma were found to be statistically significant. On the other hand, Her-2/neu expression was not found in any of the 40 cases under study. CONCLUSION: These results suggest that the c-kit expression appears to play an important role in the development of a malignant bone tumor and synovial sarcoma. In particular, it should be noted that c-kit expression is found frequently in an osteosarcoma with a pulmonary metastasis. In this respect, the tyrosine kinase inhibitors can be considered to be significant in the treatment of a malignant bone tumor and a synovial sarcoma. However, Her-2/neu does not appear to play any significant role in these malignancies.

Surgical Treatment of Ganglions in Foot and Ankle / 대한족부족관절학회지

PURPOSE: To evaluate the results of surgical treatment and relationship between the recurrence and characteristics of ganglions in foot and ankle. MATHERIALS AND METHODS: Seventeen cases of ganglions located in foot and ankle, excised at St. Benedict Hospital from Mar. 1993 to Apr. 2003, were included in the study. All of cases were analyzed retrospectively in terms of age, sex of the patients, location and size of the ganglion, symptom, operative method as well as recurrence rate were evaluated. The mean follow up was 1.8 years (11 months~6.5 years). RESULTS: The size of ganglion ranged from 0.5 cm to 5.0 cm with mean size of 2.5 cm. The most common area of ganglion was the dorsum of foot and pain was the primary chief complain The recurrence was found in 4 cases (23.5%): 1 of them occurred among 8 cases the diameter of which was less the 2.5cm and other 3 occurred among 9 casees larger than 2.5cm. 12 cases were completely excised mass with no recurrence. But 5 cases were incompletely excised & ligated stalk of mass and 4 cases of them were recurred. A correlation was only observed between complete excision and low recurrence rate. CONCLUSION: Recurrence rate of ganglions in foot and ankle was high and the correlation was obstained between complete excision and low recurrence rate.

Effect of Beraprost Sodium in Patients with Chronic Obstructive Pulmonary Disease / 결핵및호흡기질환

BACKGROUND: Pulmonary vascular changes which occur early in the course of chronic obstructive pulmonary disease (COPD) are prevalent manifestation and later cause pulmonary hypertension, which is a bad prognostic factor in COPD. Beraprost sodium (BPS), an orally active prostacyclin analogue, has been shown to improve survival in patients with primary pulmonary hypertension. This study investigated the effect of BPS in the patients with COPD. METHODS: This is a double-blind randomized placebo-controlled, two center clinical trial. Twenty one consecutive patients with COPD were enrolled from June 2003 to June 2004 (patients treated with BPS for 3 months, BPS group, n=11; those with placebo, placebo group, n=10). The baseline demographic, pulmonary function and hemodynamic data were not significantly different between two groups. RESULTS: On echocardiographic examination, trans tricuspid valve pressure gradient has decreased significantly after 3 months with beraprost in the BPS group [17.7(+/-11.4) to 8.2(+/-8.9) mm Hg, p-value<0.05], while there was no significant change in the control group. Six-minute walking distance has decreased in the control group and increased in the BPS group, but there was no statistical significance. CONCLUSION: In patients with COPD oral administration of BPS reduced the pulmonary arterial pressure. The clinical significance of this finding, that is improving symptoms and natural course of the disease, needs further study.

The Clinical Comparison of Ganglions in Hand and Foot / 대한족부족관절학회지

PURPOSE: To compare clinical characteristics of ganglions in hand & Foot. MATERIALS AND METHODS: Seventeen cases of ganglions located in foot and fifty-five cases in hand. Excised from Mar.1988 to Apr.2003, were included in the study. The clinical characteristics and recurrence ratio were evaluated RESULTS: The mean size of 2.2 cm in hand and 2.5 cm in foot. The most common area of ganglions are dorsum of foot and wrist. The cosmetic problem of palpable mass is the primary chief complaint of ganglions on hand and the pain is that of foot. The recurrence was found in 5 cases in hand and 4 cases in foot. The recurrence was related to incomplete excision of ganglion in foot and the large size of ganglion and incomplete excision of ganglion in hand. CONCLUSION: recurrence ratio in the cases of foot is higher than that of hand. The ganglions in foot and hand need to treated by meticulous surgical excision to prevent the recurrence.

Correlation of Correction Angle with Pain at First Metatarsophalangeal Joint in the Treatment of Hallux Valgus / 대한정형외과학회잡지

PURPOSE: We evaluated the correlation between correction angle and pain of the first metatarsophalangeal joint in the treatment of hallux valgus. MATERIALS AND METHODS: The 28 cases (20 patients) with moderate to severe hallux valgus deformity and pain of the first metatarsophalangeal joint who underwent the distal soft tissue procedure and proximal metatarsal closing wedge osteotomy, were divided into two groups, Group I: no pain of the first metatarsophalangeal joint after surgery, and Group II: with persisting pain. We analyzed the correc-tion angle and pain of the first metatarsophalangeal joint in each group, preoperatively and at the last follow-up. All of the patients were women and their mean age was 58 years old. The average follow-up time was 18 months. RESULTS: At the last follow-up, the 21 feet (75%) were free of pain of the first metatarsophalangeal joint. In 7 feet (25%) pain persisted. In group I, sufficient deformity correction was obtained, but in group II, the deformity was corrected insufficiently. A high correlation was observed between correction angle and pain relief. CONCLUSION: A high correlation was obtained between correction angle and pain of the first metatarsophalangeal joint in the treatment of hallux valgus deformity. Therefore, in view of the patient's expectation of pain relief, meticulous attention should be paid to the correction of hallux valgus deformity.

Diagnosis and Arthroscopic Treatment of Symptomatic Medial Patellar Plica Syndrome of the Knee / 대한정형외과학회잡지

PURPOSE: To evaluate the efficacy of physical examination and dynamic arthroscopy in the diagnosis and treatment of medial patellar plica syndrome which is likely to be overlooked. SUBJECTS AND METHODS: 23 cases diagnosed as medial patellar plica syndrome from August 1998 through December 1999 were evaluated. Diagnosis was made by a symptom of a pain and a click sound during knee flexion, a physical examination of mass palpation and dynamic arthroscopy. RESULT: A dynamic rotation test was an useful physical examination having 96% rate of sensitivity. The results of excellent and good cases were in 19 cases (83%) and there was no worsened case symptomatically after arthroscopic resection. Postoperative complications were 3 cases including incomplete excision (1 case), postoperative hemarthrosis (1 case) and medial meniscus instability due to incorrect arthroscopic technique (1 case). In patients younger than 30 year old, the result of arthroscopic excision was better than that in older ones. CONCLUSION: Careful physical examination with dynamic arthroscopy is a useful method to diagnose the medial patellar plica syndrome which is likely to be overlooked, and arthroscopic complete excision result in excellent results which is of benefit to fast rehabilitation.

A Case of a Bleeding Duodenal Diverticulum by a Dieulafoy-like Lesion / 대한소화기내시경학회지

Duodenal diverticula are first reported by Chomel in 1710. Duodenal diverticula are relatively common in adults with a prevalence of 23% in ERCP. The most duodenal diverticulum is asymptomatic. Complications such as obstruction, cholangitis, biliary stones, ulceration, perforation and hemorrhage can occur in approximately 10%. However, relatively few cases of bleeding from a duodenal diverticulum have been reported. The cause of bleeding from a duodenal diverticulum is uncertain and various suspected etiologies were suggested, such as ectopic gastric mucosa, stasis-induced ulceration, erosion into major vessels, aortoenteric fistulas, intradiverticular polyp, aspirin-induced erosion. We report a case of a bleeding duodenal diverticulum by a Dieulafoy-like lesion and suggest this lesion as one of possible causes of bleeding in duodenal diverticulum.

A Case of the Duodenal Tuberculosis Presenting as Hematemesis / 대한소화기내시경학회지

Despite the modern advance in effective chemotherapy, gastrointestinal tuberculosis is considered to be relatively frequent in developing countries. The ileocecal region is the most common site of intestinal tuberculosis and duodenal involvement is rare. The isolated duodenal tuberculosis are reported 9 cases in Korea. The symptoms and signs of gastrointestinal tuberculosis are nonspecific and vague. In the absence of pulmonary tuberculosis, the diagnosis may be difficult. Pain and vomiting are common symptoms of duodenal tuberculosis. Patients may present with upper gastrointestinal bleeding. Therefore, tuberculosis should be considered in the differential diagnosis of gastrointestinal bleeding. We herein report a case of duodenal tuberculosis presenting as hematemesis and necessitating hospitalization. After anti-tuberculosis therapy, we have confirmed the healing of the lesion by the follow-up endoscopy, and review the current literature.

Tinnitus Masking Effects Using Various Kinds of Sound and Music / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Even though various methods have been tried to diagnose and treat tinnitus, researchers have fallen short of providing the accurate characteristics since most tinnitus are presented as a subjective symptom. A few researchers have tried to assimilate tinnitus using computer and music synthesizers, however, their efforts have not yet been developed as generalized treatment modalities. In this study, we attempted to induce not only tinnitus masking but also psychological stability with various kinds of sound and music and to analyse its treatment effects. The aim of this study is to make a step toward developing tinnitus treatment. MAERIALS AND METHODS: The subjects were 28 patients with constant tinnitus, who visited the otolaryngology department of Seoul Paik Hospital, Medical College of Inje University from June to December of 1997. We tried to objectify the tinnitus as close to the actual sound as possible by synthesizing the modulation of the broad band noises and recording not only the existing pure tones and broad band noises but also the natural and artificial sounds which the patients could easily hear from their surroundings. And then we tried to mask tinitus with various natural, artificial and synthetic sounds, including its frequency band. We also let them hear the tapes for contemplation and various music. RESULTS: The results were as follows. 1) As for the quality of tinnitus, 13 patients reported similarity to the pure tone (46.4%), seven to narrow band noise (25%), eight to natural environmental sounds (21.4%), one each to artificial environmental sound and white noise (3.6%) and no one to synthetic sound. 2) The sound that masked tinnitus well was three octave broad band noise including the tinnitus frequency. 3) Twenty four patients (85.7%) chose music as the most comfortable sound to listen to. 4) Three patients (10.7%) replied that their tinnitus were decreased in amplitude and 15 patients (53.6%) reported that it was easier to stand the tinnitus even though their tinnitus persisted. CONCLUSION: Based on these results, it can be concluded that music therapy provides psycological stability in addtion to inducing masking effect, even though it can't directly decrease nor completely remove tinnitus. Thus we believe that a more effective result can be obtained if music therapy is implemented on a gradual basis as a part of the whole treatment process.

Dislocation After Total Hip Arthroplasty / 대한정형외과학회잡지

PURPOSE: Despite many recent advances in total hip arthroplasty, dislocation remains a common postoperative complication. This study was undertaken to evaluate the incidence and causes of dislocation. MATERIALS AND METHODS: We experienced 16 hip dislocations in 217 cases of total hip arthroplasty performed between June 1990 and March 1999. We analyzed the incidence and causes of dislocation retrospectively. We classified the factors of dislocation as component malposition, Soft tissue imbalance and patient factor. Radiographic measurements were performed to evaluate component malposition and soft tissue imbalance. To evaluate patient factor, we analyzed the patient's past history and posture when the dislocation occurred. RESULTS: The leading causes of hip joint dislocation after total hip arthroplasty are acetabular component malposition (9 cases), followed by patient factor (5 cases) and soft tissue imbalance (3 cases). It took an average of 40.5 days following surgery for hip joint dislocation to occur with 13 out of 16 cases (90.2%) developing hip dislocation within 2 months. CONCLUSION: In order to prevent acetabular component malposition, careful insertion of acetabular component is required. Preventive measure and care should be taken during the early postoperative period. Those presenting with improper anteversion, accurate analysis of the extent of acetabular and femoral component anteversion based on CT scanning is helpful.

A Study on the Proliferative Activity of the Squamous Epithelium of the Cholesteatoma Using Argyrophilic Nucleolar Organizer Regions / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The Nucleolar organizer regions (NORs) are one of markers of cellular proliferation. Because the NORs can be visualized by a silver staining technique, the NORs are called the argyrophilic nucleolar organizer regions (AgNORs). The expression patterns of proliferative markers have been reported in the cholesteatoma, but the AgNORs have not been studied in the cholesteatoma. We investigated the proliferative activities of the cholesteatoma by the AgNORs and the usefulness of the AgNORs as a proliferative index in the cholesteatoma. MATERIALS AND METHODS: We assessed 5 postauricular skin samples and 20 cholesteatoma specimens by the numbers of the total AgNORs and the large AgNORs (large AgNOR means a diameter of over 6 nm) in high power fields and each cell. And the total areas of the AgNORs in high power fields (HPF) were calculated. RESULTS: The numbers of the large AgNORs in HPF, the numbers of AgNORs in each cell and the total areas of the AgNORs in HPF of the cholesteatoma were higher than those of the controls (p<0.05). In the cholesteatoma, the numbers of the large AgNORs and the total areas of the AgNORs in HPF were the highest in the keratinizing squamous epithelium of thick portion followed by the non-keratinizing squamous epithelium, and the keratinizing epithelium of thin portion. The numbers of the large AgNORs in each cell of the basal and superficial layers were the highest in the thick keratinizing squamous epithelium. In the suprabasal layer, the non-keratinizing squamous epithelium showed higher numbers of the large AgNORs but showed no statistical significance. CONCLUSION: 1) The proliferative capacity of the epithelium of cholesteatoma is reactive proliferative status. 2) The proliferative activity is varied with the differentiation status of the squamous epithelium in the cholesteatoma.

Regenerate Bone Healing According to Osteotomy Methods in Ilizarov lengthening / 대한정형외과학회잡지

The Ilizarov technique for gradual distraction osteogenesis was developed in the 1950s. A correctly performed osteotomy is essential to the success of distraction osteogenesis and prepares for limb lengthening. Between Sept. of 1991 and 1994, thirty-four patients were treated by Ilizarov technique at St. Benedict Hosp. and Gang-Dong Hosp.. And then assigned to two separate groups : a corticotomy group (group A) and osteotomy group (group B; osteotomy with Gigli saw or osteotomy with multiple drill holes and osteotome). The regenerate segments were evaluated weekly for the first six weeks after operation. After the initial six-week evaluation period, observations of these segments were continued through a series of monthly radiographs. Distraction began on postoperative day seven in group A and on day eleven in group B; and continued at a rate of 1 mm/day and a frequency of 4 times/day. Group A displayed new bone formation earlier than group B: group A's mean was 16.5 ± 4.9 days, while B's mean was 25.3 ± 4.6 days. The first bridging callus occurred earlier in group A than it did in group B: A's mean was time of 36.7 ± 9.9 days, while B's mean was 44.0 ± 7.9 days. There was no significant difference between groups A & B in terms of first cortical formation : A's mean was 86.9 ± 24.0 days, and B's mean was 100.6 ± 25.2 days. There was no significant difference between groups A & B in terms of the bone healing index : A's mean was 41.6 ± 13.5 days and B's mean was 41.15 ± 8.10 days.