Dynamic Evaluation of Skin Displacement by the Frontalis Muscle Contraction Using Three-Dimensional Skin Displacement Vector Analysis

Purpose@#Understanding the muscle actions and resultant skin movement can enable more safe and effective botulinum toxin injection for the treatment of forehead wrinkles. We aimed to investigate skin displacement patterns of the forehead and adjacent skin due to frontalis muscle contraction using three-dimensional skin vector displacement analysis. @*Materials and Methods@#Thirty healthy individuals were enrolled. Photographs of the face were taken at rest and during maximal contraction of the frontalis muscle. Each expression image was aligned to its respective static image to compute the differences in the skin position. @*Results@#When frontalis muscle contracts, forehead skin displacement vectors were mostly vertical (63.4%), followed by lateral oblique (33.3%) and medial oblique (3.3%). In 53.3%, only the lower part of the forehead moved upward, while 40.0% showed bidirectional skin movement with transition line at a mean distance of 59.4 mm above the pupil. Moreover, 86.7% showed asymmetric skin displacement, and 83.3% showed both glabellar and eyebrow skin displacement. Frontalis muscle contraction also induced medial 2/3 (50.0%) or entire (33.3%) skin movement of the temple. @*Conclusion@#Botulinum toxin injection into the forehead can be individualized by considering the vector and asymmetry of skin displacement. Vertical or medial vector requires more centrally located injections, while laterial vector requires more laterally located injections. The presence and location of the vertical transition line are important for preventing ptosis when treating forehead lines with botulinum toxin. Glabellar movement during frontalis contraction suggests the need for a concomitant injection into the glabella to prevent glabella wrinkle accentuation.

Primary Localized Cutaneous Nodular Amyloidosis on Scalp Successfully Treated with Excision

Primary localized cutaneous nodular amyloidosis (PLCNA) is the rarest form of cutaneous amyloidosis, characterized by nodular deposits of light chain amyloids in the dermis and subcutaneous tissue, without apparent systemic involvement. One or several nodules are preferably located on the extremities, trunk, or face. The most useful stain for detecting amyloid fibrils is Congo red, which, when combined with polarized light, makes amyloid proteins appear apple-green under a microscope. Immunohistochemical staining can help identify the exact type of amyloid proteins. Although the exact etiology of PLCNA is unclear, removal of nodules by shaving or surgical excision has shown good results. To the best of our knowledge, only seven cases of PLCNA have yet been reported in the Korean literature. In three of these cases, the patients had lesions on the scalp. Herein, we present a case of a 34-year-old male with PLCNA on the scalp with all the results of immunohistochemical evaluation.

Correlation between Lipids Measured in the Interstitial Fluid from Suction Blister and the Serum / 대한피부과학회지

Background@#Several biomarkers are measured in the interstitial fluid (IF) obtained from suction blisters that are used by dermatologists. As abnormal lipid levels can cause health problems, several studies have investigated the composition and distribution of lipids and lipoproteins in IF. However, to date, no study has focused on examining lipid profiles in the postprandial state. @*Objective@#This study aimed to compare postprandial changes in serum lipid profiles and IF obtained from suction blisters and investigated their correlation. @*Methods@#Fasting and postprandial levels of total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides were measured in paired serum samples. IF was obtained from suction blisters from 20 healthy men using enzymatic-colorimetric methods. @*Results@#The IF/serum ratios of TC, HDL-C, and LDL-C remained unchanged postoperatively. Postprandial levels of HDL-C and LDL-C decreased in the serum but not in IF. In both fasting and postprandial states, TC, HDL-C, and LDL-C levels in the serum were positively correlated with those in the IF. @*Conclusion@#The results of this study showed that lipoprotein cholesterol levels measured from suction blister fluids could be used as a biomarker to predict their serum levels regardless of food intake. Therefore, suction blister fluid sampling can be considered as a method to monitor serum lipid concentrations.

Effects of an Infection Control Protocol for Coronavirus Disease in Emergency Mechanical Thrombectomy

Objective@#: Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, neurointerventionists have been increasingly concerned regarding the prevention of infection and time delay in performing emergency thrombectomy procedures in patients with acute stroke. This study aimed to analyze the effects of changes in mechanical thrombectomy protocol before and after the COVID-19 pandemic on procedure time and patient outcomes and to identify factors that significantly impact procedure time. @*Methods@#: The last-normal-to-door, first-abnormal-to-door, door-to-imaging, door-to-puncture, and puncture-to-recanalization times of 88 patients (45 treated with conventional pre-COVID-19 protocol and 43 with COVID-19 protection protocol) were retrospectively analyzed. The recanalization time, success rate of mechanical thrombectomy, and modified Rankin score of patients at discharge were assessed. A multivariate analysis was conducted to identify variables that significantly influenced the time delay in the door-to-puncture time and total procedure time. @*Results@#: The door-to-imaging time significantly increased under the COVID-19 protection protocol (p=0.0257) compared to that with the conventional pre-COVID-19 protocol. This increase was even more pronounced in patients who were suspected to be COVID-19-positive than in those who were negative. The door-to-puncture time showed no statistical difference between the conventional and COVID-19 protocol groups (p=0.5042). However, in the multivariate analysis, the last-normal-to-door time and door-to-imaging time were shown to affect the door-to-puncture time (p=0.0068 and 0.0097). The total procedure time was affected by the occlusion site, last-normal-to-door time, door-to-imaging time, and type of anesthesia (p=0.0001, 0.0231, 0.0103, and 0.0207, respectively). @*Conclusion@#: The COVID-19 protection protocol significantly impacted the door-to-imaging time. Shortening the door-to-imaging time and performing the procedure under local anesthesia, if possible, may be required to reduce the door-to-puncture and doorto- recanalization times. The effect of various aspects of the protection protocol on emergency thrombectomy should be further studied.

Meta-analysis of transanal versus laparoscopic total mesorectal excision for rectal cancer: a ‘New Health Technology’ assessment in South Korea

Purpose@#Under the South Korea’s unique health insurance structure, any new surgical technology must be evaluated first by the government in order to consider whether that particular technology can be applied to patients for further clinical trials as categorized as ‘New Health Technology,’ then potentially covered by the insurance sometime later. The aim of this meta-analysis was to assess the safety and efficacy of transanal total mesorectal excision (TaTME) for rectal cancer, activated by the National Evidence-based Healthcare Collaborating Agency (NECA) TaTME committee. @*Methods@#We systematically searched Ovid-MEDLINE, Ovid-Embase, Cochrane, and Korean databases (from their inception until August 31, 2019) for studies published that compare TaTME with laparoscopic total mesorectal excision (LaTME). End-points included perioperative and pathological outcomes. @*Results@#Sixteen cohort studies (7 for case-matched studies) were identified, comprising 1,923 patients (938 TaTMEs and 985 LaTMEs). Regarding perioperative outcomes, the conversion rate was significantly lower in TaTME (risk ratio, 0.19; 95% confidence interval, 0.11–0.34; P < 0.001); whereas other perioperative outcomes were similar to LaTME. There were no statistically significant differences in pathological results between the 2 procedures. @*Conclusion@#Our meta-analysis showed comparable results in preoperative and pathologic outcomes between TaTME and LaTME, and indicated the benefit of TaTME with low conversion. Extensive evaluations of well-designed, multicenter randomized controlled trials are required to come to unequivocal conclusions, but the results showed that TaTME is a potentially beneficial technique in some specific cases. This meta-analysis suggests that TaTME can be performed for rectal cancer patients as a ‘New Health Technology’ endorsed by NECA in South Korea.

Prognostic Impact of Carcinoembryonic Antigen Levels in Rectal Cancer Patients Who Had Received Neoadjuvant Chemoradiotherapy

Purpose@#Carcinoembryonic antigen (CEA) is a useful marker for rectal cancer. The aim of this study was to investigate the prognostic impact of CEA level according to neoadjuvant chemoradiotherapy (nCRT) in rectal cancer patients who underwent radical surgery. @*Methods@#A total of 245 patients with rectal cancer who underwent radical surgery were retrospectively evaluated. Serum CEA level was measured preoperatively and postoperatively. We compared survival outcomes based on CEA level before and after surgery according to nCRT. @*Results@#Of the 245 patients, elevation of CEA level was observed preoperatively in 79 and postoperatively in 30, respectively. Eighty-seven (35.5%) patients received nCRT, and elevated CEA level was a significant prognostic factor both before and after surgery. In patients who had not received nCRT, an elevated CEA level was a significant prognostic factor before surgery but was not significant after surgery. In a multivariate analysis for prognostic factors, elevation of preoperative CEA level was an independent prognostic factor of disease-free survival (DFS) regardless of nCRT. Postoperative CEA level was an independent prognostic factor of DFS in patients who had received nCRT but was not a factor in patients who had not received nCRT. @*Conclusion@#Serum CEA level was an independent prognostic factor both preoperatively and postoperatively in rectal cancer patients who had received nCRT.

Meta-analysis of transanal versus laparoscopic total mesorectal excision for rectal cancer: a ‘New Health Technology’ assessment in South Korea

Purpose@#Under the South Korea’s unique health insurance structure, any new surgical technology must be evaluated first by the government in order to consider whether that particular technology can be applied to patients for further clinical trials as categorized as ‘New Health Technology,’ then potentially covered by the insurance sometime later. The aim of this meta-analysis was to assess the safety and efficacy of transanal total mesorectal excision (TaTME) for rectal cancer, activated by the National Evidence-based Healthcare Collaborating Agency (NECA) TaTME committee. @*Methods@#We systematically searched Ovid-MEDLINE, Ovid-Embase, Cochrane, and Korean databases (from their inception until August 31, 2019) for studies published that compare TaTME with laparoscopic total mesorectal excision (LaTME). End-points included perioperative and pathological outcomes. @*Results@#Sixteen cohort studies (7 for case-matched studies) were identified, comprising 1,923 patients (938 TaTMEs and 985 LaTMEs). Regarding perioperative outcomes, the conversion rate was significantly lower in TaTME (risk ratio, 0.19; 95% confidence interval, 0.11–0.34; P < 0.001); whereas other perioperative outcomes were similar to LaTME. There were no statistically significant differences in pathological results between the 2 procedures. @*Conclusion@#Our meta-analysis showed comparable results in preoperative and pathologic outcomes between TaTME and LaTME, and indicated the benefit of TaTME with low conversion. Extensive evaluations of well-designed, multicenter randomized controlled trials are required to come to unequivocal conclusions, but the results showed that TaTME is a potentially beneficial technique in some specific cases. This meta-analysis suggests that TaTME can be performed for rectal cancer patients as a ‘New Health Technology’ endorsed by NECA in South Korea.

Prognostic Impact of Carcinoembryonic Antigen Levels in Rectal Cancer Patients Who Had Received Neoadjuvant Chemoradiotherapy

Purpose@#Carcinoembryonic antigen (CEA) is a useful marker for rectal cancer. The aim of this study was to investigate the prognostic impact of CEA level according to neoadjuvant chemoradiotherapy (nCRT) in rectal cancer patients who underwent radical surgery. @*Methods@#A total of 245 patients with rectal cancer who underwent radical surgery were retrospectively evaluated. Serum CEA level was measured preoperatively and postoperatively. We compared survival outcomes based on CEA level before and after surgery according to nCRT. @*Results@#Of the 245 patients, elevation of CEA level was observed preoperatively in 79 and postoperatively in 30, respectively. Eighty-seven (35.5%) patients received nCRT, and elevated CEA level was a significant prognostic factor both before and after surgery. In patients who had not received nCRT, an elevated CEA level was a significant prognostic factor before surgery but was not significant after surgery. In a multivariate analysis for prognostic factors, elevation of preoperative CEA level was an independent prognostic factor of disease-free survival (DFS) regardless of nCRT. Postoperative CEA level was an independent prognostic factor of DFS in patients who had received nCRT but was not a factor in patients who had not received nCRT. @*Conclusion@#Serum CEA level was an independent prognostic factor both preoperatively and postoperatively in rectal cancer patients who had received nCRT.

Clinical Significance of Decompressive Craniectomy Surface Area and Side

Objective@#: Decompressive craniectomy (DC) can partially remove the unyielding skull vault and make affordable space for the expansion of swelling brain contents. The objective of this study was to compare clinical outcome according to DC surface area (DC area) and side. @*Methods@#: A total of 324 patients underwent different surgical methods (unilateral DC, 212 cases and bilateral DC, 112 cases) were included in this retrospective analysis. Their mean age was 53.4±16.6 years (median, 54 years). Neurological outcome (Glasgow outcome scale), ventricular intracranial pressure (ICP), and midline shift change (preoperative minus postoperative) were compared according to surgical methods and total DC area, DC surface removal rate (DC%) and side. @*Results@#: DC surgery was effective for ICP decrease (32.3±16.7 mmHg vs. 19.2±13.4 mmHg, p<0.001) and midline shift change (12.5±7.6 mm vs. 7.8±6.9 mm, p<0.001). The bilateral DC group showed larger total DC area (125.1±27.8 cm2 for unilateral vs. 198.2±43.0 cm2 for bilateral, p<0.001). Clinical outcomes were nonsignificant according to surgical side (favorable outcome, p=0.173 and mortality, p=0.470), significantly better when total DC area was over 160 cm2 and DC% was 46% (p=0.020 and p=0.037, respectively). @*Conclusion@#: DC surgery is effective in decrease the elevated ICP, decrease the midline shift and improve the clinical outcome in massive brain swelling patient. Total DC area and removal rate was larger in bilateral DC than unilateral DC but clinical outcome was not influenced by DC side. DC area more than 160 cm2 and DC surface removal rate more than 46% were more important than DC side.

Prognostic value of carcinoembryonic antigen levels before and after curative surgery in colon cancer patients

Purpose@#CEA is a useful tumor marker for colon cancer. The aim of this study was to investigate the prognostic value of changes in CEA levels before and after surgery in colon cancer patients who underwent radical surgery. @*Methods@#A total of 601 colon cancer patients who underwent radical surgery from January 2007 to December 2017 at a single institution were evaluated. Patients were categorized according to preoperative and postoperative CEA levels.We adjusted patient characteristics using propensity score matched analysis between groups and compared survival outcomes according to changes in CEA levels before and after surgery. @*Results@#According to the preoperative and postoperative CEA levels, patients were classified into 3 groups: group 1, ≤5 and ≤5 ng/mL, respectively (n = 407); group 2, >5 and ≤5 ng/mL, respectively (n = 127); and group 3 (>5 and >5 ng/mL, respectively (n = 67). Postoperative CEA elevation was associated with adverse clinical features. Before and after matching, the patients in group 3 showed significantly lower disease-free survival and overall survival rates compared to the patients in group 1 and group 2. In multivariate analysis, changes in CEA levels were an independent prognostic factor of overall survival (P = 0.041). @*Conclusion@#The changes in CEA levels before and after surgery can be a useful prognostic factor for disease-free survival and overall survival in colon cancer patients.

Feasibility and Safety of Single-Incision Laparoscopic Appendectomy by a Surgical Resident under Supervision of a Staff Surgeon

PURPOSE: This study was aimed at reporting our experience with single-incision laparoscopic appendectomies (SILA) performed by a surgical resident, and to evaluate the safety and feasibility of the procedure, together with a comparison of the outcomes of the same procedure performed by a staff surgeon. METHODS: We conducted a retrospective case series analysis of 60 consecutive patients who underwent SILA. Two surgeons, an attending staff surgeon and a second-year surgical resident, performed the SILA procedures. SILA procedures performed by the resident were intraoperatively guided and supervised by the staff surgeon. RESULTS: A total of 60 case-matched patients with acute appendicitis underwent a SILA performed by either the resident or attending staff. There was no difference in patient demographics between the two groups of patients. The mean operation time was longer in the resident group than in the staff group (43.2±6.0 minutes vs. 32.9±10.5 minutes, p<0.001). There was no significant difference in the operative data between the two groups. No conversion to an open procedure occurred in either group. Postoperative pain, time to onset of oral intake, and number of days of postoperative hospital stay were similar in both groups. CONCLUSION: SILA procedures performed by a resident are safe and feasible despite longer operation times. Perioperative supervision and guidance by an attending staff surgeon may facilitate surgical outcomes.

The Overlapping Running Suture Method Using Single Knotless Barbed Absorbable Suture Material for Abdominal Wall Closure after Single Incision Laparoscopic Appendectomy: Comparison with the Traditional Interrupted Closure Technique

PURPOSE: The aim of our study was to present an abdominal wall closure technique using barbed suture V-Loc™ 90 after single incision laparoscopic appendectomy (SILA) and to compare perioperative outcomes with conventional layer by layer abdominal wall closure after SILA. METHODS: From March 2014 to July 2016, a retrospective case-control study was conducted for a total of 269 consecutive patients who underwent SILA. According to abdominal wall closure methods, 129 patients were classified into the V-Loc closure group and 140 patients were assigned into the conventional layer by layer closure group. In the V-Loc group, abdominal wall closure was performed from the fascia to the skin with a single thread of unidirectional absorbable barbed suture V-Loc™ 90 2-0 using continuous running suture and reverse overlapping reinforced running technique. Subcutaneous closure and subcuticular suture were performed with the remaining portion of V-Loc. RESULTS: The V-Loc closure group showed shorter total operation time (40.0±15.4 min vs. 44.9±16.3 min, p=0.013) and abdominal wall closure time (5.5±0.9 min vs. 6.5±0.8 min, p < 0.001). Postoperative incision length was significantly shorter in the V-Loc closure group (1.1±0.3 cm vs. 1.8±0.4 cm, p < 0.001). Postoperative wound pain, time to resume diet, postoperative hospital stay, complications including surgical site infection, or mean patient satisfaction score at one month after hospital discharge was not significantly different between the two groups. CONCLUSION: In conclusion, unidirectional knotless barbed suture is a safe alternative method for abdominal wall closure after SILA. It can save time while providing comparable cosmesis.

Relationship of Peer- and Self Assessments in the Anatomy Laboratory and Academic Performance of Gross Anatomy / 체질인류학회지

Gross anatomy, with cadaver laboratory dissection, is in a unique position to preside over a rich number of activities such as the team work, integrity, active learning, communication in the small group-all aspects of professional conduct. The purposes of this study are to investigate the correlation of professionalism with academic performance and the characteristics of groups of students in the performance variables. First-year Pusan National University School of Medicine students (n=108) from the Class of 2015 taking the gross anatomy course were required to do the self- and peer assessment about the professional behaviors of each of the six members of their dissecting group. The students were classified into one of four subgroups based on their deviation from the self- and peer assessment medians, such as high peer/high self (HP/HS), high peer/low self (HP/LS), low peer/high self (LP/HS), low peer/low self (LP/LS). There were significant higher scores in the high peer groups (HP/HS, HP/LS) in comparison with low peer groups (LP/HS, LP/LS) in the academic performance of end-of-term (F=3.24), credit (F=3.54), pre-Lab (F=3.94), practical examination (F=3.60) scores. Significant correlations among academic performance variables were observed generally. There were some differences in the correlation in the practical examination and other variables. The relatively high correlation between practical examination and other variables is HP/HS, followed by LP/LS, LP/HS and then HP/LS. In conclusion, peer- and self assessment subgroups showed a significant differences in the academic performance. This assignment would be available to evaluate work habits of professionalism in the gross anatomy laboratory. It is suggested that HP/HS group was more adaptable in the contextual leaning the gross anatomy course.

Proper Management of Posttraumatic Tension Pneumocephalus / 대한신경손상학회지

Pneumocephalus is commonly seen after craniofacial injury. The pathogenesis of pneumocephalus has been debated as to whether it was caused by ball valve effect or combined episodic increased pressure within the nasopharynx on coughing. Discontinuous exchange of air and cerebrospinal fluid due to “inverted bottle” effect is assumed to be the cause of it. Delayed tension pneumocephalus is not common, but it requires an active management in order to prevent serious complication. We represent a clinical case of a 57-year-old male patient who fell down from 3 m height, complicated by tension pneumocephalus on 5 months after trauma. We recommend a surgical intervention, but the patient did not want that so we observe the patient. The patient was underwent seizure and meningitis after 7 months after trauma, he came on emergency room on stupor mentality. Tension pneumocephalus may result in a neurologic disturbance due to continued air entrainment and it significantly the likelihood of intracranial infection caused by continued open channel. Tension pneumocephalus threat a life, so need a neurosurgical emergency surgical intervention.

Drug-Induced Anaphylaxis in a Single Korean Tertiary Hospital / 대한내과학회지

BACKGROUND/AIMS: Drug-induced anaphylaxis (DIA) is a severe, acute, and potentially life-threatening condition. In Korea, only a few well-documented cases of DIA have been described. Therefore, the aim of this study was to investigate the clinical characteristics, causes, and management of DIA in a single Korean medical institute. METHODS: This was a retrospective medical record review of all DIA patients who visited the in-patient, out-patient, and emergency departments of our hospital from January 1 2006 to October 30 2013. RESULTS: Among 605 cases of anaphylaxis, 167 were drug-induced. The culprit drugs were contrast agents (43 cases, 25.7%), antibiotics (38, 22.8%), non-steroidal anti-inflammatory drugs (35, 21.0%), anti-cancer drugs (22, 13.2%), parenteral vitamins (9, 5.4%), ranitidine (6, 3.6%), and neuromuscular blockers (3, 1.8%). The most common organ-specific symptoms/signs were cardiovascular (74.3%), cutaneous (71.3%), respiratory (55.7%), and gastrointestinal manifestations (19.2%). In most cases, DIA was treated with antihistamines (77.2%) and systemic corticosteroids (76.5%); the use of epinephrine was considerably less frequent (35.3%). CONCLUSIONS: In our institution, contrast agents were the leading cause of DIA. Although epinephrine is the drug of choice in the treatment of acute anaphylaxis, fewer than 50% of the study patients received epinephrine to treat DIA.

Methods and Effect of Management of Patients with Convergence Spasm and Aquired Pseudomyopia

PURPOSE: To evaluate changes in the degree of pseudomyopia and prognosis in patients with convergence spasm and acquired pseudomyopia. METHODS: The medical records of patients with convergence spasm and acquired pseudomyopia at the Korea University Medical Center from 2011 to 2014 were identified. We reviewed the patients' gender, age, onset time, visual acuity, refractive error, angle of strabismic deviation and the selected management (cycloplegics, patching, cycloplegics + patching, prism glasses). RESULTS: At the first medical examination, the mean age was 20.08 years. The mean spherical equivalent was -3.75 diopter (D) in the right eye and -4.03 D in the left eye based on manifest refraction and -2.59 D in right eye and -2.85 D in left eye using cycloplegic refraction. Eleven of 12 patients had esodeviation with a mean esodeviation of 10.42 D. The pupil size was 3.63 mm in the right eye and 3.63 mm in the left eye. No patient experienced severe miosis (pupil size <2 mm). Observation (5), patching (3), cycloplegics (2), patching + cycloplegics (1) and prism (1) management were performed in 12 patients. Outcomes included completely cured (3), improvement (7) and no change or recurrence (2). CONCLUSIONS: Active management is necessary for patients with convergence spasm and acquired pseudomyopia.

Critical pathway of acute asthma attack for the Emergency Center: patients' outcomes and effectiveness

PURPOSE: Early recognition and management of asthma attack is critical before it becomes worse. We developed critical pathway (CP) of asthma attack at Emergency Center (EC) for making undelayed decision and management of asthma attack. METHODS: Acute asthma attack assessment and treatment (4AT) CP began on April 1st 2012 and recruited the patients for 18 months. This study enrolled the patients who were older than 15 years and visited EC for dyspnea and wheezing. Initial assessment was done measuring peak expiratory flow rate (PEFR), oxygen saturation (SaO2). Once CP is activated, oxygen, inhalation of short acting beta2 agonist, and injection of corticosteroid were administered to the patients. Every hour after CP activated, we reassess the patients' response and make decisions whether to admit or discharge. RESULTS: Until January 10th 2014, 62 patients enrolled in this study. Seven patients hospitalized for asthma and 40 patients discharged. The other 15 patients were deactivated as they were diagnosed of heart failure, myocardial infarction, aortic dissection, anaphylaxis, chronic obstructive pulmonary disease and pneumonia for the causes of dyspnea. Mean Interval from EC arrival to 4AT activation was 32.6+/-29.1 minutes and the mean interval from 4AT activation to position decision was 254.5+/-302.0 minutes. Among 47 patients who were diagnosed with asthma attack, 13 patients were not aware of asthma before this attack. Forty patients were discharged at EC after management of CP. Among them, 34 patients revisited clinic, but 6 patients did not. We called back to the lost 6 patients but only 3 patients were connected. Even they visited EC due to asthma attack, 2 patients had no insight of importance of regular management and the other one promised to revisit. CONCLUSION: CP was successful for early management of asthma attack. However, 15% of discharged patients never show up again. So, education program about the importance of ongoing management of asthma for prevention of asthma attack is needed.

A Case of Azathioprine Induced Warfarin Resistance in Behcet's Disease

Behcet's disease is characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesions. Thrombosis associated with vascular inflammation in patients with Behcet's disease presents various clinical symptoms. Warfarin is usually administered for treatment of thrombosis. However, warfarin can interact with many medications that cause various problems. A 43-year-old woman with Behcet's disease presented with a swollen right leg. Deep vein thrombosis (DVT) was confirmed, and treated with warfarin. Due to exacerbation of Behcet's disease, she received azathioprine along with warfarin. Subsequently, the international normalized ratio (INR) decreased and DVT was exacerbated. Despite an increase in the warfarin dose, the patient did not reach the target INR. After discontinuation of azathioprine, DVT improved and the warfarin dose was decreased. There were no specific findings associated with a hypercoagulable status. This finding suggests the interaction of azathioprine and warfarin. Therefore, clinicians should be cautious regarding the possibility of drug interactions between azathioprine and warfarin.

Brain Metastases of Papillary Thyroid Carcinoma with Horner's Syndrome

Papillary thyroid carcinoma (PTC) is the most common type of thyroid malignancy and has relatively favorable prognosis. Blood-borne metastases of PTC are very rare among the thyroid malignancies. Moreover a case of blood-borne central nervous system metastasized PTC with only unilateral Horner's syndrome, and without any abnormalities in laboratory or physical examinations has not been described before. A 53-year-old female patient had been managed in ophthalmologic clinic due to vague symptoms of right monocular blurred vision with eye dryness for 3 months, but showed no signs of improvement. So it was performed a magnetic resonance imaging and magnetic resonance angiography to evaluate the possibilities of cerebral lesion. And a left frontal mass was incidentally found, and the tumor turned out to be a PTC that had metastasized to brain, regional lymph node, cervical, thoracic spine, and lung. We describe a PTC with extraordinary initial symptoms that metastasized to an unusual site. We recommend that if a papillary thyroid tumor with unusual symptoms or at an advanced stage is found, further investigation should be performed for distant metastasis.

Adverse drug reactions after taking the extract of Cudrania tricuspidata

Cudrania tricuspidata is a deciduous tree belonging to the Moraceae plant, which has been widely used as a folk remedy or health supplements in the Asian countries including Korea. As far as we know, side effects from taking the extract of C. tricuspidata has not yet been reported. We reviewed the electronic medical records of 2 patients who had adverse drug reactions to C. tricuspidata. The first case was a 30-year-old woman without a specific medical history. She was admitted with a 2-week history of jaundice and dyspepsia after taking extract of C. tricuspidata for 3 days. Initial laboratory findings were as follows: aspartate aminotransferase, 364 IU/L; alanine aminotransferase, 574 IU/L; total bilirubin, 36.3 mg/dL; and direct bilirubin, 18.3 mg/dL. She was conservatively treated for liver and renal failure while awaiting liver transplantation. However, she was expired due to combined pneumonia and progressed hepatic and renal failure. The second case was a 42-year-old woman who has chronic urticaria without other medical history. She was admitted with a 3-month history of whole body rash with small pustular vesicle after taking extract of C. tricuspidata. She was treated with intravenous steroids and antihistamines. Skin lesions were improved after 1 week. Here, we report 2 cases of adverse drug reaction to C. tricuspidata. It should be considered that C. tricuspidata ingestion could cause severe adverse drug reactions such as liver failure and acute generalized exanthematous pustulosis.