Malignant Melanoma of the Pancreas and Liver Mimicking a Neuroendocrine Tumor / 대한내과학회지

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.

Pancreatic Neuroendocrine Tumor with Primary Hepatic B Cell Lymphoma / 대한내과학회지

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.

Pancreatic Neuroendocrine Tumor with Primary Hepatic B Cell Lymphoma / 대한내과학회지

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.

Malignant Melanoma of the Pancreas and Liver Mimicking a Neuroendocrine Tumor / 대한내과학회지

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.

HER2-Positive Gastric Hepatoid Adenocarcinoma / 대한내과학회지

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.

Questionnaires for Assessing Stress and Mental Health / 한양의대학술지

Psychological factors can influence physical health. The relationship between psychological stress and physical disease is evident in everyday clinical practice and therefore, assessing stress and mental health has been an important issue in clinical practice and research. This review discusses the assessment of stress and mental health by examining the psychometric parameters and other qualities of some of the best-known instruments used to assess stress and mental health. At present, the questionnaire method is the most popular for measuring stress and mental health status. There are many different kinds of questionnaires for assessing mental stress; each questionnaire has its own advantages and disadvantages. The authors' intend to evaluate and summarize useful questionnaires for assessing stress and mental health in order to aid in choosing the appropriate questionnaire according to the clinical purpose of the examination.

Psychotropic Prescription Patterns for Inpatients with Schizophrenia: 10-Year Comparison in a University-Affiliated Hospital in South Korea

OBJECTIVES: Previous literature on the prescription change among patients with schizophrenia mainly focused on antipsychotics. This study investigated chronological change in the patterns of discharge medication among inpatients with schizophrenia at a psychiatric inpatient unit of a university-affiliated hospital. METHODS: All admission records at a psychiatric unit of Hanyang University Guri Hospital with discharge diagnosis of schizophrenia during two different five-year time frames (1996-2000 and 2006-2010) were reviewed including the demographic and clinical data and discharge medications. The data were gathered from a total of 207 patients (95 in 1990s and 112 in 2000s). RESULTS: The frequency in use of atypical antipsychotics (p < 0.01), antidepressants (p < 0.05), beta-blockers (p < 0.01), and benzodiazepine (p < 0.01) was significantly higher in 2000s. Anticholinergic drugs were less likely used in 2000s (p < 0.01). We did not find significant differences in the equivalent dose of antipsychotic drugs, the use of mood stabilizers and cholinergic drugs between two time frames. CONCLUSIONS: Increased proportion of atypical antipsychotics and decreased use of anti-parkinsonian drugs are in line with literature. Our results show that more diverse classes of psychotic medications are used for schizophrenia in recent years. It is likely that psychiatrists are becoming more conscious of negative symptoms, anxiety, and depression in the pharmacotherapy of schizophrenia as well as positive symptoms of the illness.

Acroosteolysis of Scleroderma Associated with a Felon / 대한정형외과학회잡지

The Scleroderma is a chronic inflammatory disease of the connective tissue with involvement of the skin and other organs. It can be a manifestation of various disorders and occasionally acroosteolysis in the phalanges. Acroosteolysis is characterized by bone resorption or destruction in the phalanges, while the base is preserved. The pathogenesis of acroosteolysis in patients with scleroderma is a blood-flow disorder that is mainly associated with an abnormal accumulation of collagen in all tissues, microangiopathy and infections in the phalanges. The phalanges in patients with scleroderma are prone to continuous infections as a felon or skin ulcers due to atrophy of the subcutaneous tissue, dry and sclerotic skin, or a disorder of the immune system. We experienced a patient who had acroosteolysis with scleroderma of the phalanges, and this was associated with a felon. We report on this case along with a brief review of the literature.

Peroneus Longus Dislocation associated with Trimalleolar Fracture: A Case Report / 대한족부족관절학회지

Traumatic dislocation of the peroneus longus tendon is an often unrecognized injury which has been reported to occur most commonly during sports activity. Most acute cases with early detection can be treated by simple repair of the tendon or retinaculum using one of several procedures available. Accurate treatment through a comprehensive evaluation of the ankle injury prevents suboptimal and sometimes unrecorrectable outcomes. The authors experienced concomitantly the peroneus longus tendon dislocation associated with a trimalleolar fracture of the ankle. We report this case a brief review of the literature.

Clinical Outcomes of Distraction Osteogenesis in First Brachymetatarsia / 대한정형외과학회잡지

PURPOSE: To evaluate the clinical results of lengthening in first brachymetatarsia using a distraction osteogensis with an external fixator. MATERIALS AND METHODS: Fifteen cases in nine patients, who had received firstmetatarsal distraction osteogenesis from January 1996 to December 2002, were enrolled in this study. At the final follow-up, the application time of the external fixator was measured and the percentage of lengthening, healing index, complication rate, and the patients satisfaction was analyzed. The patients satisfaction was evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) scores, which were scored according to the level of stiffness, pain, function, and alignment. RESULTS: The score according to the AOFAS-Hallux Metatarsophalangeal joint and Inter-Phalangeal joint scale was excellent in 13 patients and good in 2. All patients were satisfied with the procedure. The average percentage of lengthening was 48.7%. The average healing index was 72.8 days/cm. The major complication was a cavus foot, which was noticed in four feet. All the first toes showed some decrease in motion at the metatarsophalangeal joint. The other complications were hallux valgus, angulation of the metatarsals, and a pin tract infection each in two feet. CONCLUSION: Distraction osteogenesis is an effective method for first brachymetatarsia. However, excessive lengthening can cause potential complications.

Acetabular Rebision Using Acetabular Reinforcement Ring and Allograft Impaction

Purpose: We wanted to evaluate the clinical and radiologic results of acetabular revision using the acetabular reinforcement ring and also the allograft impaction in the acetabulum having deficient bone stock. Material and Methods: Nineteen hips revision arthroplasty were performed in 18 patients (9 males and 9 females) with using an acetabular reinforcement ring and allograft between July 1993 and December 2003. The patients were followed for an average of 64 months (range: 24-153). The mean age at the time of arthroplasty was 59 years old (range: 34-76). The causes of revision were aseptic loosening of the acetabular component in 16 cases, severe progressive osteolysis around the acetabular component in 2 cases and Girdlestone state after infected total hip arthroplasty in one case. The acetabular deficiency was type II in 5 hips, type III in 13 hips, and type IV in one hip according to the AAOS classification. The clinical results were evaluated using the modified Harris hip score, and the radiologic results were evaluated by assessing the preoperative and serial follow-up radiographs. Results: The mean preoperative Harris hip score of 47 was improved to 86 points at the latest follow-up. Periacetabular osteolysis was found in 2 cases, which did not progress at follow-up. The anatomic hip center was restored after revision arthroplasty (p<0.05). Complications were dislocation in 2 cases, breakage of the hook of the Ganz ring in one case, heterotopic ossification in one case and femoral artery injury in one case. All cases showed stable fixation of the acetabular component and good remodelling of the impacted allograft. There was neither recurrence of dislocation nor progression of the acetabular component loosening on the radiographs. Conclusion: Acetabular revision with acetabular reinforcement ring and allograft impaction showed satisfactory clinical and radiologic results with restoration of the hip center and consolidation of the allograft.

Medial Gastrocnemius Flap in the Reconstruction of Infected Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: To evaluate the results of the medial gastrocnemius muscle flap to cover the wound necrosis and dehiscence caused by repeated surgery in the reconstruction of infected total knee arthroplasty (TKA). MATERIALS AND METHODS: Out of forty three reconstructions of infected TKA performed between 1995 and 2002, eleven cases (25.6%)underwent medial gastrocnemius flap to cover the anterior skin defects at the time of reimplantation in two cases and in an average 3.3 weeks after reimplantation in seven cases. Two cases which refused reimplantation were treated by arthrodesis and delayed flap coverage and by flap surgery only resulting in pseudarthrosis respectively. They were five male and six female patients of 61 years (range, 56-77 years)of age in average. Clinical and radiological assessments were done for minimum two years of follow-up. RESULTS: Nine cases (81.8%)maintained TK prostheses with less range of motion (77 degrees in average)than ordinary TKAs of primary healing. Two patients refused TKA which resulted in one arthrodesis and one pseudarthrosis. There was no case of recurrence of wound dehiscence or infection. CONCLUSION: Medial gastrocnemius flap can salvage the prostheses by providing good soft tissue coverage for compromised operative wounds caused by infected TKA and repeated surgical interventions.

Clinical Outcomes of Infective and Non-infective groups in Revision Total Knee Arthroplasty

PURPOSE: To compare clinical outcomes of infective and non-infective groups in revision total knee arthroplasty. MATERIAL AND METHODS: From December 1993 to December 2001, 29 cases of revision total knee arthroplasty were performed in 27 patients. The mean age at the time of surgery was 64.2 years (48~74). The average follow-up was 45.4 months (24~90). All cases were divided into two groups (fourteen noninfective and fifteen infective groups). The clinical results were evaluated according to range of motion, Hospital of Special Surgery score, Knee Society score and tibiofemoral angle. The causes of revision in noninfective group were aseptic loosening in eleven, instability in two, and femoral periprosthetic fracture in one. RESULTS: There was a significant improvement of range of motion, Hospital for Special Surgery Knee score and Knee Society score at the final follow-up compared with the pre-operative status. The above three evaluation criteria showed no significant difference between the two groups except higher further flexion in non-infective than infective group. Preoperative average tibiofemoral angle was varus 1.4degrees in non-infective group and valgus 2.6degrees in infective group (P0.05). There were three complications in infective group, which were two reinfections, and one avulsion of osteotomized tibial tubercle. CONCLUSION: Preoperative planning, choice of proper implants, meticulous management of bony defect and soft tissue enabled successful results in infective group as well as non-infective group except less further flexion in infective group.

An Epidemiological Study of Hip Fracture in Jeju Island, Korea / 대한정형외과학회잡지

PURPOSE: This prospective study conducted to estimate incidence of hip fracture among persons over 50 years of age, in Jeju island, Korea during the year 2002. MATERIALS AND METHODS: Patients over 50 years of age who lived in Jeju island and sustained a femoral neck or intertrochanteric fracture during the year 2002 (from January 1st 2002 to December 31th 2002) were investigated. The information collected from the hospital records for each patient included age, sex, the nature of injury, the day of injury, location, the method of treatment, and the degree of osteoporosis. The population figures were derived from the National Statistical Office. RESULTS: There were 151 fractures of the neck or intertrochanteric region of the femur (36 in men, 115 in women) in population over 50 years of age. The incidence was 12.8/10, 000 for total patients (7.3/10, 000 for men, 16.8/10, 000 for women). The standardized incidence rate against the 1985 U.S. population was 119/100, 000 for men and 187/100, 000 population for women. The incidence rate showed seasonal variations, being highest in fall. The mean age of patients was 77.1 years (range 50 -98 years). The most common cause of injury was a simple fall (131/151, 86.8%). There were 92 (60.9%) fractures of the neck and 59 (39.1%) of the intertrochanteric fracture. One hundred twenty six patients (83.4%) showed definite osteoporosis (Singh index, Grade I-III). CONCLUSION: The incidence rate of hip fracture increased 3.8 times in 2002 data (12.8/10, 000) in Jeju island when compared with 1991 data (3.4/10, 000) in Honam area. To have more accurate trend and estimate of incidence rate of osteoporotic fractures in the elderly, further longitudinal study need to be conducted.

Two-Stage Reconstruction of Infected Nonunion of Long Bones using Antibiotics-Impregnated Cement Beads

PURPOSE: To evaluate treatment results between internal and external fixation groups in two-stage reconstruction of infected nonunion of long bones using antibiotics-impregnated cement beads. MATERIALS AND METHODS: In the first stage, preexisting hardwares were removed and radical debridement was done. The dead space was filled with antibiotics -impregnated cement beads and the nonunion site was immobilized by external fixation, cast or skeletal traction. In the second stage, all cases were divided into two groups; the nonunion was fixed by internal fixation in group I versus external fixation in group II. The intervening period between the first and second stage was average 8.7 weeks (range, 3~23 weeks). RESULTS: The follow-up period was average 45 months (range, 16~71 months). Infection control and bone union were achieved in all 13 cases of group I. Infection recurred in two of 28 cases in group II, one underwent above-knee amputation and the other case was lost in follow-up. The mean number of supportive operations including repeated curettage, augmentation and change of infected pins, angular correction, and soft tissue flap was average 2 and 6.2 times respectively in group I and group II. Bony union period was average 19.3 and 23.1 weeks in each group. According to Paley's classification, group I was similar to group II in bony and functional result (p>0.05). CONCLUSION: Antibiotics-impregnated cement beads provided positive effect on infection control. Internal fixation group showed less number of additional operations and earlier bony union than external fixation group.

Arthroscopic Evaluation of Posterolateral Rotatory Instability of the Knee / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to confirm the efficacy of arthroscopic findings for the diagnosis of posterolateral rotatory instability (PLRI) of the knee. MATERIALS AND METHODS: We retrospectively evaluated 27 patients (28 cases) who had been operated upon for PLRI between February 1998 and June 2001. All patients underwent preoperative or intraoperative arthroscopic examinations including anterior/posterior cruciate ligament, popliteus tendon, inferior and superior popliteomeniscal fascicle, popliteofibular ligament, lateral meniscus, instability and abnormal popliteomeniscal motion for internal and external rotation. RESULTS: Instability, which means popliteal hiatus widening during internal rotation of the tibia, was identified in all cases (100%). Tear of the inferior and superior popliteomenical fascicle was identified in 24 cases (86%) and abnormal popliteomeniscal motion during rotation was identified in 20 cases (71%). Popliteus tendons were abnormal in 18 cases (65%) with 5 cases (19%) of complete tear and 13 cases (46%) of partial tear or elongation. CONCLUSION: These results suggest that arthroscopic evaluation of the popliteal hiatus structures in the patients suspected for PLRI of the knee is helpful for diagnosis and the determination of treatment modality.

Evaluation of the Elmslie-Trillat-Marquet Procedure for Recurrent Patellar Subluxation or Dislocation / 대한정형외과학회잡지

PURPOSE: To assess the clinical and radiographic results of the Elmslie-Trillat-Marquet procedure used to treat recurrent patellar subluxation or dislocation with patellar malalignment. MATERIALS AND METHODS: A total of 15 knees in 14 patients were evaluated at an average of 54.5 months (12 to 106) following the Elmslie-Trillat-Marquet procedure; carried out between May 1993 and March 2000. The evaluation included subjective, objective and radiographic assessments. RESULTS: The causes of recurrent patella dislocation were patella alta (11 knees), tight lateral retinaculum (8 knees), patella dysplasia (7 knees), femoral condyle dysplasia (13 knees) and joint hyperlaxity (1 case). The average preoperative Q-angle was 28.5degrees and the postoperative angle 13 degrees. Subjective evaluation using Cox's criteria showed excellent or good results in 13 knees (87%), and the objective evaluation using Fulkerson's functional knee score showed excellent or good results in 14 knees (93%). The mean anterior tibial tubercle displacement was 8 mm (7-11 mm), and the patella congruence angle and Insall-Salvati index were significantly corrected (p<0.001). Lateral subluxation and patellar tilt angle were corrected in all cases. The only complication was an irritation due to nonabsorbable suture material. There were no redislocations, infections, nonunions, or fractures of the transferred tibial tubercle during the follow-up period. CONCLUSION: The Elmslie-Trillat-Marquet procedure for recurrent patellar subluxation or dislocation can basically correct malalignment tridimensionally.