Prevalence of renal dysfunction in patients with cirrhosis according to ADQI-IAC working party proposal

BACKGROUND/AIMS: A revised classification system for renal dysfunction in patients with cirrhosis was proposed by the Acute Dialysis Quality Initiative and the International Ascites Club Working Group in 2011. The aim of this study was to determine the prevalence of renal dysfunction according to the criteria in this proposal. METHODS: The medical records of cirrhotic patients who were admitted to Konkuk University Hospital between 2006 and 2010 were reviewed retrospectively. The data obtained at first admission were collected. Acute kidney injury (AKI) and chronic kidney disease (CKD) were defined using the proposed diagnostic criteria of kidney dysfunction in cirrhosis. RESULTS: Six hundred and forty-three patients were admitted, of whom 190 (29.5%), 273 (42.5%), and 180 (28.0%) were Child-Pugh class A, B, and C, respectively. Eighty-three patients (12.9%) were diagnosed with AKI, the most common cause for which was dehydration (30 patients). Three patients had hepatorenal syndrome type 1 and 26 patients had prerenal-type AKI caused by volume deficiency after variceal bleeding. In addition, 22 patients (3.4%) were diagnosed with CKD, 1 patient with hepatorenal syndrome type 2, and 3 patients (0.5%) with AKI on CKD. CONCLUSIONS: Both AKI and CKD are common among hospitalized cirrhotic patients, and often occur simultaneously (16.8%). The most common type of renal dysfunction was AKI (12.9%). Diagnosis of type 2 hepatorenal syndrome remains difficult. A prospective cohort study is warranted to evaluate the clinical course in cirrhotic patients with renal dysfunction.

A Gangliocytic Paraganglioma Presenting as a Submucosal Tumor in the Ampulla / 대한내과학회지

A gangliocytic paraganglioma (GP) is a rare benign neuroendocrine tumor. However, its origin remains unclear. It is seen most frequently in the second portion of the duodenum. At endoscopy, a GP characteristically appears as a pedunculated nodular submucosal tumor with erosions and surface ulcers. The histological diagnosis is usually made from endoscopic biopsies showing the presence of epithelioid, spindle, and ganglion cells. We experienced a case of GP in a 38-year-old female who was referred because of a possible ampullary tumor. The endoscopic images showed a 1.5-cm, oval ampullary tumor covered with normal mucosa. An endoscopic biopsy showed chronic duodenitis. The tumor was removed by an endoscopic papillectomy. We report a case of duodenal GP that presented as a submucosal tumor that was treated with a papillectomy and review the literature.

Beneficial Effects of Stroke-Unit Care in Stroke Patients with Atrial Fibrillation

PURPOSE: Continuous cardiac monitoring in a stroke unit (SU) may improve detection of atrial fibrillation (AF), and SU care may improve the rate of anticoagulation by better adherence to a standardized treatment protocol in patients with AF. We investigated the effects of the SU on the detection of AF and the rate of warfarin therapy in patients with AF. MATERIALS AND METHODS: Acute stroke patients who had been admitted before or after the opening of the SU were included in our study. SU patients were monitored continuously with electrocardiography. Rates of AF and warfarin therapy were compared between patients admitted to the SU (SU group) and those admitted to the general ward (GW) prior to the opening of the SU (GW group). RESULTS: Total 951 patients had been admitted to the GW prior to the opening of the SU (from January 2000 to November 2002), and 2349 patients to the SU (from January 2003 to December 2008). AF was found in 149 patients (15.7%) in the GW group and in 487 (20.7%) in the SU group. Most of AF detected during admission was paroxysmal AF (84.8%). The frequency of newly detected AF was higher in the SU group than the GW group (2.5% vs. 0.7%, p=0.001). The rate of anticoagulation consideration was also higher in the SU group. CONCLUSION: SU care improved the detection of AF and the rate of anticoagulation consideration in acute stroke patients. Our findings support the benefits of continuous cardiac monitoring in the SU for stroke patients.

Changing Trends of Serum Pepsinogen I/II Ratio in Asymptomatic Subjects

BACKGROUND/AIMS: Gastric atrophy can be diagnosed by serum pesinogen I/II ratio. The aim of this study was to investigate whether the changes of serum pepsinogen I/II ratio can be predicted by gastroscopy. MATERIALS AND METHODS: Sixty healthy subjects who underwent screening for serum pepsinogen I/II levels, serum Helicobacter pylori (H. pylori) antibody, and gastroscopy for two sequential years were included. Endoscopic findings were classified into four different categories according to the degree of chronic atrophic gastritis; none, mild, moderate, and severe. Changes of the serum pepsinogen I/II ratio, body mass index, H. pylori antibody, and endoscopic findings were analyzed after a year. RESULTS: The serum pepsinogen I/II ratio showed a tendency to decrease after a year in subjects with H. pylori infection (P=0.013) and those with moderate to severe atrophic gastritis (P=0.004), whereas it increased in subjects without H. pylori infection and those with none to mild atrophic gastritis. On multivariate analysis, the degree of atrophic gastritis was the only factor that was related to the changing trends of the serum pepsinogen I/II ratio (odds ratio=5.385, P=0.023). CONCLUSIONS: The degree of atrophic gastritis on endoscopic findings can predict the changes of the serum pepsinogen I/II ratio after a year. Regardless of the current status of H. pylori infection, the serum pepsinogen I/II ratio decreases after a year in subjects with moderate to severe atrophic gastritis.

Clinical Significance of Bronchoalveolar Lavage in Severely Burned Patients with Diffuse Lung Infiltrations

PURPOSE: Pulmonary infiltrates are often encountered in mechanically ventilated burned patients and represent a challenge for pulmonologists and burn intensivists. The etiology is often multiple and empiric therapy is frequently initiated on the basis of clinical diagnosis, which is of uncertain accuracy. This approach can lead to inadequate treatment with increasing the risks of possible adverse events, while potentially reversible causes may be unrecognized. We performed bronchoalveolar lavage (BAL) study to know the causes of lung infiltration in severely burned patients. METHODS: From August 2003 to August 2008, severely burned patients who have been managed in burn intensive care unit (ICU) and shown diffuse lung infiltration during the courses were included prospectively. BAL was used to make the diagnosis of the respiratory infection, with 104> or = organisms considered a positive result. We also analyzed BAL isolates such as fungus, atypical pathogens and virus. RESULTS: Total 50 patients (M 43, F 7) were enrolled. The percent of total body surface area burn was 48.1+/-19.0% and APACHE II score was 10.0+/-5.6. Overall mortality was 64% (32 cases). 44 cases (88%) met criteria for positive BAL culture and 12 cases (24%) of those were combined with alveolar hemorrhage. The frequent bacterial isolates were Acinetobacter species in 19 cases (38%), Pseudomonas aeruginosa in 18 cases (36%) and methicillin-resistant Staphylococcus aureus in 14 cases (28%). Through BAL study, respiratory viruses were isolated in 15 cases (30%), and Legionella pneumonia, Tuberculosis and Pneumocystis pneumonia were reported in one of each (2%). CONCLUSION: BAL seems to be a useful tool for identifying infectious pathogens and may give guidance for adequate choices of antimicrobial agents in severely burned patients with diffuse lung infiltrations.

Staged Management of High Energy Proximal Tibia Fractures with Severe Soft Tissue Damage

PURPOSE: To find out the efficiency of two staged operation of patients with high energy proximal tibia fracture with severe soft tissue damage, the first step being external fixation, and the second, internal fixation with plates. MATERIALS AND METHODS: The study group was the 42 patients who had followed for one year out of a group of 56, performed the first step external fixation and the second step internal fixation with plates retrospectively, from March 2003 to March 2007. The average age of the study group was 51.4, 26 men, and 16 women participating in this study. The average time of follow up was 32 months. In the final follow up, investigations of the radiological assessments and functional abilities of the bony fusion were carried out along with the complications of the soft tissue. RESULTS: The duration after the first step external fixation until second step internal fixation to be performed was 14.9 (6~40) days in average. The final bone fusion took about 15 weeks, and according to the final follow up, the range of motion of the knee was around 110.8 degrees (6.2~117 degrees). In 31 cases, only the internal fixation was performed, while in 11 cases, soft tissue reconstruction was carried out with the internal fixations. As for the complications there were 2 cases of deep soft tissue infection, 2 cases of nonunion, 1 case of malunion and 1 case of knee joint stiffness. CONCLUSION: In cases of proximal tibia fracture with severe soft tissue damage, external fixation was important to secure the safety of the fracture, carry forward the anatomical alignment, plan the soft tissue safety and manage the wound to decrease the number of microbial in the next operation, which is the internal fixation with plates.

Internal Fixation Using Double Plates for Comminuted Olecranon Fractures in Adults

PURPOSE: To evaluate the clinical usefulness of internal fixation with double plates for comminuted olecranon fractures. MATERIALS AND METHODS: Nine patients with olecranon fractures which are classified into Mayo type IIB (7 cases) and type IIIB (2 cases) underwent internal fixation using double plates from June 2002 to September 2005. They were followed-up for more than 12 months and average period of follow-up was 14 (12~18) months. Six cases were males and three were females. Mean age was 40.7 (21~63) years. We used open reduction and internal fixation using double plates. Clinical assessment index was pain, range of motion (ROM), stability and function of joint at last follow-up. The sum of four indices were compared. Also, we evaluated starting time of full ROM exercise, bony union time and complications. RESULTS: All cases started postoperative ROM within 7 days and clinical results were evaluated using Mayo elbow performance index. 'Excellent', 'good' were 2, 6 cases, respectively and 1 case was 'fair'. Elbow ROM was more than 110o in all cases except one. Mean radiological bony union time was 3.9 (2.5~5) months postoperatively. There were heterotrophic ossifications in 3 cases as complication. CONCLUSION: Internal fixation using double plates for comminuted olecranon fractures in adults can be good treatment option which obtains good clinical results and enables early ROM.

A spontaneous pseudoaneurysm of the common hepatic artery / 대한내과학회지

Hepatic pseudoaneurysms were once relatively uncommon and often associated with hepatic trauma. Currently, the main etiology of pseudoaneurysms is iatrogenic injuries with the increased use of percutaneous procedures and laparoscopic surgery. However, a spontaneous hepatic pseudoaneurysm is very rare. The clinical manifestations can include pain, swelling, thrombosis, bleeding, and rupture. Early detection is critical for the proper treatment, because ruptured pseudoaneurysms have high morbidity and mortality. We present a case of spontaneous pseudoaneurysm in the common hepatic artery that was treated successfully with transarterial coil embolization.

Clinical Results of Carpal Tunnel Release with Open Minimal Incision

PURPOSE: To find out the clinical usefulness of carpal tunnel release with open minimal incision MATERIALS AND METHODS: We studied 149 patients (152 carpal tunnel) who were able to follow up for more than 6 months after being treated with carpal tunnel release with open minimal incision from January 2000 to January 2006. We compared the clinical results of this procedure using recovery time, the disappearance of symptoms, the presence of the kelloid and the scar tenderness and analyzed preoperative and postoperative VAS score of tingling sensation, dull sensation, inappropriate hand movement, muscle weakness, edema, palmar pain as subjective satisfaction. We used the independent t-test for the statistical significance. RESULTS: All cases had complete disappearance or marked improvement in symptoms, and there was no kelloid formation. Residual symptoms and tenderness of the scar was found in 8 cases (5.4%), but gradually disappeared. In last follow up, tingling sensation decreased from 7.8 to 1.0 and dull sensation from 7.0 to 1.5, inappropriate hand movement from 4.8 to 1.1, muscle weakness from 5.9 to 0.8, edema from 2.0 to 0.5, palmar pain from 2.1 to 0.2 in preoperative and postoperative VAS score, all were significantly improved statistically (P<0.05). CONCLUSIONS: We think that carpal tunnel release with open minimal incision has little complication and is a safe and effective operation method having similar effect with endoscopic surgery or conventional open surgery.

A Case of Combined POEMS Syndrome and Multiple Myeloma with Positive M protein Only on Immunofixation / 대한혈액학회지

POEMS syndrome is a plasma cell proliferative disorder is characterized by the presence of peripheral neuropathy (P), organomegaly (O), monoclonal gammopathy (M), endocrinopathy or edema (E) and skin change (S). It can be rarely related to multiple myeloma. A 48-year-old man was admitted to our hospital due to paresthesia of both inguinal areas and weakness of both lower extremities. He had a history of Castleman's disease, and showed features of polyneuropathy, multiple osteoblastic lesions, hepatosplenomegaly, pretibial pitting edema, and papilledema. The serum and urine electrophoresis were negative, but urine immunofixagion could detect monoclonal protein. Plasmacytoma was confirmed through the biopsy for the osteoblastic lesions. We present a case of combined POEMS syndrome and multiple myeloma with positive M protein only on immunofixation in order to share our experience with physicians and specialists.

A Case of a Cavernous Hemangioma in the Distal Jejunum Detected by Double-Balloon Enteroscopy in a Patient with Small Bowel Obstruction / 대한소화기내시경학회지

Primary neoplasms of the small intestine are relatively rare. Early diagnosis and treatment of small bowel disease is difficult due to the low sensitivity of conventional examination methods. Double-balloon enteroscopy allows an exact examination of the small intestine, including a biopsy and other procedures, and the use of this technique provides an improvement in the diagnosis and treatment of small bowel disease. We report a case of a cavernous hemangioma of the distal jejunum that was detected by the use of double-balloon enteroscopy in a patient with recurrent periumbilical pain and small bowel obstruction that was treated by a small bowel segmental resection.

A Case of Primary Tracheal Lymphoma of a 65-year-old Female: Extremely Rare Primary Localization of a Diffuse Large B-cell Lymphoma / 대한혈액학회지

Primary extranodal non-Hodgkin's lymphomas comprise approximately 10% of all non-Hodgkin's lymphomas. However, primary tracheal non-Hodgkin's lymphoma is extremely rare, being mainly mucosa-associated lymphoid tissue lymphoma. A 65-year-old female has dry cough for one year. She was diagnosed as diffuse large B-cell lymphoma via bronchoscopic-guided biopsy. She was treated with four cycles of the R-CHOP regimen and adjuvant radiotherapy. After completion of the combined treatment, the treatment response was complete remission, and the disease free survival was 26 months.

Minimally Invasive Percutaneous Plate Osteosynthesis Using Periarticular Plate for Distal Tibial Fractures

PURPOSE: To evaluate the clinical results of minimally invasive percutaneous plate osteosynthesis using a periarticular plate (Zimmer, Warsaw, IN, USA) for distal tibia fractures. MATERIALS AND METHODS: 27 patients with distal tibia fractures were treated operatively by minimally invasive percutaneous plate osteosynthesis. The patients were followed for at least 1 year. The duration for bone union, complications after the surgery, the amount of skin irritation at the site of plate insertion was evaluated using the VAS score and the Olerud and Molander ankle score. The average age of the patients was 56 years old (range, 30~81 years) with an average follow up period of 21 months (range, 12~30 months). RESULTS: The average time from trauma to surgery was 6 days (range, 2~19 days). 10 cases showed an associated distal fibular fracture. The average time for bone fusion was 14 weeks (range, 8~40 weeks) with 1 case of angular deformity with more than 5 degrees. The amount of skin irritation due to the periarticular plate resulted in a VAS score of 2.2 points. Evaluation of the ankle function test showed an average of 90.2 points, resulting in satisfactory. CONCLUSION: The periarticular plate used in minimally invasive percutaneous plate osteosynthesis for distal tibia fractures was concluded to give a firm fixation of the fracture site as bony fusion could be acquired without any callus formation, and few skin irritation due to plate has seem to be an advantage.

Minimally Invasive Percutaneous Plate Osteosynthesis Using Periarticular Plate for Distal Tibial Fractures

PURPOSE: To evaluate the clinical results of minimally invasive percutaneous plate osteosynthesis using a periarticular plate (Zimmer, Warsaw, IN, USA) for distal tibia fractures. MATERIALS AND METHODS: 27 patients with distal tibia fractures were treated operatively by minimally invasive percutaneous plate osteosynthesis. The patients were followed for at least 1 year. The duration for bone union, complications after the surgery, the amount of skin irritation at the site of plate insertion was evaluated using the VAS score and the Olerud and Molander ankle score. The average age of the patients was 56 years old (range, 30~81 years) with an average follow up period of 21 months (range, 12~30 months). RESULTS: The average time from trauma to surgery was 6 days (range, 2~19 days). 10 cases showed an associated distal fibular fracture. The average time for bone fusion was 14 weeks (range, 8~40 weeks) with 1 case of angular deformity with more than 5 degrees. The amount of skin irritation due to the periarticular plate resulted in a VAS score of 2.2 points. Evaluation of the ankle function test showed an average of 90.2 points, resulting in satisfactory. CONCLUSION: The periarticular plate used in minimally invasive percutaneous plate osteosynthesis for distal tibia fractures was concluded to give a firm fixation of the fracture site as bony fusion could be acquired without any callus formation, and few skin irritation due to plate has seem to be an advantage.

Usefulness of Hip Joint AP Plain X-ray Radiographs in Femoroacetabular Impingement

PURPOSE: We wanted to report the usefulness of both hip AP views, which are some of the various radiographs that are used as a primary diagnostic method for identifying the pistol grip deformity of the femur. MATERIALS AND METHODS: There were 27 cases in patients who were from 20 to 50 years old and who had undergone arthroscopic treatment for femoroacetabular impingement (5 cases of both femoroacetabular impingement) from March 2004 to March 2006, Their preoperative radiographs (both hip APs, the frog leg lateral, the groin lateral and the false profile) were investigated; the most narrow point of the femoral neck, the diameter of the femoral head, the length of the femoral head at the midpoint of these two lines (which is assumed to be the anterosuperior prominence of the femoral neck) were measured on both hip AP views. 15 persons of the same age and who didn't have hip joint pain were chosen as the control group (30 cases) and the same measures was performed and then retrospectively compared with the FAI group. RESULTS: In the FAI group, the femoral head diameter was 53.45 mm, the minimal femoral neck length was 37.58 mm and the femoral head length at the midpoint was 41.52 mm. In the control group, the femoral head diameter was 53.38 mm, the minimal femoral neck length was 35.43 mm and the femoral head length at the midpoint was 39.03 mm. The ratio of the femoral head diameter to the minimal femoral neck length was 0.67 in the FAI group and it was 0.65 in the control group; this was similar in both groups. Yet the ratio of the femoral head diameter to the femoral head length at the midpoint was 0.84 in the FAI group and this was 0.75 in the control group (p=0.01). CONCLUSION: We tried to define the actual value that allows physicians to estimate the pistol grip deformity on both hip AP view of the patients who have hip joint pain, and the ratio of the femoral head diameter to the minimal femoral neck length can be a useful primary indicator for diagnosing femoroactabular impingement when this is over 0.8.

Arthroscopic Treatment of Osseous Abnormalities as a Cause of Femoroacetabular Impingement: Preliminary Clinical Results

PURPOSE: We wanted to report the clinical results of arthroscopic resection of osseous abnormality that caused femoroacetabular impingement MATERIALS AND METHODS: Among 38 cases of patients who had their causes diagnosed as femoroacetabular impingement and who were treated by arthroscopy from April 2000 to August 2005, 21 cases of the patients who were operated on for resection of the acetabular labrum before August 2004 are categorized as group 1; after that, 17 cases of patients who were operated on for bumpectomy or acetabuloplasty were categorized as group 2. RESULTS: The pain scores for all the patients during the preoperative phase, the 2nd week, the 6th week, the 3rd month, the 6th month and the 1st year were 0.57, 1.57, 2.10, 2.19, 2.38 and 2.33, respectively, for group 1 and 0.65, 0.59, 1.41, 1.65, 2.12 and 2.47, respectively, for group 2, which showed improvement from the medical view. The differences between the pain scores of the preoperative phase and the 2nd week postoperatively were an average of 1.00 and -0.06, respectively, in group 1 and group 2, which showed aggravation of the clinical condition of group 1 compared to that of group 2. The differences between the pain scores of the preoperative phase and the 1st year of the postoperative phase were an average of 1.76 and 1.82 in group 1 and group 2, respectively, which presents the better improvement in the medical condition of group 2. 15 out of 21 people in group 1 (71%) and 14 out of 17 people in group in group 2 (82%) were satisfied after the operation. CONCLUSION: Removal of osseous deformity through arthroscopy, compared with the aspects of the clinical conditions as based on the result of partial labrectomy, causes pain in the early days of the postoperative phase. However, the results of the 1 year progression of postoperative phase present a favorable turn of the patients' clinical condition.

Pigmented Villonodular Synovitis of the Ankle Joint / 대한정형외과학회잡지

PURPOSE: To evaluate the clinical manifestations and results of treatment, we have analyzed five cases of Pigmented villonodular synovitis (PVNS) involving the ankle joint, a very rare disease in which the intraarticular joint has active inflammation with hypertrophy of the synovium. MATERIALS AND METHODS: From January 2002 to July 2004, five patients who presented with a mass in the ankle joint had histopathologically confirmed PVNS, retrospectively identified after surgery. Four male patients and one female patient were included in the study. All five patients had preoperative ankle joint swelling and a mass without a history of trauma; all had standard x-rays and three of the five patients had Magnetic resonance imaging (MRI). RESULTS: As a result of the testing there were two localized and three diffuse types identified. For one diffuse type, arthroscopy assisted intraarticular synovectomy was carried out before invasive synovectomy. Mass excision and broad synovectomy were carried out in all cases, and histological evaluations were performed after surgery. For two cases that had incomplete synovectomy, due to adhesions surrounding soft tissue and severe bony invasion, the surgical region was simultaneously treated with postoperative radiation therapy. After an average postoperative follow-up period of 13 months, the pain, swelling and edema resolved and there were no signs of recurrence. CONCLUSION: Mass excision and broad synovectomy provided both accurate diagnosis and successful treatment of PVNS of the ankle joint. In cases where incomplete synovectomy is performed due to anatomical difficulties or bony invasion, combination with postoperative radiation therapy may help reduce the recurrence rate.

Radiologic and Clinical Findings of Anterior Femoroacetabular Impingement in Early Osteoarthritis of the Hip / 대한정형외과학회잡지

PURPOSE: A patient diagnosed with early osteoarthritis due to hip pain who went through arthroscopic treatment were studied in the radiologic aspect and clinical aspect of anterior femoroacetabular impingement (FAI). MATERIALS AND METHODS: The subjects were 43 early osteoarthritis patients from May 1995 to May 2003 who underwent arthroscopic treatment and were able to be followed for at least 1 year. These patients were divided into two groups, the first group with patients who had no osteoarthritis on simple radiograph but with degenerative changes of the labrum and cartilage on MR arthorgram and arthroscopy, and the second group with osteoarthirtic findings on simple radiograph. Both groups were checked to see if they showed signs of anterior FAI at the acetabulum and proximal femur on radiograph and MR arthrogram. Improvement after surgery was evaluated using the JOA (Japanese Orthopaedic Association) pain score. RESULTS: About FAI, 6 patients (29%) out of 21 in group 1 showed radiologic evidence of FAI, while 12 of out 22 (56%) had it in group 2, with a total of 18 patients (42%). The pain score of pre/post operation were improved in group 1 which showed evidence of FAI and while the score of group 2 were improved from 0.83 to 1.83 and 0.92 to 1.67 in group 2. And the pain score of the group 1 which showed no evidence of FAI were improved from 0.73 to 2.60 and the score of group 2 were improved from 0.60 to 2.10. As a result, there was small improvement in pain scores of patient group with FAI. CONCLUSION: Among the patients who were diagnosed with early primary osteoarthritis of th hip, we could find anterior femoroacetabular impingement in the radiogram in some cases and the patients with FAI have low pain relief. Therefore we can expect more improved clinical result with inspection of the anterior FAI.

Arthroscopic Treatment of the Lipoma Arborescens in All Compartments of the Knee: A Case Report / 대한정형외과학회잡지

Lipoma arborescens is a villous proliferation of fatty tissue in the synovial membrane, and known causes are trauma, meniscal injury, inflammation, infection, degenerative change, tumor, and so forth. The reported cases are extremely rare. We report a case of lipoma arborescens developed in all compartments of the knee joint, and treated well with arthroscopic surgery.

A Case of Polyarteritis Nodosa Involving Entire Gastrointestinal Tract / 대한소화기내시경학회지

Polyarteritis nodosa is a systemic vasculitis that affects mainly small and medium-sized muscular arteries. About half of the cases, it involves gastrointestinal tract, mainly jejunum and ileum. Major clinical manifestations are bleeding, ulcer, infection, necrosis, atrophy and stricture. Gastrointestinal involvement suggests a poor prognosis. We have experienced one case of polyarteritis nodosa involving entire gastrointestinal tract that showed various endoscopic features and confirmed by renal biopsy.