Sorafenib Induces Delayed-Onset Cutaneous Hypersensitivity: A Case Series

Sorafenib is an oral multikinase inhibitor with clinical activity against hepatocellular carcinoma (HCC) and renal cell carcinoma. Administration of sorafenib carries a variety of adverse cutaneous reactions. Common adverse effects induced by sorafenib include hand-foot skin reactions, facial erythema, splinter subungual hemorrhage, and alopecia. Although erythema multiforme (EM) related to sorafenib has been reported, delayed-type cutaneous hypersensitivity reactions are rare in patients treated with sorafenib and there has been no case of Stevens-Johnson syndrome (SJS) reported so far. We recently experienced 3 cases of delayed-type cutaneous hypersensitivity related to administration of sorafenib. The first case was a 47-year female had targetoid erythematous rashes on her arms 12 days after starting sorafenib for HCC. The rashes spread from the arms to the trunk rapidly except for the hands and feet, and erosive lesions developed in the oral mucosa and lips. She was diagnosed as SJS. The second case was an 81-year-old male had maculopapular eruptions with multiple targetoid lesions on the trunk, arms, and legs 10 days after starting sorafenib for his HCC. There was no evidence of mucosal involvement. He was diagnosed with EM. The last one was a 20-year-old female developed generalized maculopapular eruptions in the whole body 10 days after starting sorafenib for the treatment of HCC. All 3 patients completely recovered after discontinuation of sorafenib.

The Prevalence Rate of Tuberculin Skin Test Positive by Contacts Group to Predict the Development of Active Tuberculosis After School Outbreaks / 결핵및호흡기질환

BACKGROUND: The tuberculin skin test (TST) is the standard tool to diagnose latent tuberculosis infection (LTBI) in mass screening. The aim of this study is to find an optimal cut-off point of the TST+ rate within tuberculosis (TB) contacts to predict the active TB development among adolescents in school TB outbreaks. METHODS: The Korean National Health Insurance Review and Assessment database was used to identify active TB development in relation to the initial TST (cut-off, 10 mm). The 7,475 contacts in 89 schools were divided into two groups: Incident TB group (43 schools) and no incident TB group (46 schools). LTBI treatment was initiated in 607 of the 1,761 TST+ contacts. The association with active TB progression was examined at different cut-off points of the TST+ rate. RESULTS: The mean duration of follow-up was 3.9+/-0.9 years. Thirty-three contacts developed active TB during the 4,504 person-years among the TST+ contacts without LTBI treatment (n=1,154). The average TST+ rate for the incident TB group (n=43) and no incident TB group (n=46) were 31.0% and 15.5%, respectively. The TST+ rate per group was related with TB progression (odds ratio [OR], 1.025; 95% confidence interval [CI], 1.001-1.050; p=0.037). Based on the TST+ rate per group, active TB was best predicted at TST+ > or = 16% (OR, 3.11; 95% CI, 1.29-7.51; area under curve, 0.64). CONCLUSION: Sixteen percent of the TST+ rate per group within the same grade students can be suggested as an optimal cut-off to predict active TB development in middle and high schools TB outbreaks.

Two Cases of Epidermoid Cysts in the Intrapancreatic Accessory Spleen Mimicking Pancreatic Cystic Neoplasm / 대한췌담도학회지

Epidermoid cyst in the intrapancreatic accessory spleen is extremely rare condition which could be mistaken for pancreatic cystic neoplasm. We report two cases of epidermoid cysts of intrapancreatic accessory spleen which mimicking pancreatic cystic neoplasm. Two patients, both male, aged 47 and 53 respectively were referred to our department for pancreatic mass. One was asymptomatic, whereas the other presented worsening abdominal pain and progressive weight loss. In both cases, the mass with cystic component was detected in the pancreatic tail in a computed tomography scan. Under a suspicion of pancreatic cystic neuronendocrine tumor, they underwent a distal pancreatectomy. Pathologic feature of resected specimens were shown to benign squamous lined cyst with splenic tissue in and around cyst wall which suggested that epidermoid cysts in the accessory spleen. We should take into account the possibility of epidermoid cyst in the intrapancreatic accessory spleen in the differential diagnosis of pancreatic cystic lesion.

Diagnostic Accuracy of Notified Cases as Pulmonary Tuberculosis in Private Sectors of Korea

The diagnostic accuracy of the data reported in the Korean tuberculosis surveillance system (KTBS) has not been adequately investigated. We reviewed the clinical data of pulmonary tuberculosis (PTB) cases notified from private medical facilities through KTBS between January and June, 2004. PTB cases were classified into definite (culture-proven), probable (based on smear, polymerase chain reaction, histology, bronchoscopic finding, computed tomography, or both chest radiograph and symptoms) or possible (based only on chest radiograph) tuberculosis. Of the 1126 PTB cases, sputum AFB smear and culture were requested in 79% and 51% of the cases, respectively. Positive results of sputum smear and culture were obtained in 43% and 29% of all the patients, respectively. A total of 73.2% of the notified PTB cases could be classified as definite or probable and 81.7% as definite, probable, or possible. However, where infection was not confirmed bacteriologically or histologically, only 60.1% of the patients were definite, probable, or possible cases. More than 70% of PTB notified from private sectors in Korea can be regarded as real TB. The results may also suggest the possibility of over-estimation of TB burden in the use of the notification-based TB data.

Tuberculin Survey to Estimate the Prevalence of Tuberculosis Infection of the Elementary Schoolchildren under High BCG Vaccination Coverage / 결핵및호흡기질환

BACKGROUND: Although the prevalence of tuberculosis infections (PTBI) is one of the basic epidemiologic indices, no survey has been carried out since 1995 because the nation-wide tuberculosis prevalence survey was changed to a surveillance system. Subjects without a BCG scar are examined in a tuberculin survey. However, it is very difficult to select these subjects under high vaccination coverage. It is important to evaluate the impact of BCG vaccinations on the tuberculin response and estimate the PTBI regardless of the BCG vaccination status. METHODS: A nation-wide, school-based cross-sectional tuberculin survey was carried out among first graders in elementary school in 2006. A total of 5,148 children in 40 schools were selected by quota sampling. Tuberculin testing with 0.1 ml of two tuberculin units of PPD RT23 was carried out on 4,018 children. The maximum transverse diameter of induration was measured 48 to 72 hours later. The presence of a BCG scar was checked separately. RESULTS: There were no BCG scars in 6.3% of the subjects. The mean induration size of tuberculin testing was 3.7+/-4.4 mm, which included 1,882 (46.8%) subjects with an induration size of 0 mm. The PTBI was 10.9% (439 subjects) using a cut-off point of > or =10 mm (conventional method). The annual risk of tuberculosis infections (ARTI) was 1.9% when the mean age of the subjects was assumed to be 6 years. There was no difference in the PTBI according to the presence or absence of a BCG scar [11.2% vs 7.6% (OR: 1.54, 95% CI: 0.98m2.43)]. Using a mirror image technique with 16 mm as the cut-off point, the PTBI and ARTI had decreased to 2.4% and 0.4% respectively. CONCLUSION: PTBI and ARTI, as estimated by conventional methods, appear to be high among BCG vaccinated children. A mirror image technique is more suitable for estimating the indices in a country with an intermediate burden of tuberculosis than the conventional method.

Effects of R. Glutinosa and E. Senticosus on Postmenopausal Osteoporosis

In this study, we investigated the therapeutic effects of a novel formulation of low-dose calcium and vitamin D3, blended with Rehmannia glutinosa Libosch and Eleutherococcus senticosus Max (RE+), in postmenopausal women. The controls were given either a placebo or high dose calcium and vitamin D3 (Ca+D). Bone mineral density (BMD) in the L2-3 lumber spines and femur regions was assessed, and serum osteocalcin, bone-specific alkaline phosphatase (BALP), and cross-linked N-telopeptide of type I collagen (NTx) were used as markers of osteoblast and osteoclast activity. Furthermore, all variables were measured before and after 6 and 12 months of treatment. The osteocalcin level was higher in the RE+ group, and BALP was almost the same in all groups. Serum NTx was significantly decreased in the RE+ group after 12 months (p<0.05). The NTx in the Ca+D and placebo groups showed no significant change. The decrease of femur BMD was further demonstrated in the placebo group, but significantly increased in the RE+ group after 6 and 12 months of treatment (p<0.05). There were significant differences in the percent changes of femur BMD between the placebo and RE+ groups (p<0.01) and Ca+D and RE+ groups (p<0.05). The decrease of spine BMD in the placebo group was inhibited both in the Ca+D and RE+ groups, however, there was significant difference only between the placebo and RE+ groups (p<0.05). These findings suggest that continuous oral therapy of the RE+ formulation reduces rapidly decreasing bone mineral density in postmenopausal women more effectively than high doses of calcium and vitamin D3 alone by inhibiting osteoclastic activity. Therefore, it seems that the RE+ has its own antiosteoporotic effects. We suggest larger clinical studies to determine the most efficacious dosage and benefits of this novel treatment.

The Effect of Cognitive Deficit on Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: To investigate the functional outcome with regard to cognitive deficits in patients with aneurysmal subarachnoid hemorrhage (SAH). METHOD: Two hundred thirty-four patients who underwent surgical procedure for aneurysmal SAH were enrolled. Medical records of the patients were reviewed. RESULTS: Mental confusion (52.1%) was more common symptom than the motor (20.3%) and language (30.9%) impairment in patients with aneurysmal SAH. Neurological grade at admission (Hunt and Hess grade), cerebral vasospasm, and mental confusion were major prognostic factors. In terms of functional outcome, patients with mental confusion showed lower Functional Independence Measure (FIM) scores at admission and on discharge, lower FIM gain and FIM efficiency, and longer hospital stay with statistical significance than those without confusion. CONCLUSION: The patients with cognitive deficits achieved poor functional outcome in the patients with aneurysmal SAH. More attention to cognitive impairment is necessary to achieve better rehabilitation goal.

Dynamic Imbalance of Lumbo-Pelvic Motion in Pregnant Women with Back and Pelvic Pain

OBJECTIVE: To investigate a biomechanism of pelvic pain in pregnancy by use of motion analyzer. METHOD: Ten pregnant women in the early third trimester and 10 healthy women as control were enrolled. A gait analysis by a Vicon 370 motion analyzer system was performed to investigate the dynamic lumbo-pelvic motion of pregnancy in biomechanical aspects. RESULTS: The mean maximal surface lordotic angle of pregnant women was 24.42+/-3.98 degrees, the mean minimal surface lordotic angle 20.64+/-4.27 degrees, and the mean maximal surface lordotic angle of controls was 21.61+/-2.43 degrees, the mean minimal surface lordotic angle 18.38+/-2.29 degrees (p>0.05). The mean maximal anterior pelvic tilt of pregnant women was 21.11+/-5.91 degrees, and the mean maximal anterior pelvic tilt of controls was 15.28+/-4.94 degrees (p<0.05). CONCLUSION: The angle of lumbar lordosis was within normal ranges but the anterior pelvic tilt was increased significantly in pregnancy. This can place mechanical stress on lumbo-pelvic region. This dynamic sagittal imbalance of the spine may be a considerable cause for low back and pelvic pain in pregnancy as indicated by the results of this study.

Insomnia in Inpatients during Rehabilitation Treatment

OBJECTIVE: To investigate incidence, characteristics, and risk factors of insomnia and to compare the functional outcomes between insomnia and non-insomnia group in rehabilitation patients. METHOD: Sixty nine consecutive admissions between May and June, 1999 have been evaluated. The St. Mary's Hospital Sleep Questionnaire were employed and medical records of the patients have been reviewed. RESULTS: Incidence of insomnia was 60.9%. The most common type of insomnia was difficulty in maintaining sleep during the night (interrupted type). 66.9% of the total patients with insomnia had recognizable causal factors. The common factors influencing insomnia were somatic symptoms, environmental, and psychological factors. On discharge, lower FIM gain was noted in insomnia group even though statistical significance was not found. CONCLUSION: Since sleep disturbances have been common to the rehabilitation patients, and may influence functional outcome, early diagnosis and therapeutic intervention may be needed.