Clinical Characteristics, Drug Adherence to Antipsychotics and Medical Use Trends in Patients First Diagnosed with Psychotic Disorder: A Preliminary Study / 대한정신분열병학회지

OBJECTIVES: In this preliminary study, we investigated the clinical characteristics of patients who were first diagnosed with psychotic disorder and explored the impact of the adherence to antipsychotics on long-term medical use. METHODS: All national health insurance claims related to psychotic disorders including gender, age, income, and drug compliance, from January 1, 2008 to December 31, 2015, were examined. With trend test using Medication Possession Ratio (MPR), we compared the medical use between the compliant group (MRP≥0.8) and the comparative non-compliant group (0.2≤MPR<0.8). RESULTS: Among 28,095 participants in total, 16,239 patients (57.8%) were diagnosed as schizophrenia; the 30s were the most common (n=7,151, 25.5%). Drug compliance was generally low regardless of the diagnosis and was the lowest among 20s with the 40–60% range of income. The compliant group showed lower psychiatric and medical use than the comparative group in the following years (p<0.0001). CONCLUSION: These findings suggest that patients in the 20s and 30s with the 40–60% range of income, who are diagnosed with schizophrenia at the first psychiatric visit, may need more clinical and political attention. The results also emphasize the importance of initial drug adherence to antipsychotics in reducing long-term psychiatric costs.

The Effect of Leukoaraiosis on the Severity and Course of Delirium / 정신신체의학

OBJECTIVES: The significance of leukoaraiosis on brain magnetic resonance imaging (MRI) is uncertain, but it is often seen with vascular risk factors or in the context of cognitive impairment. We aimed to investigate the effect of leukoaraiosis on the severity and course of delirium. METHODS: Periventricular hyperintensity and deep white matter hyperintensity on brain MRI were rated in 42 patients with delirium by semiquantative visual rating scale. Correlations between their grades and the scores of Korean version of Delirium Rating Scale-Revised-98 (K-DRS-R-98) were analyzed, and the interaction effects between the groups according to the levels of leukoaraiosis and two evaluation points were also analyzed. RESULTS: The grade of deep white matter hyperintensity in the occipital lobe was positively correlated with the scores on the total, severity items, cognitive items, and non-cognitive items of K-DRS-R-98. The cognitive items scores of K-DRS-R-98 in the low grade group of periventricular hyperintensity showed significantly steeper decrease than the high grade group. CONCLUSIONS: A difference in severity or recovery speed of delirium according to the level of leukoaraiosis may result from disruption in brain functional connectivity. Our results have a clinical implication in that the severity and course of delirium can be possibly predicted using the level of leukoaraiosis.

The Effect of Psychological Factors on Postoperative Pain in Gastric Tumor Patients after Endoscopic Submucosal Dissection / 정신신체의학

OBJECTIVES: Since pain in cancer patients is an important factor that greatly affects the quality of life and prognosis, many attempts have been actively made to reduce the pain. Despite continuous effort on reducing pain after Endoscopic submucosal dissection (ESD), research has not been done on psychological factors as much as on biological factors affecting pain. The objective of this study is to investigate the psychological factors affecting postoperative pain in gastric tumor patients who underwent gastric ESD. METHODS: 91 gastric tumor patients who visited National Health Service Ilsan Hospital in Korean between May 2015 and June 2016, and received ESD were evaluated. Baseline characteristics including sociodemographic factors, anxiety, depression, and resilience were evaluated before the procedure. Multivariate logistic regression was done to analyze factors affecting postoperative pain. RESULTS: The group with high postoperative pain showed lower alcohol consumption and higher depressive symptom scores than the group with low postoperative pain. Also, the group with high postoperative pain showed lower total resilience score with lower subtotal scores in self-control and positive item. Multivariate logistic regression analysis of the postoperative pain showed that patients with lower score in self-control of resilience [odd ratio (OR), 0.911 ; 95% CI, 0.854–0.971, p=0.004) reported more pain after ESD. CONCLUSIONS: This study showed that patients with lower self-control ability of resilience felt more pain after ESD. Among the psychological factors evaluated in this study, resilience of an individual seems to have effect on pain.

Reflection of Pain in Cancer Patients Using a New Screening Tool for Psychological Distress / 정신신체의학

OBJECTIVES: The objective of this study was to investigate the relationship between psychological distress and pain in cancer patients. METHODS: 249 patients with cancer who visited National Health Insurance Service Ilsan Hospital between April 2013 and March 2014 were evaluated with National Cancer Center Psychological Symptom Inventory(NCC-PSI) which consisted of Modified Distress Thermometer(MDT) and Modified Impact Thermometer(MIT). Each scale was divided into 3 subscales targeting separate symptoms: insomnia, anxiety, and depression. Psychological distress was defined as positive for those who scored above the cutoff values in at least one of all six subscales. The Numeric Rating Scale for Pain(NRS-Pain) was used to assess the subjective severity of pain. Logistic regression was performed to investigate the association between psychological distress and pain. RESULTS: Univariate logistic regression analysis showed that pain, gender, compliance, and two subscale scores of Hospital Anxiety and Depression Scale(HADS) were significantly associated with psychological distress. Multivariate logistic regression analysis showed that pain and HADS anxiety subscale score maintained a statistically significant association with psychological distress adjusted for variables including age, gender, years of education, Eastern Cooperative Oncology Group performance status, cancer stage, Charlson Comorbidity Index, compliance, and HADS depression subscale score. One point increase in pain was 1.31 times more likely to cause psychological distress. In secondary analysis, pain was significantly associated with all subscales of NCC-PSI, except MIT-anxiety subscale. CONCLUSIONS: This study suggests that NCC-PSI, a screening tool for psychological distress, reflects pain. We recommend that physicians who treat cancer patients consider the examination of psychological distress which provides comprehensive evaluation of various factors regarding quality of life.

Diagnostic Accuracy and Detection Rate of Real-Time PCR for Detection of Group B Streptococcal Colonization in Pregnant Women: Systemic Review of Literature and Meta-Analysis / 대한임상미생물학회지

BACKGROUND: Group B streptococcus (Streptococcus agalactiae, GBS) was reported as a major cause of neonatal infection and death. To prevent vertical transmission, CDC recommended that all women in week 35-37 of pregnancy should receive the GBS colonization test. We conducted a systematic review and meta-analysis to evaluate diagnostic accuracy and detection rate of real-time PCR for GBS in pregnant women. METHODS: The literature review for GBS using real-time PCR was done including KoreaMed, Ovid-MEDLINE, Ovid-EMBASE, and Cochrane Library on November 3, 2015. 443 articles were collected. Two authors select articles and evaluated the quality of studies using Scottish Intercollegiate Guidelines Network tool independently. RESULTS: Diagnostic accuracy of the real-time PCR was assessed by meta-analysis through 34 articles (13,516 for real-time PCR, 1,815 for culture and other comparison test). The GBS colonization was assessed through 34 articles, which reported varying values of 2.0–69.2% using real-time PCR. The real-time PCR for GBS was shown to have overall sensitivity of 0.93 (95% CI 0.92–0.94, I2=86.3%), overall specificity of 0.96 (95% CI 0.96–0.96, I2=90.2%), SROC AUC of 0.99. CONCLUSION: Real-time PCR is an effective test for detecting GBS colonization in pregnant women, resulted in preventing the infection in a new born baby.

Severity of Comorbidities among Suicidal Attempters Classified by the Forms of Psychiatric Follow-up / 정신신체의학

OBJECTIVES: Suicide attempters have impaired decision making and are at high risk of reattempt. Therefore it is important to refer them to psychiatric treatment. Especially, People with medical comorbidity are at higher risk of suicidal attempt and mortality. The aim of this study was to investigate the characteristics of suicidal attempters and to analyze the influence of the medical comorbidity on decision to receive psychiatric treatment after visit to an emergency department. METHODS: One hundred and thirty two patients, who visited the emergency room of a general hospital in Gyeonggi-do between January, 2012 and December, 2012 were enrolled as the subjects of this study. After reviewing each subject's medical records retrospectively, demographic and clinical factors were analyzed. RESULTS: Regardless of the engagement type, either via admission or outpatient clinic, the determinant factors of psychiatric treatment engagement were psychiatric diagnosis, employment status, previous psychiatric treatment history, and previous attempt history. Comparison of severity of medical comorbidity(Charlson Comorbidity Index) showed that suicide attempters who received psychiatric treatment via admission or refused the treatment tended to have higher level of medical comorbidity than who received psychiatric treatment via outpatient department. CONCLUSIONS: Our findings showed that medical comorbidity of suicide attempters affected the decision to accept psychiatric treatment. All psychiatrists should evaluate the presence and the severity of medical comorbidity of the suicide attempters and consider implementing more intervention for the medically ill attempters who are willing to discharge against advice.

Validation of the Korean version of Center for Epidemiologic Studies Depression Scale-Revised(K-CESD-R) / 정신신체의학

OBJECTIVES: The Center for Epidemiologic Studies Depression scale-Revised is a recently revised scale which has been reported as a valid tool for the assessment of depressive symptoms. It encompasses cardinal symptoms of depression described in the Diagnostic and Statistical Manual of Mental disorders, fourth edition. In this study, we assessed the reliability, validity and psychometric properties of the Korean version of the CESD-R(K-CESD-R). METHODS: Forty-eight patients diagnosed as major depressive disorder, dysthymia, depressive disorder NOS according to the DSM-IV criteria using Mini International Neuropsychiatric Interview and 48 healthy controls were enrolled in this study. They were assessed with K-CESD-R, K-MADRS, PHQ-9, KQIDS-SR, STAI to check cross-validation. Statistical analyses were performed using calculation of Cronbach's alpha, Pearson correlation coefficient, Principal Component Analysis, ROC curve and optimal cut-off value. RESULTS: The Cronbach's alpha of K-CESD-R was 0.98. The total score of K-CESD-R revealed significantly high correlations with those of K-MADRS, PHQ-9, KQIDS-SR(r=0.910, 0.966 and 0.920, p<0.001, respectively). Factor analysis showed two factors account for 76.29% of total variance. We suggested the optimal cut-off value of K-CESD-R as 13 according to analysis of the ROC curve which value sensitivity and specificity both equally. CONCLUSIONS: These Results showed that the K-CESD-R could be a reliable and valid scale to assess depressive symptoms. The K-CESD-R is expected as a useful and effective tool for screening and measuring depressive symptoms not only in outpatient clinic but also epidemiologic studies.

Analysis of Factors Related to the Prescription of Antibiotics for the Acute Upper Respiratory Infection / 보건행정학회지

BACKGROUND: Initial treatment of acute upper respiratory infection (AURI) should not include antibiotics because most AURIs are caused by virus. However, the prescription rate of antibiotics in Korea is higher than in any other countries. Inappropriate use of antibiotics in Korea accelerated the emergence of antibiotics resistance and increased the social and economic burden. The objective of this study was to investigate the factors related to antibiotics use for the AURI among children-adolescents and adults. METHODS: This study analyzed the Health Insurance Review and Assessment Service-National Patient Sample data which was nationally representative sampling stratified by sex and age. RESULTS: The influencing factors of antibiotics use for AURI are gender, age, types of medical security, primary disease, existence of concomitant disease, treatment seasons, first visit or revisit, indicated specialty, types of medical institution, and location of medical institution. CONCLUSION: The results showed health policy makers are required to place more efforts to resolve inappropriate antibiotics use. Especially they need to establish a health policy to reduce the gap between areas and specialties and recommend standardized clinical guidelines according to the subgroup code of AURI and the age group of patients.

Evaluation of the Effectiveness of the Heavy-Light Chain Quantitative Test

BACKGROUND: The heavy-light chain (HLC) quantitative test can identify and quantify the heavy and light chains of each immunoglobulin class. The purpose of this study was to evaluate the effectiveness of the HLC quantitative test. METHODS: To evaluate the effectiveness of the HLC quantitative test, a systemic review of the literature, using Ovid-MEDLINE, EMBASE, Cochrane library, and eight domestic databases including KoreaMed, was performed until October 10, 2013. We included five cohort studies and one diagnostic evaluation study in the final evaluation. Two reviewers independently assessed the quality of the included studies and extracted data from the studies. The quality of the studies was assessed according to the Scottish Intercollegiate Guidelines Network (SIGN) tool. RESULTS: A correlation between the HLC quantitative test and previous assays was evaluated in one study, which enrolled patients with increased monoclonal IgA. The correlation coefficient was reported as 0.94 in this study. The clinical significance of the quantitative HLC test to predict a prognosis was also reported in five cohort studies. The survival rate in patients with higher HLC ratio was significantly lower and the increased IgA kappa/lambda ratio or IgM kappa/lambda ratio was significantly correlated with higher survival rate in patients with monoclonal gammaglobulinemia. CONCLUSIONS: The HLC quantitative test is an effective test that can quantitatively measure the identified immunoglobulin type and predict the prognosis of patients with monoclonal gammopathy.

A Needle Penetrating the Stomach Cavity after Acupuncture

Although acupuncture is known as a safe procedure that is widely used in many countries, complications including infection, hemorrhage, hematoma, pneumothorax, nerve damage, and cardiac tamponade have been reported. A needle penetrating the stomach after acupuncture, however, is very rare. Here, we report the case of 47-year-old woman who experienced abdominal pain 2 days after receiving acupuncture. Upper gastrointestinal endoscopy identified an approximately 2.5-cm long needle in the posterior wall of the antrum. The needle was removed endoscopically using rat tooth forceps with no complications.

Changes in the Antibiotic Resistance Rates of Helicobacter pylori Strains Isolated in Tertiary Medical Institutions in Seoul / 대한내과학회지

BACKGROUND/AIMS: Patient compliance and resistance to antibiotics are main factors determining the success of Helicobacter pylori eradication. This study provides basic data to verify the efficacy of currently implemented eradication therapy and reports changes in H. pylori resistance to all antibiotics used at Asan Medical Center, Seoul, Korea from 2004 to 2010. METHODS: We investigated the resistance rates to amoxicillin, clarithromycin, metronidazole, ciprofloxacin, and levofloxacin in 88, 100, and 47 strains isolated from adult patients without H. pylori eradication history in 2004, 2007, and 2010. RESULTS: The resistance rate to amoxicillin increased from 5.0% in 2007 to 10.6% in 2010. The resistance rate to clarithromycin increased from 10.2% in 2004 and 11.0% in 2007 to 14.8% in 2010. However, no difference was observed in the resistance rate to metronidazole, and strains resistant to tetracycline were not detected at all in this study. The resistance rates to quinolone lingered at 15-17% for 3 years. The non-resistant strains to antibiotics accounted for 56% of the total in 2004 and 62% in 2007. In contrast, a decreasing tendency was found for those strains in 2010 (43%). No significant differences were shown in the multi-drug resistance rate or the co-resistance rates of amoxicillin and clarithromycin over the 3 years. CONCLUSIONS: We showed increased resistance rates to clarithromycin and amoxicillin over the last 7 years, aligning with the results of previous studies performed domestically. Efforts are needed to inhibit the increase in resistant bacteria to maintain the effectiveness of eradication therapy.

Relationship of Suicide Risk with Early Life Stress and Resilience in Patients with Major Depressive Disorder / 신경정신의학

OBJECTIVES: The aim of this study is to investigate the relationship of suicide risk with early-life stress (ELS) and resilience in patients with major depressive disorder (MDD). METHODS: The participants were 60 patients with MDD and 29 healthy volunteers. Each subject was assessed concerning ELS, resilience factors, suicide ideation, and depressive symptom severity using self-report questionnaires. Mann-Whitney test and stepwise multiple linear regression analyses were performed. RESULTS: Emotional abuse, physical abuse, neglect, and exposure to inter-parental violence were higher in the patient group than in the control group. Resilience factors were significantly lower in the patient group. In multiple regression analyses, final regression model including physical abuse, neglect, and self-regulation factor was significant explaining 45.6% variance of suicide ideation score. CONCLUSION: We found that ELS experiences, particularly exposure to inter-parental violence, might be a significant risk factor for development of depression. In particular, experiences of physical abuse and neglect might increase the risk of suicide in depression but resilience may play a protective role in development of depression and prevention of suicide in depressive patients.

Clinical Features of Pancreatic Cancer Associated with Chronic Pancreatitis in Korean Patients / 대한내과학회지

BACKGROUND/AIMS: A positive correlation between chronic pancreatitis (CP) and pancreatic cancer (PC) has been reported. The aim of this study was to compare the clinical features of PC occurring in CP versus PC without CP with the aim of contributing to the earlier detection of PC in CP patients. METHODS: The study was based on a retrospective chart review performed from 1989 to 2009, of 38 PC patients with underlying CP versus controls. RESULTS: Compared with PC without CP, PC with CP patients were younger at the time of the diagnosis of PC (57.42 vs. 63.94 years; p = 0.01), a greater percentage were smokers (71.1% vs. 50.0%, p = 0.047), and there was pancreatic duct dilatation without a mass on CT findings (15.8% vs. 2.0%, p = 0.018). There was no difference in clinical presentation at the time of PC diagnosis and the CA 19-9 level was elevated in most patients in both groups. Additionally, there was no difference between the groups in terms of resectability (39.5% vs. 26.0%; p = 0.179) or preoperative stage; however, a greater proportion of the PC with CP group underwent surgery (34.2% vs. 16.0%; p = 0.047). CONCLUSIONS: When there is a high suspicion of PC, even if no definite mass is seen on CT in CP patents, we should endeavor to make a diagnosis of PC. Active follow-up of CP patients can allow earlier detection of pancreatic cancer.

Relationship between Negative Mental Adjustment to Cancer and Distress in Thyroid Cancer Patients

PURPOSE: Previous studies have reported that over a third of cancer patients experience significant psychological distress with diagnosis and treatment of cancer. Mental adjustment to cancer as well as other biologic and demographic factors may be associated with their distress. We investigated the relationship between mental adjustment and distress in patients with thyroid cancer prior to thyroidectomy. MATERIALS AND METHODS: One hundred and fifty-two thyroid cancer patients were included in the final analysis. After global distress levels were screened with a distress thermometer, patients were evaluated concerning mental adjustment to cancer, as well as demographic and cancer-related characteristics. A thyroid function test was also performed. Regression analysis was performed to discern significant factors associated with distress in thyroid cancer patients. RESULTS: Our regression model was significant and explained 38.5% of the total variance in distress of this patient group. Anxious-preoccupation and helpless-hopeless factors on the mental adjustment to cancer scale were significantly associated with distress in thyroid cancer patients. CONCLUSION: Negative emotional response to cancer diagnosis may be associated with distress in thyroid cancer patients awaiting thyroidectomy. Screening of mental coping strategies at the beginning of cancer treatment may predict psychological distress in cancer patients. Further studies on the efficacy of psychiatric intervention during cancer treatment may be needed for patients showing maladaptive psychological responses to cancer.

Systematic review for new health technology assessment

We used a systematic review to evaluate the safety and effectiveness of a new health technology in Korea. The results of the systematic review are being used by the Health Insurance Review and Assessment Service when the Ministry of Health and Welfare introduces new medical technology. The purpose of this study is to introduce this systematic review, which is the main methodology for evaluating the safety and effectiveness of new medical technology, and to share our experience of performing a systematic review to guide the reader in performing a systematic literature review accurately and easily. This paper presents the process of new health technology evaluation using a systematic review. A systematic review involves collecting current available evidence of health technology systematically. According to the evaluation process, in the first meeting of sub-committee, we develop a systematic review protocol including PICO and criteria for inclusion/exclusion. In the second meeting of sub-committee, we search comprehensively for appropriate literature according to the clinical question and to select in a clear and reproducible method. We also assess study quality, considering the internal validity and external validity of the selected literature, and make a table of extracted data. In the third meeting of sub-committee, we extract general information, study characteristics information, and study outcome information, and synthesize the outcomes. In the forth meeting of sub-committee, we finalize the conclusions based on synthesizing the studies. After the subcommittees' assessments, the results are presented to the Committee for New Health Technology. Finally, we report this result to the Ministry of Health and Welfare. The systematic review is useful for helping policymakers make decisions about the introduction of new health technology based on evidence. It enables people to minimize confusion due to weak evidence for health technology. In case of domestically developed technology and technology for rare disease, it is difficult assess health technology due to a lack of evidence, so assessing raw data (charts, results of clinical trials) is needed in addition to a systematic review. Furthermore, the government should support clinical studies to develop evidence on new health technologies with potential benefit, and the introduction of a conditional coverage decision in the new health technology assessment system is necessary to deal with uncertainty.

Effects of Surgical Operation and Induced Thyroid Hormone Deficiency During Cancer Treatment on Emotional Distress in Thyroid Cancer Patients / 정신신체의학

OBJECTIVES: Thyroid cancer patients may experience emotional distress during cancer treatment including surgical operation and radioactive iodine treatment. The aims of this prospective study were to investigate changes of anxiety and depressive symptoms in patients with differentiated thyroid cancer(DTC) under preoperative, postoperative and short-term hypothyroidism state. METHODS: Using the Hospital Anxiety and Depression scale(HAD) and the Distress Thermometer, we sequentially assessed the levels of anxiety, depression and distress in 41 DTC patients at 3 time points such as preoperative state, postoperative state and short-term hypothyroidism state. RESULTS: The HAD-anxiety score was significantly higher in preoperative state(6.93+/-3.97) than postoperative state(4.22+/-2.92) and short-term hypothyroidism state(4.93+/-3.64). Any other significant change in depression or distress thermometer score was not observed. Especially, difference of HADS score between the distress and none-distress groups was significant in preoperative state and post-operative state, but the difference become not significant in the short-term hypothyroidism state. CONCLUSIONS: Induced thyroid hormone deficiency during cancer treatment does not significantly affect emotional distress in patient with DTC. Anxiety and depression in these patients may be associated with distress of the patient before active cancer treatment.

Biochemical Biomarkers for Alzheimer's Disease in Cerebrospinal Fluid and Peripheral Blood

The diagnosis of Alzheimer's disease (AD) is still obscure even to specialists. To improve the diagnostic accuracy, to find at-risk people as early as possible, to predict the efficacy or adverse reactions of pharmacotherapy on an individual basis, to attain more reliable results of clinical trials by recruiting better defined participants, to prove the disease-modifying ability of new candidate drugs, to establish prognosis-based therapeutic plans, and to do more, is now increasing the need for biomarkers for AD. Among AD-related biochemical markers, cerebrospinal beta-amyloid and tau have been paid the most attention since they are materials directly interfacing the brain interstitium and can be obtained through the lumbar puncture. Level of beta-amyloid is reduced whereas tau is increased in cerebrospinal fluid of AD patients relative to cognitively normal elderly people. Remarkably, such information has been found to help predict AD conversion of mild cognitive impairment. Despite inconsistent findings from previous studies, plasma beta-amyloid is thought to be increased before the disease onset, but show decreasing change as the disease progress. Regarding other peripheral biochemical markers, omics tools are being widely used not only to find useful biomarkers but also to generate novel hypotheses for AD pathogenesis and to lead new personalized future medicine.

Endoscopic Cryotherapy of Lung and Bronchial Tumors: A Systematic Review

BACKGROUND/AIMS: We made a systematic review and evaluation of endoscopic cryotherapy of endobronchial tumors, investigating safety and efficacy. METHODS: Qualified studies regarding endoscopic cryotherapy of lung tumors were systemically evaluated using available databases according to predefined criteria. RESULTS: In total, 16 publications were included in the final assessment. A narrative synthesis was performed because a formal meta-analysis was not viable due to the lack of controlled studies and study heterogeneity. Overall success rates for significant recanalization of the obstruction were approximately 80%, although they varied, depending on disease status in the patient population. Complications from the procedure developed in 0-11.1% of cases, most of which were minor and controlled by conservative management. Although limited data were available on comprehensive functional assessment, some studies showed that respiratory symptoms, pulmonary function tests, and performance status were significantly improved. CONCLUSIONS: Endoscopic cryotherapy was found to be a safe and useful procedure in the management of endobronchial tumors although its efficacy and appropriate indications have yet to be determined in well-designed controlled studies.

A Case Report of Rituximab Therapy for Recurrent Thrombotic Thrombocytopenia Purpura

Thrombotic thrombocytopenic purpura (TTP) is a rare medical condition characterized by thrombocytopenia, microangiopathic hemolytic anemia, neurologic manifestations, and infrequently, renal involvement. In many cases, TTP is associated with deficiency of the von Willebrand factor-cleaving protease, ADAMTS13, and treatment with plasma exchange is effective in the majority of patients. We report a patient with acute TTP in whom remission was not achieved by initial treatment consisting of plasma exchange and corticosteroids. In view of the severe autoantibody-mediated ADAMTS-13 deficiency, treatment was initiated with rituximab, a chimeric monoclonal antibody directed against the CD 20 antigen present on B lymphocytes. The patient received 4 weekly infusions of rituximab (375 mg/m2). Four weeks after the last infusion of rituximab, a complete clinical and laboratory remission was documented. We conclude that rituximab should be considered in patients with TTP with acquired ADAMTS-13 deficiency, who fail to respond to standard treatment with plasma exchange and corticosteroids. Rituximab may result in a lowered requirement for plasmapheresis and avoid the complications of salvage immunosuppressive therapy.

A case of hemobilia caused by an intraductal papillary neoplasm of the bile duct / 대한내과학회지

Intraductal papillary neoplasm of the bile duct (biliary IPN) is a rare disease characterized by multicentric proliferation of adenomatous epithelium within the bile ducts. The common clinical manifestations are recurrent abdominal pain, jaundice, and acute cholangitis. We report a case of hemobilia caused by biliary IPN. A 59-year-old man was referred to our hospital because of hemobilia of unknown origin. Computed tomography and magnetic resonance cholangiography revealed dilatation of the S6 segmental duct with an ovoid-shaped intraductal mass. Percutaneous transhepatic cholangioscopy showed multiple papillary masses with bleeding in the S6 segmental duct. The patient underwent a right lobectomy, and the pathology revealed a well differentiated intraductal papillary adenocarcinoma.