An atypical case of Lemierre syndrome following oropharyngeal infection / 고신대학교의과대학학술지

Lemierre syndrome is characterized by anaerobic bacterial infection in the head and neck and clinical or radiological evidence of internal jugular vein thrombophlebitis. The most common pathogens are Fusobacterium species, particularly Fusobacterium necrophorum. Septic emboli resulting from infected thrombophlebitis of the internal jugular vein leads to metastatic infections involving lung, liver, kidney, bone and central nervous system. The accurate diagnosis and treatment is important because it may be associated with a high mortality rate if untreated. We present a case of 28-year-old man with an atypical history for the diagnosis of Lemierre syndrome, which showed no definite evidence of internal jugular thrombophlebitis.

Association of Serotonin 1A Receptor Polymorphism with Variation in Health-Related Quality of Life in Korean Hemodialysis Patients

OBJECTIVE: Hemodialysis patients may have psychological distress and reduced quality of life (QoL) related to chronic physical health problems. Genetic polymorphisms associated with reduced QoL in hemodialysis patients. The aim of this study was to investigate the relationship between genetic polymorphisms and variation in health-related QoL in Korean hemodialysis patients. METHODS: The 36-item Short-Form Health Survey and the Korean Hospital Anxiety and Depression Scale were used to assess health-related QoL and psychological distress, respectively. Twenty hundred and five clinically stable patients from 6 hemodialysis centers have participated with informed consents. Sociodemographic factors, clinical factors, and genotypes of serotonin 1A receptor, brain-derived neurotrophic factors, and glucocorticoid receptor were assessed. Independent t-tests, correlation analyses, multiple regression analyses were performed for statistical analyses. RESULTS: The serotonin 1A receptor CC genotype group showed significantly higher physical and mental QoL levels than those with the GG/GC genotypes. In the final linear regression analysis, serotonin 1A receptor CC genotype was significantly associated with positive physical and mental QoL levels. CONCLUSION: ConclusionaaSerotonin 1A receptor polymorphism, as well as age and depression, were significantly associated with mental and physical QoL in hemodialysis patients. Functional activity in the serotonin receptor system may have a modulating effect on health-related QoL in hemodialysis patients.

Chronic Myeloid Leukemia Following Radioactive Iodine Treatment for Thyroid Cancer: Two Case Reports and a Literature Review / 대한내과학회지

The incidence of thyroid cancer has increased rapidly worldwide, although most patients can survive for a long time without developing symptoms. While most thyroid cancers are treated with thyroidectomy alone, some patients are given additional radioactive iodine (RAI) in the form of 131I to treat thyroid cancer metastasis. RAI is associated with acute and chronic complications. Secondary malignancies are the most important in long-term cancer survivors. While many studies have reported the occurrence of acute myeloid leukemia after high-dose RAI, there are few reports on chronic myeloid leukemia (CML) after low-dose RAI treatment. Moreover, previous cases of CML following thyroid cancer were reported before the tyrosine kinase inhibitor (TKI) era. Here, we describe two cases of CML following thyroid cancer that were successfully treated with second-generation TKIs.

Incidentally Found Chronic Neutrophilic Leukemia in a Patient with Rectal Cancer / 대한내과학회지

Chronic neutrophilic leukemia (CNL) is a rare myeloproliferative neoplasm characterized by sustained neutrophilia, splenomegaly, and hypercellular bone marrow without Philadelphia chromosome. Diagnosis of CNL requires exclusion of identifiable causes of reactive neutrophilia, such as infection and tumors. Our patient presented with general weakness and weight loss. Computed tomography (CT) showed a mass in the distal rectum, which was confirmed to be an adenocarcinoma by colonoscopic biopsy. Positron emission tomography-CT showed multiple liver, bone, and lymph node metastases. Liver and lymph node biopsies revealed neutrophilic infiltration with no evidence of adenocarcinoma. The pathological findings of the bone marrow were compatible with CNL. Cytogenetic analysis revealed a normal karyotype, and molecular analysis was negative for BCR/ABL. Here, we present a 73 year-old man diagnosed with concurrent CNL and rectal cancer.

Transfusion-free Management for the Severe Anemia Developed after Nephrectomy / 이화의대지

A 56-year-old woman with emphysematous pyelonephritis underwent an emergent left nephrectomy due to her religious creed. Postoperative hemoglobin level was decreased to 4.4 g/dL from preoperative value of 13.9 g/dL. The patient completely recovered without transfusion and was discharged on the 40th postoperative day without complication.

Endoscopic Submucosal Dissection for Recurrent or Residual Superficial Esophageal Cancer after Chemoradiotherapy: Two Cases

We report two cases of endoscopic submucosal dissection (ESD) for recurrent or residual esophageal squamous cell carcinoma (ESCC) lesions after chemoradiotherapy for advanced esophageal cancer. Case 1 involved a 64-year-old man who had previously undergone chemoradiotherapy for advanced ESCC and achieved a complete response (CR) for 22 months, until metachronous recurrent superficial ESCC was detected on follow-up esophagogastroduodenoscopy (EGD). We performed ESD and found no evidence of recurrence for 24 months. Case 2 involved a 59-year-old man who had previously undergone chemoradiotherapy for advanced ESCC. He responded favorably to treatment, and most of the tumor had disappeared on follow-up EGD 4 months later. However, there were two residual superficial esophageal lugol-voiding lesions. We performed ESD, and he had a CR for 32 months thereafter. ESD can be considered a viable treatment option for recurrent or residual superficial ESCC after chemoradiotherapy for advanced esophageal cancer.

Morphological evaluation during in vitro chondrogenesis of dental pulp stromal cells

OBJECTIVES: The aim was to confirm the stem cell-like properties of the dental pulp stromal cells and to evaluate the morphologic changes during in vitro chondrogenesis. MATERIALS AND METHODS: Stromal cells were outgrown from the dental pulp tissue of the premolars. Surface markers were investigated and cell proliferation rate was compared to other mesenchymal stem cells. Multipotency of the pulp cells was confirmed by inducing osteogenesis, adipogenesis and chondrogenesis. The morphologic changes in the chondrogenic pellet during the 21 day of induction were evaluated under light microscope and transmission electron microscope. TUNEL assay was used to evaluate apoptosis within the chondrogenic pellets. RESULTS: Pulp cells were CD90, 105 positive and CD31, 34 negative. They showed similar proliferation rate to other stem cells. Pulp cells differentiated to osteogenic, adipogenic and chondrogenic tissues. During chondrogenesis, 3-dimensional pellet was created with multi-layers, hypertrophic chondrocyte-like cells and cartilage-like extracellular matrix. However, cell morphology became irregular and apoptotic cells were increased after 7 day of chondrogenic induction. CONCLUSIONS: Pulp cells indicated mesenchymal stem cell-like characteristics. During the in vitro chondrogenesis, cellular activity was superior during the earlier phase (within 7 day) of differentiation.

Recurrence Rates of Nasal Polyps after Endoscopic Sinus Surgery in regards to Underlying Allergic Rhinitis and Asthma

BACKGROUND AND OBJECTIVES: Nasal polyp is a disease of the mucous membranes in the nose and the paranasal sinuses that develops as a reaction to a variety of stimuli including allergens and various microbes. The etiology and formation of nasal polyp are still unclear and have been debated for many years. The objective of the present study is to investigate the correlation among allergic rhinitis, asthma and recurrent nasal polyps. MATERIALS AND METHODS: We conducted a retrospective review of patients with severe nasal polyps who underwent endoscopic sinus surgery. Patients who had a minimum Lund- MacKay score of 16 and a minimum of 12 months of follow-up were included in the analysis. Data collection included demographics, presence of asthma or documented allergic rhinitis, recurrence rates, and follow up. RESULTS: Three hundred and forty one records were reviewed. Two hundred and forty-three (71.3%) patients had no underlying asthma and allergic rhinitis. Seventy-nine (32.5%) patients among them developed recurrent nasal polyps. Seventy-two (21.1%) patients had documented allergic rhinitis without asthma. Twenty-one (29.2%) patients among them developed recurrent nasal polyps. Fifteen (4.4%) patients had both asthma and allergic rhinitis. Eight (53.3%) patients among them developed recurrent nasal polyps. Eleven (3.3%) patients had asthma without allergic rhinitis. Six (54.6%) patients among them developed recurrent nasal polyps. CONCLUSION: Knowing recurrence rates after endoscopic sinus surgery for nasal polyps in regards to underlying asthma and allergic rhinitis is clinically significant. In our study, the presence of asthma significantly correlated with higher recurrence (p<0.05). But, the presence of allergy was not statistically significant.

A Case of Petrositis with Abducens Palsy / 대한이비인후과학회지

Petrous apicitis is an extension of infection from the mastoid air cell tract into petrous apex. Petrous apicitis, a potentially fatal complication of suppurative otitis media, presents a variety of symptoms. But the classical findings of petrous apicitis, called Gradenigo's syndrome that include abducens nerve palsy, deep facial pain and acute suppurative otitis media, rarely occur. Gradenigo's syndrome can be treated with surgery, but the advent of antibiotics and early imaging study allow conservative treatment in some uncomplicated cases. With the widespread use of antibiotics, petrous apicitis has become an uncommon disease. So most physicians have little clinical experience in their diagnosis and treatment of this disease. We present a case of Gradenigo's syndrome, which was unresponsive to conservative treatment. We provide here details of our experience of treating the patient with surgery without complication.

Clinical Manifestations of Cerebellar Infarction Mimicking Unilateral Vestibulopathy

BACKGROUND AND OBJECTIVES: Pseudo-labyrinthine symptom without any other accompanying neurologic symptoms or signs occur with cerebellar infarction. The prognosis and management of cerebellar infarction differ from those of vertigo associated with unilateral vestibulopathy. The objective of study was to analyze the clinical symptoms of cerebellar infarction mimicking unilateral vestibulopathy according to the infarction territory. MATERIALS AND METHOD: Among 273 patients who showed pseudo-labyrinthine symptoms or signs, 28 patients were diagnosed cerebellar infarction on MRI between January 2003 and October 2006. Out of the 28 patients, 9 patients accompanying with focal neurologic symptoms or signs in early stage were excluded, and a retrospective analysis of total 19 patients was done through chart reviews. Using diffusion-weighted imaging, we divided 19 patients into two groups, AICA and PICA territory infarction. Clinincal features, outcome of audiologic and vestibular function test were compared between the groups. RESULTS: Among the 19 subjects, 10 were males and 9 were females, the mean age was 63.1+/-.0. On MRI, 5 (26.3%) subjects showed infarction in unilateral AICA territory, 14(73.7%) in unilateral PICA territory. In the patients with AICA territory infarction, audiological tests confirmed unilateral sensorineuronal hearing loss in all 5 subjects. On V-ENG, 4/5 (80%) demonstrated horizontal or mixed horizontal torsional spontaneous nystagmus, and 4/5 (80%) had a canal paresis to caloric stimulation. In several days of hospital stay, 3/5 (60%) showed new neurologic signs, facial numbness. In the patients with PICA infarction, there was no hearing change. On V-ENG, 12/14(85.7%) demonstrated horizontal or mixed horizontal torsional spontaneous nystagmus, and 7/14 (50%) had a canal paresis to caloric stimulation. In several days of hospital stay, 10/14 (71.4%) accompanied with cerebellar ataxia. CONCLUSION: Cerebellar infarction simulating unilateral vestibulopathy is more common than previously thought. Early recognition of the cerebellar infarction showing pseudo-vestibular symptom may allow specific management. Also taking into account that clinical features differ by infarction territory will assist in determining the patient's status of the disease.

Monostotic Fibrous Dysplasia of the Temporal Bone with Unilateral Vestibular Weakness and Sensorineuronal Hearing Loss

Fibrous dysplasia is an uncommon benign disorder of unknown etiology. The disease was first described by McCune and Albright in separate publications in 1937. The term, fibrous dysplasia was suggested by Lichtenstein in 1938. The disease has since been found to have 3 different variants: monostotic, polyostotic, and McCune-Albright syndrome. It is a slowly progressive bony disorder where normal bone is replaced by abnormal fibrosseous tissue. Involvement of fibrous dysplasia of the temporal bone is usually unilateral. The squama becomes thickened and the pneumatic system is obliterated. Because fibrous dysplasia shows a predilection for the facial and cranial bone, where it causes deformity and dysfunction. In this paper, we report a case of fibrous dysplasia of the temporal bone. We discuss the characterisitic features of this specific location of the disease, the differential diagnosis, and the treatment policy. We also address the issue of vertigo.

Introduction to Clinical Medicine Course for Teaching Basic Clinical Skills / 한국의학교육

BACKGROUND: One of major weakness in medical education in Korea is clinical skills has not been uniformly well taught during undergraduate period. To reinforce the basic clinical skill education, we developed introduction to clinical medicine(ICM) course In this study, we described the ICM course development process and the experience. METHODS: We performed comprehensive literature review related to ICM and doctoring curriculum. ICM/OSCE sub-commitee members discussed several time to develop the course. To assess the level of accomplishment of this course, we got feedback from 115 third year medical students by questionnaires. RESULTS: ICM was composed of 9 topics which covers the basic clinical skills. For each topic, three hours per week was allocated, one hour for didactic session and the other 2 hours for practical exercise. Standardized patients were used to teach interview skill. Most of students revealed history taking, abdominal examination, musculo-skeletal system, and interview skill session were valuable learning experience. However, for Gynecology and Pediatric session which were taught by mainly lectures, students evaluated them negatively. INTERPRETATION: This year, we focused on teaching basic clinical skills at ICM. However, our ultimate goal is to develop the ICM course which can allow the students to learn both the art and the science of Medicine.

Evaluation of Introduction to Clinical Medicine by Objective Structured Clinical Examination / 한국의학교육

BACKGROUND: OSCE was conducted to measure the immediate outcome of ICM. The measurement focused on basic clinical skills. METHODS: The subject of study was 115 third year medical students who took ICM course. The examination consisted of ten 5-minute stations with nine cases that represented commonly encountered problems in primary care. OSCE stations were duplicated into two sites. Therefore, same OSCE was performed six times in each sites. We evaluated the reliability of OSCE scores and compared the mean scores according to the examination sites and time sequences. Also, we got feedback from all participants by questionnaires. RESULTS: Mean of total OSCE score was 52.1. Cronbach alpha of total station was 0.559. For blood pressure check, lung physical examination, and neck mass physical examination station, there was a significant difference in mean scores as the time sequences(p<0.05). Both students and examiners evaluated the OSCE positively, and felt that OSCE was meaningful experience to prepare clinical skills. CONCLUSION: We can confirm that OSCE is a reasonable evaluation tool for ICM. However, further trials to develop the more reliable and valid examinations will be warranted.

Ultrastructural Changes of the Thymic Cortex of the Mouse on Age / 대한해부학회지

In this study, the structural components of thymic cortex were compared in aging process. Thymic tissues of 1 week, 8 weeks, 6 months, 12 months, 18 months and 24 months-old ICR mice were fixed in the 2.5% glutaraldehyde- 1% paraformaldehyde solution, and refixed in the 1% osmium tetroxide solution. Dehydrated tissue blocks were embedded in the araldite mixture. Ultrathin sections were stained with uranyl acetate and lead citrate solution. Results from the electron microscopic observations are as follow; 1. In the thymic cortex of 1 week old mice, epithelial reticular cells incompletely surrounded thymoblasts and thymocytes, resulting variable spaces between thymocyte and cytoplasm of epithelial reticular cells. 2. Microenvironments of the thymus of 8 weeks to 6 months old mice showed typical thymic structure, and thymocytes and thymoblasts were completely surrounded with epithelial reticular cells. 3. In the thymic cortex of a 12 months old mouse, many epithelial reticular cells contains vacuolated cytoplasm and apoptotic thymocytes. 4. Epithelial reticular cells of 18 months old mouse were shrunken, and intercellular spaces between them and thymocytes and/or thymoblasts are increased. Deep cortex shows activated macrophage and mature plasma cells with a well developed rough endoplasmic reticulum. 5. Epithelial reticular cells of a 24 months old mouse were shrunken, since decreased cytoplasmic volume and increased lipidic globules. Deep cortex showed many activated macrophages and mature plasma cells. Epithelial reticular cells showed increasing electron density in their cytoplasmic plates and lipomatous atropy on aging. In conclusion, on aging, the components of microenvironment of thymus are more or less involute for preventing immunological actions in the thymic parenchyme. The digestion of cellular material results in a accumulation of lipid within the cells. Morphological change of epithelial reticular cell were characterized by the prominent cytoplasmic vacuolization. The cortical and subcapsular epithelial cells exhibited a loss of the cytoplasmic processes in all animals except in the 6 months old animals. At the same time, the thinning of thymic cortex, alterations of epithelial reticular cells, more macrophages, and other cell elements were pronounced, which may well be correlated with the age involution of the thymus.

Comparison of Mechanical and Manual Ventilation with Jackson-Rees System in Pediatric Anesthesia / 대한마취과학회지

BACKGROUND: Manual ventilation in pediatric anesthesia limits the anesthesiologist's ability to manage patients suffering from unexpected problems. Although modified Mapleson D systems connected to ventilators have been used for controled ventilation of anesthetized infants and children, the complexity of factors affecting rebreathing within the Mapleson D circuit has resulted in a variety of recommendations for fresh gas flow and minute ventilation. The aim of this study was to devise a formula for ventilator settings which would provide normal tidal volume, respiratory rate, and minute ventilation without rebreathing during mechanical ventilation in pediatric anesthesia and compare this method to manual ventilation. METHODS: 56 infants and small children anesthetized with enflurane and nitrous oxide were studied. We have constructed a formula for ventilator settings which would generate a predictable normocapnia. PetCO2, PaCO2, SpO2, and SaO2 were measured during manual ventilation (control) and during mechanical ventilation. RESULTS: Mean PaCO2 with the mechanical ventilation was within normal range. PaCO2 was significantly lower (P<0.05) with the manual ventilation than with the mechanical ventilation. CONCLUSIONS: We conclude that our formula for ventilator settings can be safely and competently applied to mechanical ventilation with Jackson-Rees system in pediatric anesthesia.

Astigmatic Changes According to Incision Length After Sutureless Cataract Surgery

We analyzed an astigmatism and an uncorrected visual acuity in 235 eyes for 6 months following sutureless cataract surgery(167 eyes) with 5 mm(Group 1), 6 mm(Group 2), and 7 mm(Group 3) incision lengths at 2.5 mm posteriorly from the corneoscleral limbus, and shoelace sutured cataract surgery(68 eyes) with 7 mm(Group 4) incision length at 1 mm posteriorly from the corneoscleral limbus performed by one surgeon. In three groups of sutureless cataract surgery, the surgically induced corneal astigmatisms were stable after one month postoperatively, but decreasing the length of incision substantially reduced the astigmatic changes(p>0.05), the astigmatic swings(p>0.05) and the astigmatic ranges. In comparison to sutured cataract surgery with 7 mm incision length, sutureless cataract surgery with same incision length reduced the astigmatic changes(p0.05) was noted. In comparison to sutured catarct surgery with 7 mm incision length, suture less cataract surgery with same incision length had higher incidence of an uncorrected visual acuities of 20/40 or better(p0.05) and a better uncorrected visual acuity(p>0.05). And sutureless cataract surgery rather than sutured cataract surgery was associated with a lower surgically induced astigmatism(p<0.01), an earlier stability, and a better uncorrected visual acuity(p<0.01).

Corneal Astigmatic Changes by Temporal Incision or Oblique Incision in Sutureless Cataract Surgery

We analyzed postoperative astigmatic changes according to the location of incision in 129 eyes that sutureless cataract surgeries were performed. We followed up the astigmatic changes until six months postoperatively, and compared the results of two groups of which the one is the preoperative against-the-rule astigmatic cases with superior incisions and temporal incisions, the other is the preoperative oblique astigmatic cases with superior incisions and superotemporal incisions. In the preoperative against-the-rule astigmatic cases, postoperative astigmatic changes were shifted toward against-the-rule astigmatism(0.23 diopters) in superior incisions and toward with-the-rule astigmatism(0.20 diopters) in temporal incisions until 6 months following surgery(p0.05). Surgically induced astigmatisms were less in superotemporal incisions than superior incisions (p<0.01) and corneal astigmatisms were stabilized after one month postoperatively in both groups(p<0.05). These results demonstrated that surgically induced astigmatisms were decreased by the incision at steep axis, and in the cases of preoperative againstthe rule astigmatism, the preexisting astigmatisms were decreased by the temporal incisions.

Posterior Chamber Intraocular Lens Implantation in High Myopia

We evaluated pseudophakia in high myopic patients whose an axial lenght were 26mm and over. Cataract surgery was performed with ECCE and posterior chamber intraocular lens implantations from May 1986 to May 1991 on 69 patients (80 eyes). The results were as follows; 1. Most myopic patients were good candidates for posterior chamber intraocular lens implantation regardless of axial length. 2. Posterior chamber intraocular lens implantations in high myopia were a good refractive surgery. 3. The theoretical formula had better predictabilized than the empirical formula in apredictive accuracy.

Changes of Internal Jugular Venous Oxygen Content with Differences in Arterial CO2 Tension / 대한마취과학회지

The routine management of head injury includes hyperventilation to produce hypocapnis with arterial CO2 tension 25~30 torr. But a decrease in cerebral blood flow with hypocapnia may result in cerebral ischemia. Our study was to evaluate the change of cerebral blood flow during hyperventilation in halthane anesthesia. The jugular venous oxygen saturation(SjvO2), arterio-venous oxygen content difference(CaO2-CjvO2), and oxygen extraction ratio(O2ER) were used as criteria of cerebral ischemia with reduced cerebral blood flow. The results are as follows: 1) SjvO2 was lower in group 2(PaCO2=22.8torr) than group 1(PaCO2=30.3 torr). 2) CaO2-CjvO2 and O2ER were higher in Group 2 than group 1. 3) No more increased possibility of cerebral ischemia with reduced cerebral blood flow was observed Group 2 than group 1.

A Case of Arachnoid Cyst in the Middle Cranial Fossa

The authors report a case of arachnoid cyst arisen in the middle cranial fossa combined with intracystic hemorrhage. The pre-operative diagnosis was confused with chronic subdural hematoma. The post-operative final pathologic diagnosis was arachnoid cyst. The plain skull and C-T findings are illustrated. The light microscopic features of arachnoid cyst are presented. The brief description of the treatment and its prognosis are given.