Renal Tubular Damage Marker, Urinary N-acetyl-β-D-Glucosaminidase, as a Predictive Marker of Hepatic Fibrosis in Type 2 Diabetes Mellitus

Background@#Non-alcoholic steatohepatitis is closely associated with the progression of diabetic kidney disease (DKD) in type 2 diabetes mellitus (T2DM). We investigated whether urinary N-acetyl-β-D-glucosaminidase (u-NAG), an early renal tubular damage biomarker in DKD, could be related to the degree of hepatic fibrosis in patients with T2DM. @*Methods@#A total of 300 patients with T2DM were enrolled in this study. Hepatic steatosis and fibrosis were determined using transient elastography. The levels of urinary biomarkers, including u-NAG, albumin, protein, and creatinine, and glucometabolic parameters were measured. @*Results@#Based on the median value of the u-NAG to creatinine ratio (u-NCR), subjects were divided into low and high u-NCR groups. The high u-NCR group showed a significantly longer duration of diabetes, worsened hyperglycemia, and a more enhanced hepatic fibrosis index. A higher u-NCR was associated with a greater odds ratio for the risk of higher hepatic fibrosis stage (F2: odds ratio, 1.99; 95% confidence interval [CI], 1.04 to 3.82). Also, u-NCR was an independent predictive marker for more advanced hepatic fibrosis, even after adjusting for several confounding factors (β=1.58, P<0.01). @*Conclusion@#The elevation of u-NAG was independently associated with a higher degree of hepatic fibrosis in patients with T2DM. Considering the common metabolic milieu of renal and hepatic fibrosis in T2DM, the potential use of u-NAG as an effective urinary biomarker reflecting hepatic fibrosis in T2DM needs to be validated in the future.

Data Configuration and Publication Trends for the Korean National Health Insurance and Health Insurance Review & Assessment Database

Background@#Big data reports related to diseases and health care for the Korean population have been published since the National Health Insurance Service (NHIS) and the Health Insurance Review & Assessment (HIRA) Service provided limited open access to their databases. Here, we reviewed the structure, content, and means of using data from the National Health Insurance (NHI) system for the benefit of Korean researchers and presented the latest publication trends in Korean healthcare data procured from the NHI and HIRA databases. @*Methods@#Since 2013, researchers have been able to obtain nationwide population-based studies using the NHI and HIRA databases of the insured. We searched publications using the NHI and the HIRA databases between 2013 and 2019 retrieved from PubMed. @*Results@#The NHI and HIRA databases provide nationwide population-based data. The total number of publications from 2014 to 2019 using NHI and HIRA databases is 2,541 and 655, respectively. A total of 5,465 endocrinology-related studies were performed during 2014 to 2019. @*Conclusion@#The NHIS and HIRA databases have provided tools for guidelines to approach world-leading population-based epidemiology and disease research.

Paraplegia after celiac plexus neurolysis in a patient with pancreatic cancer: A case report and literature review

A 65-year-old male patient underwent C-arm fluoroscopy-guided bilateral celiac plexus neurolysis to relieve peritoneal seeding-related pain associated with pancreatic cancer. Following confirmation of spreading, and no intravascular injection of contrast media, 7.5 ml of 0.25% chirocaine was injected in each side. The pain subsided after the block, with no motor or sensory deficits. Subsequently, celiac plexus neurolysis with 99.8% alcohol was performed using a posterolateral approach under fluoroscopic guidance. The patient was instructed to maintain a prone position for 2 hours while the procedure was performed. Approximately 4 hours later, the patient experienced paralysis of both lower extremities and hypoesthesia. Emergent magnetic resonance imaging of the thoracic and lumbar spine revealed gray matter signal change in the cord and conus medullaris at the T10-L1 level, and decreased perfusion at the T11-T12 vertebral bodies, suggesting spinal cord infarction. The patient remained paraplegic until his death 24 days later.

Association between Serum Gamma-Glutamyltransferase and Prevalence of Metabolic Syndrome Using Data from the Korean Genome and Epidemiology Study

BACKGROUND: The aim of this study was to determine whether there is a positive correlation between gamma-glutamyltransferase (GGT) levels and the prevalence of metabolic syndrome and whether GGT can be used as an easily checkable metabolic index using data from the large-scale Korean Genome and Epidemiology Study (KoGES).METHODS: We obtained data of 211,725 participants of the KoGES. The collected data included age, sex, height, weight, waist circumference, and various biochemical characteristics, including serum GGT levels. The data of study participants who ingested more than 40 g/day of alcohol and who were diagnosed with metabolic syndrome at baseline was excluded. We analyzed the prevalence of metabolic syndrome according to GGT quartiles in both genders.RESULTS: The GGT level was significantly higher in subjects with metabolic syndrome compared to normal subjects (37.92±48.20 mg/dL vs. 25.62±33.56 mg/dL). The prevalence of metabolic syndrome showed a stepwise increase with GGT quartiles in both male and female subjects. Compared to the lowest GGT quartile, the odds ratio was 1.534 (95% confidence interval [CI], 1.432 to 1.643), 1.939 (95% CI, 1.811 to 2.076), and 2.754 (95% CI, 2.572 to 2.948) in men and 1.155 (95% CI, 1.094 to 1.218), 1.528 (95% CI, 1.451 to 1.609), and 2.022 (95% CI, 1.921 to 2.218) in women with increasing GGT quartile. The cutoff value of GGT predicting risk of metabolic syndrome was 27 IU/L in men and 17 IU/L in women.CONCLUSION: We suggested that GGT could be an easily checkable marker for the prediction of metabolic syndrome.

Characteristics Influencing the Occurrence of Respiratory Medical Device-related Pressure Ulcers in the Pediatric Intensive Care Unit

PURPOSE: This prospective study was conducted to determine the incidence and related characteristics of respiratory medical device-related pressure ulcers (MDRPU) in children admitted to a pediatric intensive care unit (PICU). METHODS: The participants were 184 children who were admitted to the PICU of P University Hospital from April 2016 to January 2017. Data were collected on the occurrence of respiratory MDRPU and characteristics regarding the application of respiratory medical devices. RESULTS: Respiratory MDRPU occurred in 11.9% of participants (58.3%: stage I ulcers, 37.5%: mucosal ulcers). The devices associated with respiratory MDRPU were endotracheal tubes (54.2%), high-flow nasal cannulas (37.5%), and oximetry probes (8.3%). Respiratory MDRPU associated with an endotracheal tube were significant differences according to the site and strength of fixation, the use of a bite block and adhesive tape, skin dryness, and edema. In high-flow nasal cannulas, significant differences were found according to the site of fixation, immobility after fixation, and skin dryness. CONCLUSION: The occurrence of respiratory MDRPU is significantly affected by the method and strength of fixation, as well as skin dryness and edema. Therefore, appropriate consideration of these factors in nursing care can help prevent respiratory MDRPU.

Long-Term Experience of Sperm Cryopreservation in Cancer Patients in a Single Fertility Center

PURPOSE: Sperm cryopreservation before cancer treatment is the most effective method to preserve the fertility of male patients. We present our 21 years experience with sperm cryopreservation for cancer patients, including an examination of semen quality, the current status of cryopreserved sperm, and the rate of sperm use for assisted reproductive technology (ART). MATERIALS AND METHODS: A total of 721 cancer patients at Fertility Center of CHA Gangnam Medical Center successfully performed sperm cryopreservation for fertility preservation from January 1996 to December 2016. Medical chart review was used to analyze patient age, marital status, cancer type, semen volume, sperm counts and motility, length of storage, and current banking status. RESULTS: The major cancers of the 721 patients were leukemia (28.4%), lymphoma (18.3%), testis cancer (10.0%). The mean age at cryopreservation was 27.0 years, and 111 patients (15.4%) performed sperm cryopreservation during or after cancer treatment. The mean sperm concentration was 66.7±66.3 ×106/mL and the mean sperm motility was 33.8%±16.3%. During median follow-up duration of 75 months (range, 1–226 months), 44 patients (6.1%) used their banked sperm at our fertility center for ART and 9 patients (1.2%) transferred their banked sperm to another center. The median duration from cryopreservation to use was 51 months (range, 1–158 months). CONCLUSIONS: Sperm cryopreservation before gonadotoxic treatment is the most reliable method to preserve the fertility of male cancer patients. Sperm cryopreservation should be offered as a standard of care for all men planning cancer therapy.

Subcapsular Hepatic Hematoma after Endoscopic Retrograde Cholangiopancreatography / 대한내과학회지

Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool for the diagnosis and management of diseases of the pancreas and biliary tract. However, ERCP has a high risk of procedure-related complications compared with other endoscopic procedures performed in the upper gastrointestinal tract. The most common complications are pancreatitis, cholangitis, hemorrhage, and perforation. Extraluminal hemorrhagic complications after ERCP are relatively rare but potentially life threatening and should be identified and treated immediately. We report a case of subcapsular hepatic hematoma after guidewire injury during ERCP in a 64-year-old woman with choledocholithiasis who had undergone ERCP with guidewire-assisted papillotomy for stone extraction. Although subcapsular hepatic hematoma is a very rare complication after ERCP, it should be considered in the differential diagnosis of patients complaining of abdominal pain after ERCP.

The Recurrence Rate of Graves' Disease among Patients with Subclinical Thyrotoxicosis after Initial Remission with Antithyroid Agents

BACKGROUND AND OBJECTIVES: The recurrence rate of patients with Graves' disease (GD) is estimated to be 50-55% after withdrawal of antithyroid drug therapy, and relapse is frequent in the first year after discontinuing the medication. Follow-up examination of these patients frequently reveals laboratory findings consistent with subclinical thyrotoxicosis in the first year after stopping the antithyroid agents. We investigated the risk of recurrence of GD among patients with resurfacing subclinical thyrotoxicosis state after remission of initial GD with antithyroid treatments. MATERIALS AND METHODS: We reviewed the patients diagnosed with GD who visited the Department of Endocrinology at two tertiary medical centers: Wonju Severance Christian Hospital and Gangneung Asan Hospital. We enrolled patients whose GD was completely treated after initial treatment with antithyroid agents who then developed subclinical thyrotoxicosis after discontinuation of antithyroid agents. RESULTS: We reviewed a total of 44 patients (29 females, 15 males; age, 48.93±18.04; range, 17-85 years). The recurrence rate was 27.3% (12/44 patients), and recurrence occurred 3 months to 12 months later resurfacing of subclinical thyrotoxicosis. Patients with recurred GD was significantly older than non-recurred patients (44.63±17.75 years vs. 58.58±15.48 years, p=0.02). Other clinical parameters measured at the time of initial diagnosis were not different between the two groups. CONCLUSION: The recurrence rate of GD in patients with resurfacing subclinical thyrotoxicosis after initial remission of the disease was less than 30%. A close monitoring is recommended in these subgroup patients, especially in older patients.

A Case of Duodenal Diverticulitis / 대한소화기내시경학회지

Duodenal diverticulitis is difficult to diagnose because it can mimic other common diseases such as cholecystitis and perforated ulcer. Recently, we experienced a rare case of duodenal diverticulitis that was initially suspected on abdominal computed tomography as focal pancreatitis. Although duodenal diverticulitis has been increasingly recognizable before surgery, with the advent of multi-detector computed tomography, misdiagnosis remains problematic since duodenal diverticulitis is commonly not considered in the differential diagnosis of acute abdominal pain. We have to consider this rare disease entity because delayed diagnosis might be a cause of substantial morbidity and mortality.

A Case of Early Bile Duct Cancer Arising from Villous Adenoma in Choledochal Cyst / 대한소화기학회지

Choledochal cyst is an uncommon premalignant anomaly. The morphology and pathogenesis of the premalignant lesion of cholangiocarcinoma arising from the choledochal cyst has not been well described. Herein, we report a rare case of bile duct adenoma arising from choledochal cyst with anomalous union of pancreaticobiliary duct (AUPBD). 50-year-old woman was admitted to our hospital with the complaint of epigastric pain. She had received common bile duct (CBD) exploration and choledocholithotomy and cholecystectomy 3 months earlier under the diagnosis of multiple CBD stones. Intraoperalive cholangiogram was not remarkable except CBD dilatation at that time. Endoscopic retrograde cholangiopancreatography revealed choledochal cyst with AUPBD and round filling defect which disappeared easily on the balloon cholaniogram. On magnetic resonance cholangiopancreatography, the filling defect was confirmed as 2 cm polypoid mass attached to the distal bile duct wall. At laparotomy, a soft whitish mass was palpable on the lower CBD. On histological examination, adenoma with focal carcinoma change arising from choledochal cyst was diagnosed.

A Case of Anti-LKM 1 Positive Autoimmune Hepatitis Accompanied by Systemic Lupus Erythematosus / 대한소화기학회지

Overlap of autoimmune hepatitis and systemic lupus erythematosus (SLE) is a comparatively rare condition. Although both autoimmune hepatitis and SLE can share common autoimmune features such as polyarthralgia, hypergammaglobulinemia and positive ANA, it has been considered as two different entities. We report a case of anti-LKM1 positive autoimmune hepatitis who developed SLE two years later. The presence of interface hepatitis with lymphoplasma cell infiltrates and rosette formation points to the autoimmune hepatitis rather than SLE hepatitis. Autoimmune hepatitis is infrequently accompanied by SLE, therefore, it could be recommended to investigate for SLE in patients with autoimmune hepatitis.

A Case of Diphyllobothrium latum Infection in a Patient with Abdominal Pain / 대한소화기학회지

The growing popularity of eating raw fish has resulted in increase of certain human parasitic infection, such as diphyllobothriasis. Even though, upper and lower gastrointestinal endoscopy reveal no specific abnormality, if a patient complains of persistent abdominal pain, we should consider the possibility of parasitic infection. Careful history taking and stool examination can avoid further invasive study. We report a case of Diphyllobothrium latum infection in a patient with vague abdominal pain who showed normal finding on endoscopy.

A case of recurred gastric dysplasia associated with eosinophilic gastroenteritis / 대한내과학회지

The association of malignant tumors and peripheral eosinophilia or tissue eosinophilic infiltration has been uncommonly described. Moreover, a recent study has demonstrated some gastric cancers can express eosinophilic chemotactic factor. Interestingly, we recently experienced a case of recurrent eosinophilic gastroenteritis with relapsing gastric dysplasia. It is suggested that gastric dysplasia can also produce eosinophilic chemotactic factors and eosinophilic gastroenteritis can develop with recurred dysplasia. In this patient, eosinophilia served as an indicator of disease activity or as a marker. Eosinophilia may represent an important disease marker with prognostic significance and may rarely cause disease on its own.

A Case of Sarcomatoid Hepatocellular Carcinoma in a Young Female without Risk Factor / 대한소화기학회지

A previously healthy 22-year-old woman was admitted with a complaint of right upper quadrant abdominal pain for 2 weeks. Her past history was not remarkable. On admission, HBsAg and anti-HCV were negative and alpha-FP was within normal range. Abdominal sonography and CT showed a mass in liver measuring 10 11 cm with features of central necrosis and hemorrhage. On 6th hospital day, hemoperitoneum developed suddenly. She underwent emergency laparotomy and trisegmentectomy. Intraoperative finding revealed a hemoperitoneum with a tumor filled with liquefied necrotic tissues. Microscopically, the tumor was mostly composed of pleomorphic spindle cells with abundant anastomosing vascular channels and partly composed of tumor cells with trabecular arrangement. On immunohistochemical staining, tumor cells reacted with cytokeratin and vimentin, while CD34 and hepatocyte staining revealed negative. She died 2 months after the operation. We report a case of rapidly deteriorated primary sarcomatoid hepatocellular carcinoma in a young female without any risk factor.

A Case of Lymphoepithelial Cyst of the Pancreas Showing Characteristic Findings on Endoscopic Ultrasonography / 대한소화기내시경학회지

Lymphoepithelial cyst of the pancreas is a rare benign cystic tumor which is histologically characterized by cyst containing keratin, lined by mature squamous epithelium surrounded by lymphoid tissue, often with prominent follicles. Cystic lesions of the pancreas are more often detected because sensitive abdominal imaging tests are used for multiple indications, but preoperative differential diagnosis is difficult despite the advancements of imaging technologies. We herein report a case of lymphoepithelial cyst incidentally found on routine abdominal ultrasonography which showed characteristic findings on endoscopic ultrasonography preoperatively and discuss the radiologic features of lymphoepithelial cyst.

A Case of Hydrogen Peroxide Induced Proctocolitis / 대한소화기내시경학회지

Hydrogen peroxide is commonly used for cleansing superficial wounds because of its antimicrobial action attributed to oxidizing capacity. In the past, hydrogen peroxide was used for the management of meconium ileus and fecal impaction because liberated oxygen tend to break up impaction and initiate peristaltic reflux. During 1980s, hydrogen peroxide was also introduced for disinfection of endoscope but this stronger solution has a caustic action. Several authors reported hydrogen peroxide induced colitis. We report a case of hydrogen peroxide induced chemical colitis in a 28-year-old man who complained bloody stools and lower abdominal pain after introducing hydrogen peroxide solution into the rectum to relieve rectal bleeding. His symptoms were improved with conservative treatment.

The Effects of Music on Maternal Anxiety and the Evaluation of Explicit and Implicit Memory during Cesarean Section / 대한마취과학회지

BACKGROUND: Music is widely used to help a patient relax, and divert their attention from unpleasant and stressful situations. In addition, it eliminates the noise in the operating room. A light level of general anesthesia for a cesarean section is usually applied to the mother to improve the fetal safety. Therefore, there is an increased incidence of maternal explicit and implicit memory with the bispectral index (BIS) monitoring. METHODS: Fifty patients undergoing a cesarean section under general anesthesia were allocated randomly to either a control group (group 1) or a music group (group 2). Patients in group 2 listened to music with a headphone during the procedure. The blood pressure, heart rate, intraoperative awareness, postoperative explicit and implicit memory and the plasma cortisol level were assessed. RESULTS: The systolic blood pressure and heart rate were significantly lower in group 2 than group 1 at 1 minute before intubation and 5 minutes after extubation (P <0.05). The BIS value were significantly lower in group 2 than group 1 at 1 minute after intubation and 10 minutes after delivery (P <0.05). The hit ratios of the implicit of memorial test were significantly higher in the group 2 (2.4 +/- 0.7) than in group 1 (1.6 +/- 0.4) (P <0.05). The hits of the implicit memorial test had no corresponding BIS value (P <0.05). The plasma cortisol level was significantly higher group 1 than in group 2 at 30 minutes after intubation and 10 minutes after arriving at the recovery room (P <0.05). CONCLUSIONS: It was found that the music played to the mother during a cesarean section under general anesthesia decreased the anxiety and stress response, and this technique may help protect patients from unwanted explicit and implicit memory.

The Effects of Intravenous Anesthetics on Human Cytomegalovirus Infection / 대한마취과학회지

BACKGROUND: Reactivation of human cytomegalovirus (HCMV) from latency is a frequent complication of organ transplantation, and the molecular mechanism by which this occurs is unknown. Previous studies have shown that allogenaic transplantation combined with immunosuppression may be required to achieve complete reactivation in vivo and many anesthetics have wide range immunomodulatory properties. HCMV infection of endothelial cells plays an important role in the establishment of latency and persistence, which appears critical for the maintenance of HCMV within the host. METHODS: We compared the effects of intravenous anaesthetics (propofol, thiopental, and ketamine) on the susceptability of endothelial cells to HCMV infection by indirect immunofluorescent assay at 48 hour postinfection and we also have investigated the time course of luciferase gene expression in human umbilical vein endothelial cell (HUVEC) infected with recombinant HCMV. RESULTS: Treatment with anesthetics after HCMV strain Towne inoculation did not increase HUVEC susceptibility to HCMV infection by indirect immunofluorescent assay. Treatment of HUVEC with propofol, thiopental, and ketamine after the recombinant virus inoculation had no significant effects on the level of the late genes expression. CONCLUSIONS: Intravenous anesthetics (propofol, thiopental, and ketamine) did not increase the susceptability of endothelial cells to HCMV infection at plasma concentrations. Further studies are required to evaluate higher anesthetic concentration which may increases the susceptability of HUVEC to HCMV infection without cell destruction.

What is the Optimal Dosage of Alfentanil Required to Attenuate Hemodynamic Change to Tracheal Intubation during Induction with Propofol? / 대한마취과학회지

BACKGROUND: Laryngoscopy and tracheal intubation may cause hemodynamic changes, such as hypertension and tachycardia. Moreover, opioids are the most widely used drugs for hemodynamic stability. The purpose of this study was to determine the optimal dosage of alfentanil required to attenuate hemodynamic changes during anesthesia induction with propofol. METHODS: 120 ASA class 1-2 patients, scheduled for elective surgery, were divided randomly into 6 groups. Anesthesia was induced with propofol (2microgram/kg) followed by rocuronium (0.9microgram/kg). The control group received no alfentanil, and the study groups received 5, 10, 15, 20, or 25microgram/kg of alfentanil, respectively. Systolic blood pressure, mean arterial blood pressure, diastolic blood pressure and heart rate were measured preinduction (base), after propofol induction, immediately before & after intubation, and 1, 2, 3, 4, 5 minutes after intubation, respectively. RESULTS: After intubation, the increased heart rate and blood pressure were higher in the control and A5 groups, and this increased heart rate was not suppressed in the A10 group. The incidences of bradycardia and hypotension were also higher in the A20, and A25 groups. CONCLUSIONS: When anesthesia is induced with propofol, we suggest that the dosage of alfentanil for attenuating hemodynamic change during tracheal intubation be about 15microgram/kg.

A case of ruptured infected aneurysm of abdominal aorta caused by septic salmonellosis / 대한내과학회지

Salmonella infected aneurysm of aorta is one of the local complications by systemic salmonellosis. We have experienced a case of the rupture of infected abdominal aortic aneurysm in 47-year old man. He was admitted because of 39degrees C fever, abdominal pain, back pain of 7 day's duration. Diabetes mellitus had been diagnosed previously, but not managed. Abdominal CT scans showed aneurysmal dilatation with periaortic air bubbles and severe atherosclerotic change of abdominal aorta from renal hilum to the iliac bifurcation level. Blood cluture yielded Salmonella group B strains. He was treated with intravenous ceftriaxone, metronidazole, ciprofloxacin. On the seventh hospital day, the patient showed sign of shock with blood pressure 80/60 mmHg and comatous conciousness. Abdominal CT scans revealed the rupture of infected aneurysm of abdominal aorta just superior to the iliac artery bifurcation. The patient had not underwent surgery, then he was expired.