A Comprehensive Analysis of the Association of Psoas and Masseter Muscles with Traumatic Brain Injury Using Computed Tomography Anthropometry

Objective@#: Psoas and masseter muscles are known markers of sarcopenia. However, the relative superiority of either muscle as a marker is unclear. Therefore, this study analyzed the two muscles in patients with a prognosis of traumatic brain injury (TBI). @*Methods@#: Patients with TBI visiting a regional trauma center between January 2017 and December 2018 were selected, and their medical records were reviewed. TBI patients with an abbreviated injury score (AIS) of 4 or 5 were selected. Patients with an AIS of 4 or 5 at the chest, abdomen, and extremity were excluded. Patients with a hospital stay of 1 to 2 days were excluded. Both muscle areas were measured based on the initial computed tomography. The psoas muscle index (PMI) and the masseter muscle index (MMI) were calculated by dividing both muscle areas by height in meters squared (cm2/m2). These muscle parameters along with other medical information were used to analyze mortality and the Glasgow outcome scale (GOS). @*Results@#: A total of 179 patients, including 147 males (82.1%), were analyzed statistically. The mean patient age was 58.0 years. The mortality rate was 16.8% (30 patients). The mean GOS score was 3.7. Analysis was performed to identify the parameters associated with mortality, which was a qualitative study outcome. The psoas muscle area (16.9 vs. 14.4 cm2, p=0.028) and PMI (5.9 vs. 5.1 cm2/m2, p=0.004) showed statistical differences between the groups. The PMI was also statistically significant as a risk factor for mortality in logistic regression analysis (p=0.023; odds ratio, 0.715; 95% confidence interval, 0.535–0.954). Quantitative analyses were performed with the GOS scores. Bivariate correlation analysis showed a statistically significant correlation between PMI and GOS scores (correlation coefficient, 0.168; p=0.003). PMI (p=0.004, variation inflation factor 1.001) was significant in multiple regression analysis. The masseter muscle area and MMI did not show significance in the study. @*Conclusion@#: Larger PMI was associated with statistically significant improved survival and GOS scores, indicating its performance as a superior prognostic marker. Further analyses involving a larger number of patients, additional parameters, and more precise settings would yield a better understanding of sarcopenia and TBI.

Systematic Preventable Trauma Death Rate Survey to Establish the Regionbased Inclusive Trauma System in a Representative Province of Korea

Background@#Trauma mortality review is the first step in assessing the quality of the trauma treatment system and provides an important basis for establishing a regional inclusive trauma system. This study aimed to obtain a reliable measure of the preventable trauma death rate in a single province in Korea. @*Methods@#From January to December 2017, a total of 500 sample cases of trauma-related deaths from 64 hospitals in Gyeonggi Province were included. All cases were evaluated for preventability and opportunities for improvement using a multidisciplinary panel review approach. @*Results@#Overall, 337 cases were included in the calculation for the preventable trauma death rate. The preventable trauma death rate was estimated at 17.0%. The odds ratio was 3.97 folds higher for those who arrived within “1–3 hours” than those who arrived within “1 hour.” When the final treatment institution was not a regional trauma center, the odds ratio was 2.39 folds higher than that of a regional trauma center. The most significant stage of preventable trauma death was the hospital stage, during which 86.7% of the cases occurred, of which only 10.3% occurred in the regional trauma center, whereas preventable trauma death was more of a problem at emergency medical institutions. @*Conclusion@#The preventable trauma death rate was slightly lower in this study than in previous studies, although several problems were noted during inter-hospital transfer; in the hospital stage, more problems were noted at emergency medical care facilities than at regional trauma centers. Further, several opportunities for improvements were discovered regarding bleeding control.

Systematic Preventable Trauma Death Rate Survey to Establish the Regionbased Inclusive Trauma System in a Representative Province of Korea

Background@#Trauma mortality review is the first step in assessing the quality of the trauma treatment system and provides an important basis for establishing a regional inclusive trauma system. This study aimed to obtain a reliable measure of the preventable trauma death rate in a single province in Korea. @*Methods@#From January to December 2017, a total of 500 sample cases of trauma-related deaths from 64 hospitals in Gyeonggi Province were included. All cases were evaluated for preventability and opportunities for improvement using a multidisciplinary panel review approach. @*Results@#Overall, 337 cases were included in the calculation for the preventable trauma death rate. The preventable trauma death rate was estimated at 17.0%. The odds ratio was 3.97 folds higher for those who arrived within “1–3 hours” than those who arrived within “1 hour.” When the final treatment institution was not a regional trauma center, the odds ratio was 2.39 folds higher than that of a regional trauma center. The most significant stage of preventable trauma death was the hospital stage, during which 86.7% of the cases occurred, of which only 10.3% occurred in the regional trauma center, whereas preventable trauma death was more of a problem at emergency medical institutions. @*Conclusion@#The preventable trauma death rate was slightly lower in this study than in previous studies, although several problems were noted during inter-hospital transfer; in the hospital stage, more problems were noted at emergency medical care facilities than at regional trauma centers. Further, several opportunities for improvements were discovered regarding bleeding control.

Ideal Time to Surgery for Acute Abdomen

Timing of surgery is important for prognosis. In patients with acute abdomen, the urgency means timing of surgery is even more important. However early emergency surgery is often logistically daunting because of constraints on resources such as operating room, supporting anesthesiologist, and nurses. Therefore it is worthwhile reviewing the timing of surgery in the patient with acute abdomen. The authors discuss the ideal time to surgery based on their experience and a review of the literature. For appendicitis and for peptic ulcer perforation, the authors recommend surgery within 24 hours from symptom onset. However, for other acute abdomen disease, evidence for a consensus is not as strong. If a surgeon faces a large number of emergent patients, if resources are limited, the surgeon must decide priorities for surgery. Therefore, an emergency triage system is needed, based on expert opinion and evidence. Although several triage systems are described in the literature, there is some controversy. If we follow a triage system, utilization of resources will be more efficient and acute care surgery might be performed within the ideal time.

Effect of surgical timing and outcomes for appendicitis severity

PURPOSE: This study was aimed to evaluate the effect of time of surgery for acute appendicitis on surgical outcomes to optimize the timing of appendectomies. METHODS: Medical records of patients who underwent an appendectomy were reviewed to obtain data on time of symptom onset, time of hospital presentation, and start times of surgery. Surgical findings were used to define appendicitis as either uncomplicated or complicated. The uncomplicated group included patients with simple, focal, or suppurative appendicitis, and the complicated group included patients with gangrenous, perforated appendicitis or periappendiceal abscess formation. The 2 groups were analyzed by age, sex, and time. RESULTS: A total of 192 patients were analyzed. The mean time from symptom onset to start of operation showed a significant difference between both groups (1,652.9 minutes vs. 3,383.8 minutes, P < 0.001). The mean time from hospital visit to start of operation showed no difference between both groups (398.7 minutes vs. 402.0 minutes, P = 0.895). Operating within 24 hours of symptom onset had a relative risk of 1.738 (95% confidence interval, 1.319-2.425) for complications. Operating more than 36 hours after symptom onset was associated with an increased risk of postoperative ileus and a longer hospital stay. CONCLUSION: Complicated appendicitis is associated with a delay in surgery from symptom onset rather than a delay at hospital arrival. Surgeons should take into account the time from symptom onset when deciding on the timing of appendectomy. We recommend that appendectomy be performed within 36 hours from symptom onset.

Left-sided appendicitis in a patient with situs inversus totalis / 대한외과학회지

Situs inversus totalis is a rare inherent disease in which the thoracic and abdominal organs are transposed. Symptoms of appendicitis in situs inversus (SI) may appear in the left lower quadrant, and the diagnosis of appendicitis is very difficult. We report a case of left-sided appendicitis diagnosed preoperatively after dextrocardia that was detected by chest X-ray, although the chief complaint of the patient was left lower-quadrant pain. The patient underwent an emergent laparoscopic appendectomy under the diagnosis of appendicitis after abdominal computed tomography (CT). In patients with left lower quadrant pain, if the chest X-ray shows dextrocardia, one should suspect left-sided appendicitis. A strong suspicion of appendicitis and an emergency laparoscopic operation after confirmation of the diagnosis by imaging modalities including abdominal CT or sonography can reduce the likelihood of misdiagnosis and complications including perforation and abscess. Laparoscopic appendectomy in SI was technically more challenging because of the mirror nature of the anatomy.

Free Floating Thrombus of the Aorta: An Unusual Cause of Peripheral Embolization

PURPOSE: Free-floating thrombus (FFT) of the aorta is very rare but has a high risk of distal embolization. While the necessity of treating such a condition is evident, the diagnostic and therapeutic modalities remain controversial. Thus, we reviewed seven cases of FFT of the aorta. METHODS: A retrospective study was performed usings even patients diagnosed with FFT of the aorta at the Catholic University of Korea between January 1999 and December 2008. We excluded those patients who had thrombi with concomitant atherosclerotic or aneurysmal aorta. RESULTS: The mean patient age was 59.6+/-13.6 years old. The male-to-female ratio was 3:4. Embolization to arteries of the extremities occurred in two patients and to visceral arteries in four patients. Of these seven patients, four were initially treated with anticoagulation, and two were initially treated with thrombectomy; one patient refused any kind of treatment. Of the four patients treated with anticoagulation, three experienced complete dissolution of the thrombi while anticoagulation proved ineffective in the remaining patient who subsequently underwent thrombectomy. In all of the three patients who had received thrombectomy, postoperative anticoagulation was employed. There was no recurrence of FFT of the aorta during the follow-up period. CONCLUSION: Were commend systemic anticoagulation with low molecular weight heparin (LMWH) as the first line of treatment for FFT of the aorta. If the thrombus persists or recurrent embolism occurs during anticoagulation therapy, surgery should be undertaken.

Clinical Significance of MMP-2, MMP-9 and HIF-1alpha Expression in Thyroid Micropapillary Cancer

PURPOSE: Papillary Thyroid Microcarcinoma (PTMC) is rapidly increasing due to increased interests in the public health care system and improvements in ultrasonographic instruments and fine-needle-aspiration technique. The aim of this study is to investigate relationships between clinicopathologic features and molecular markers of PTMC and to help in developing therapeutic strategies in PTMC. METHODS: Tissue samples from patients with 38 PTMC and 21 benign thyroid tumors that were operated on from Jan. 2006 to Nov. 2008 were used to make microarrays and immunohistochemical staining for ER-alpha, E-CD, VEGF, MMP-2, MMP-9, and HIF-1alpha were performed. Clinicopathologic features of each immunohistochemical staining group were analyzed retrospectively. RESULTS: There is no immunohistochemistry staining in cases with benign thyroid lesions. The expression rate of ER-alpha, E-CD, VEGF, MMP-2, MMP-9, and HIF-1alpha in PTMC group was 66%, 58%, 82%, 66%, 71% and 63%, respectively. Bilateral tumor was statistically significant (48.0% vs 7.7%, P=0.015) related to MMP-2(+) PTMC group than in MMP-2(-) group. Bilateral tumor (44.4% vs 9.1%, P=0.060) and lymphovascular invasion (25.9% vs 0%, P=0.084) seemed to have greater relation to MMP-9(+) PTMC group than to MMP-9(-) group, but there is no statistically significant difference. Bilateral tumor (50.0% vs 7.1%, P=0.012), lymph node metastasis (45.8% vs 0%, P=0.003) and lymphovascular invasion (29.2% vs 0%, P=0.033) were significantly related to HIF-1alpha (+) PTMC group compared to HIF-1alpha(-) group. CONCLUSION: Our findings suggest that MMP-2, MMP-9 and HIF-1alpha expression could be used as a prognostic marker in PTMC. Larger studies are needed to assess its prognostic value in PTMC.

Laparoscopic Splenectomy in a Case of Stable Blunt Abdominal Trauma

Splenic rupture is a frequent surgical emergency in blunt abdominal trauma patients. There are several treatment options, including conservative treatment, a partial splenectomy, splenorrhaphy, and a splenectomy for splenic injury. Although reports on the safety and the efficacy of an elective laparoscopic splenectomy are abundant in the literature, a laparoscopic splenectomy for a ruptured spleen has only been reported in a few cases. We report a case of a laparoscopic splenectomy in the patient with Grade III traumatic splenic injury. To our knowledge, this is the first report in which a laparoscopic splenectomy was performed in Korea for the treatment of a traumatic splenic injury.

Eosinophilic Enteritis Involving the Entire Intestinal Wall Presenting as Small Bowel Obstruction and Acute Abdomen

Eosinophilic enteritis is an uncommon disease that rarely manifests as an acute abdomen. A 50-year-old man visited our hospital and complained of epigastric and periumbilical pain. He reported direct and rebound tenderness over the periumbilical area. Laboratory examinations showed leukocytosis without eosinophilia. Plain abdominal radiography revealed air-fluid levels in the small intestine and computed tomography revealed concentric wall thickening in the small bowel and ascites in the pelvic cavity. We conducted an emergency operation and segmental resection of the jejunum was performed. Histologically, transmural, eosinophilic infiltration was observed. In patients with intestinal obstruction, even when presenting with an acute abdomen with no peripheral eosinophilia, eosinophilic enteritis should be included in the differential diagnosis.

Cardiac Toxicity in Patients with Antidepressant Intoxication

PURPOSE: Although cardiac toxicity is a key parameter of significant toxicity, in antidepressant intoxication, there are few studies on the cardiac toxicity of serotonin reuptake inhibitor and the intoxication with the new generation of antidepressants. The aim of this study is to investigate the relative cardiac toxicity of serotonin reuptake inhibitor and intoxication with the new generation of antidepressants as compared with that of tricyclic antidepressant intoxication. METHODS: We retrospectively reviewed the medical records of 109 antidepressant intoxicated patients who visited the Emergency Department from January, 2005 to December, 2009 to collect and analyze the demographic and clinical data. Sixteen patients were excluded. The enrolled seventy eight patients were classified into three groups: the tricyclic antidepressant group (TCA) (n=32), the selective serotonin reuptake inhibitor subgroup (SSRI) (n=28) and the new generation antidepressant subgroup (NGA) (n=18). RESULTS: The demographic and clinical data of the SSRI and NGA groups were not significantly different from that of the TCA group. The QRS duration of the SSRI subgroup (86.4+/-12.0 msec) and the NGA subgroup (91.8+/-11.9 msec) was not significantly different from that of the TCA group (90.0+/-13.5msec) (p=0.598). CONCLUSION: Intoxication with SSRI and the new generation antidepressants seemed to show significant cardiac toxicity, like what is seen in tricyclic antidepressant intoxication. Clinicians must pay attention to SSRI and new generation antidepressant intoxication.

Double Strand Break of DNA in Gastric Adenoma and Adenocarcinoma / 대한소화기학회지

BACKGROUND/AIMS: DNA double strand break (DSB) is one of the critical types of DNA damage. When unrepaired DSB is accumulated in the nucleus of the cells having mutations in such genes as p53, it will lead to chromosomal instability and further more to mutation of tumor-activating genes resulting in tumorogenesis. Some of malignant cancers and its premalignant lesions were proven to have DSB in their nuclei. The aim of this study was to define the differences in expression of 53BP1 and gamma-H2AX, the markers of DSB, among normal, gastric adenoma, and gastric adenocarcinoma tissues. METHODS: Tissue microarray was made with the tissues taken from 121 patients who underwent gastrectomy for gastric adenocarcinoma, and 51 patients who underwent endoscopic mucosal resection for gastric adenoma. Immunochemical stain was performed for the marker of DSB, 53BP1 and gamma-H2AX in the tissue microarray. The normal tissues were collected from histologically confirmed tissues with no cellular atypia obtained from the patients with gastric adenocarcinoma. RESULTS: In gastric carcinoma cells, 53BP1 and gamma-H2AX were highly expressed as compared to normal epithelial cells and gastric adenoma (p<0.01). There were no differences in the expression of 53BP1 and gamma-H2AX between normal epithelium and gastric adenoma. The expression of 53BP1 in the adenoma with grade II and III atypism was more elevated than in those with grade I atypism. The expression of 53BP1 and gamma-H2AX were not significantly different according to the clinicopathologic parameters in the patients with gastric adenocarcinoma. CONCLUSIONS: The DSB in DNA seems to be associated with the development of gastric adenocarcinoma, but does not affect the premalignant adenoma cells.

Comparative Study of Endoscopic Thyroidectomy: Total Thyroidectomy versus Near Total Thyroidectomy / 대한내분비외과학회지

PURPOSE: The aim of this study was to evaluate and compare the surgical outcomes of endoscopic total and near-total thyroidectomies in patients with thyroid cancer. METHODS: Between February 2000 and January 2009, among 387 patients who underwent endoscopic thyroidectomy in our hospital, we evaluated 50 patients who underwent endoscopic total or near-total thyroidectomy. Thirtyfive and 15 patients underwent endoscopic total thyroidectomy and near-total thyroidectomy, respectively. We analyzed the patients' clinicopathologic characteristics and post-operative complications between the two groups. RESULTS: The mean size of tumors was 1.08 cm (range, 0.1 ~3.5 cm) and the mean operative time was 192 minutes. Forty-nine tumors were papillary cancers and 1 tumor was a follicular cancer. Two patients in the endoscopic total thyroidectomy group underwent re-operation because of bleeding. In the near-total thyroidectomy group, one patient had transient hypocalcemia and one patient had temporary recurrent laryngeal nerve palsy. In the total thyroidectomy group, nine patients had transient hypocalcemia and one patient had temporary recurrent laryngeal nerve palsy. There was no statistical difference in the post-operative complicationrates between the two groups (P=0.254 for hypocalcemia and P=0.470 for injury to the recurrent laryngeal nerve). CONCLUSION: Based on our experience, endoscopic total thyroidectomy is a safe and feasible alternative to endoscopic near-total thyroidectomy.

Laparoscopic Totally Extraperitoneal Hernia Repair versus Open Lichtenstein Hernia Repair: Comparison of the Early Postoperative Outcomes and Complications / 대한내시경복강경외과학회지

PURPOSE: This study compared the postoperative outcomes and complications between laparoscopic totally extraperitoneal (TEP) hernia repair and open Lichtenstein hernia repair. METHODS: A total of 64 cases (30 cases by the TEP method and 34 cases by Lichtenstein repair) were enrolled in this study. The operative time, the hospital stay, the VAS score, the amount of analgesic used, the postoperative complications and recurrence were compared between the 2 methods. RESULTS: The mean operative time was 71 min for the TEP group, which was not significantly longer than that for the Lichtenstein group (66 min). The mean postoperative hospital stay was 3.7 days for the TEP group, which was significantly shorter than that for the Lichtenstein group (4.2) (p=0.035). The mean postoperative analgesic dose was 0.9+/-0.7 and 1.1+/-1.0 within 24 hours and 0.2+/-0.5 and 0.7+/-0.8 after 24 hours, respectively. The dose of analgesic after 24 hours was significantly lower for the TEP group (p=0.011), but the dose within 24 hours and the total dose was not significantly different. The VAS score was 2.3+/-1.0 and 2.6+/-0.9 at 12 hrs and 1.2+/-0.8 and 1.7+/-0.8 at 48 hrs, respectively. The VAS score was significantly lower for TEP group than that for the Lichtenstein group at 48 hrs (p=0.011), but there was no significant difference between the groups at 12 hrs. There was one recurrence in the TEP group. CONCLUSION: For the TEP group, the hospital stay was significantly shorter than that for the Lichtenstein group and this is maybe because the postoperative pain after 24 hours from the operation was less for the TEP group. Laparoscopic TEP repair may be performed efficiently with an acceptable operating time and a shorter hospital stay, as compared to open Lichtenstein hernia repair.

The Relatioships Between Tumor-related Gene Expression and Tumor Budding, Tumor Nodule and Lymph Node Extracapsular Extension in Colorectal Cancer

PURPOSE: Despite the similar lymph node metastasis observed in patients with advanced colorectal cancer (CRC), there was a different clinical outcome. The relationships between tumor-related gene expression and prognostic factors such as tumor budding, tumor nodule and extracapsular extension (ECE) of lymph nodes in patients with CRC remain unclear yet. The purpose of this study was to evaluate the relationship between expression of molecular markers such as vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), matrix metalloproteinases (MMPs) and E-cadherin and the tumor budding, tumor nodule and ECE of lymph nodes in patients with stage III CRC. METHODS: The tissue of 87 patients with stage III CRC were investigated for expressions of molecular markers using immunohistochemical methods. RESULTS: VEGF and MMP-9 expression in tumor tissue were positively associated with the colorectal cancer prognostic factors such as tumor budding, tumor nodule and extracapsular lymph node extension (P<0.05). But, MMP-2, EGF and E-cadherin expression were of no value with regard to them. CONCLUSION: Our results suggest that molecular markers, in particular VEGF and MMP-9, may provide additional prognostic information regarding tumor budding, ECE and tumor nodule.

The Combination Effect of Sodium Butyrate, 5-aza-2'-deoxycytidine on the Tumor Suppressive Activity in RKO Colorectal Cancer and MCF-7 Breast Cancer Cell Lines

PURPOSE: It is known that DNA methylation is associated with histone acetylation status in regulation of gene expression. In this study, we investigate the effect of demethylating agents and histone deacetylase (HDAC) inhibitor on the tumor suppression and the combined effect of two agents according to methylation status in human colon and breast cancer cell lines. METHODS: In this study, the RKO colorectal cancer cell line, MCF-7 breast cancer cell lines were considered. For each cell line, we used HDAC inhibitor sodium butyrate (SB), demethylating agent 5-aza-2'-deoxycytidine (5-aza-DC) and a combination of both agents. We estimated the percentage of cell survival using the XTT method and experimented with the augmentative effects of both agents. RESULTS: In RKO cell line in which most of the genes are methylated, 74% of cell survival was shown for 5-aza-DC treatment and 83% of cell survival for SB treatment. In MCF-7 cell line that approximately half of the genes are methylated, 82% cell survival was shown for 5-aza-DC treatment and 63% cell survival for SB treatment. We observed that the survival fraction is lower after the combined treatment of 5-aza-DC and SB than that of 5-aza-DC or SB alone in both RKO (53%) and MCF-7 (49%) cell lines (P<0.001). CONCLUSION: For highly methylated genes, 5-aza-DC is more effective on the tumor suppression than SB. On the other hand, if the methylation of the promoter region is at low density, SB is noted to be more effective than 5-aza-DC. Furthermore, the combined treatment of 5-aza-DC and SB is more effective than using each agent alone.

The Role of Abdomen-pelvis CT for the Diagnosis of Appendicitis

PURPOSE: We wanted to evaluate the value of intravenous contrast enhanced abdomen-pelvis computed tomography (CT) for diagnosing acute appendicitis and we wanted to determine which patients groups will benefit from preoperative CT. METHODS: Between January and June 2006, the medical records of 354 patients who had clinically suspected acute appendicitis were retrospectively reviewed. Appendectomy was performed in 260 patients and CT was conducted in 108 patients of the 260 patients. The 5mm slice CT scans were evaluated for the presence of appendicitis. The sensitivity, specificity and accuracy of CT were calculated. The negative appendectomy rate (NAR) was compared between the patients with CT scans and those without CT scans. Furthermore, the patients were classified into the children and adults groups and the male and female groups and the differences of the NARs were analyzed for each group. RESULTS: The sensitivity, specificity and accuracy were 95%, 93% and 94%, respectively. The NAR was lower for the patients with a CT scan (12%) compared to 27% for those patients without CT scans (P=0.002). The difference of the NAR between the preoperative CT group and the without CT group was statistically significant for the female (P=0.004) and adult groups (P=0.012) (14% vs 36%, 11% vs 26%, respectively). CONCLUSION: Preoperative intravenous contrast enhanced abdomen-pelvis CT was effective in reducing the negative appendectomy rate in patients who were suspected of having acute appendicitis. Especially, the adults and women benefit more from CT scanning and they had a significantly lower negative appendectomy rate than the children and men, respectively.

Rectal Arteriovenous Malformation Misdiagnosed as Intussusception

The rare cause of lower gastrointestinal bleeding is angiodysplasia. Angiolysplasia is most common in the right colon, but it can be found throughout the whole gastrointestinal tract. The main lesion of angiodysplasia is located at the submucosal layer. So, it is sometimes very difficult to search for the focus of bleeding via laparotomy or colonoscopy. We recently experienced a case of rectal arteriovenous malformation that was misdiagnosed as intussusception. A 57-year-old man visited the emergency room because of abrupt anal bleeding and low abdominal pain, and this was the third episode he'd experienced during the past 20 years. Sigmoidoscopy and abdominal CT revealed that his rectum was obstructed with a dark black colotuberant mass, which was suggestive of ischemic intussusception. We performed emergency laparotomy and we found an extremely swollen rectum with surrounding hematoma instead of intussusception. We performed low anterior resection and colo-anal anastomosis with ileostomy. The final pathologic diagnosis showed that the protuberant mass was a hematoma in the submucosal layer, and this developed by bleeding from an arteriovenous malformation in the rectum.

Clinical Findings of Appendiceal Mucocele

PURPOSE: A mucocele of the appendix is an uncommon pathology, representing 0.2% to 0.3% of all appendix specimens. It is often diagnosed clinically as a result of its ability to cause signs and symptoms similar to those of acute appendicitis. If it is asymptomatic, it is often detected as an incidental finding during ultrasonography, computed tomography, radiographic examination of the gastrointestinal tract, or laparotomy. The purpose of this study was to identify the clinical features of mucocele of the appendix. METHODS: We describe 35 cases of mucocele of the appendix diagnosed at Uijeongbu St. Mary's hospital between January 1993 and December 2006. We analyzed demographic, clinical, and pathologic data of all the cases. RESULTS: A total of 12 males and 13 females with mean age of 54.7+/-14.9 years are described. The peak incidence occurred in the seventh decade (34.3%). Sixteen patients presented with symptoms and signs similar to those found in acute appendicitis. Ten patients complained of a palpable mass, 2 patients complained of non-specific abdominal pain, and 7 patients were asymptomatic. Fourteen cases were diagnosed preoperatively, and 3 cases were discovered incidentally. Pathologic examination revealed mucosal hyperplasia in 20% of the cases, cystadenoma in 71%, and cystadenocarcinoma in 9%. The mean age of cystadenocarcinoma patients was older than the mean age of mucosal hyperplasia patients, and the diameter of the appendix was larger in cystadenoma patients than in mucosal hyperplasia patients. CONCLUSION: The preoperative diagnosis of appendiceal mucocele is very important to make in order to facilitate treatment planning and avoid inadvertent rupture of the mucocele during operation. We recommend more diagnostic studies in cases of suspected mucocele. Mucocele of the appendix must be included in the differential diagnosis of patients with pain in the right iliac fossa, patients older than 40 years of age, patients suffering from long-term symptoms, and patient with a palpable mass in the right iliac fossa.

Splenic Infarction Caused by Vivax Malaria

Splenic infarction caused by malaria is a rare complication and this is mostly caused by plasmodium falciparum. We report here on a 38 year-old female patient who developed symptomatic splenic infarction that was caused by vivax malaria. She presented with fever and left upper quadrant pain. Computed tomography showed multiple low density areas in the spleen, and the peripheral blood smear revealed plasmodium vivax infestation. We examined for other causes of splenic infarction, but all were negative. This is just the second report of symptomatic splenic infarction that was caused by vivax malaria only. Unlike the previous case, the levels of D-dimer and fibrinogen degradation factor were elevated. This may be related with the hypercoagulable state caused by malaria. Treatment was conservative and the further course was uneventful.