Non-Alcoholic Fatty Liver Disease with Sarcopenia and Carotid Plaque Progression Risk in Patients with Type 2 Diabetes Mellitus

Background@#We aimed to evaluate whether non-alcoholic fatty liver disease (NAFLD) with or without sarcopenia is associated with progression of carotid atherosclerosis in patients with type 2 diabetes mellitus (T2DM). @*Methods@#We investigated 852 T2DM patients who underwent abdominal ultrasonography, bioelectrical impedance analysis, and carotid artery ultrasonography at baseline and repeated carotid ultrasonography after 6 to 8 years. NAFLD was confirmed by abdominal ultrasonography, and sarcopenia was defined as a sex-specific skeletal muscle mass index (SMI) value <2 standard deviations below the mean for healthy young adults. SMI was calculated by dividing the sum of appendicular skeletal mass by body weight. We investigated the association between NAFLD with or without sarcopenia and the progression of carotid atherosclerosis. @*Results@#Of the 852 patients, 333 (39.1%) were classified as NAFLD without sarcopenia, 66 (7.7%) were classified as sarcopenia without NAFLD, and 123 (14.4%) had NAFLD with sarcopenia at baseline. After 6 to 8 years, patients with both NAFLD and sarcopenia had a higher risk of atherosclerosis progression (adjusted odds ratio, 2.20; P<0.009) than controls without NAFLD and sarcopenia. When a subgroup analysis was performed on only patients with NAFLD, female sex, absence of central obesity, and non-obesity were significant factors related to increased risk of plaque progression risk in sarcopenic patients. @*Conclusion@#NAFLD with sarcopenia was significantly associated with the progression of carotid atherosclerosis in T2DM patients.

Operational Definition Identifying Osteoporotic Vertebral Fractures in the Claims Database

Background@#We analyzed the International Classification of Diseases, 10th edition (ICD-10) diagnostic codes, procedure codes, and radiographic image codes for vertebral fracture (VF) used in the database of Health Insurance Review and Assessment Service (HIRA) of Korea to establish a validated operational definition for identifying patients with osteoporotic VF in claims data. @*Methods@#We developed three operational definitions for detecting VFs using 9 diagnostic codes, 5 procedure codes and 4 imaging codes. Medical records and radiographs of 2,819 patients, who had primary and subordinated codes of VF between January 2016 and December 2016 at two institutions, were reviewed to detect true vertebral fractures. We evaluated the sensitivity and positive predictive value (PPV) of the operational definition in detecting true osteoporotic VF and obtained the receiver operating characteristic (ROC) curve. @*Results@#Among the 2,819 patients who had primary or secondary diagnosis codes for VF, 995 patients satisfied at least one of the criteria for the operational definition of osteoporotic VF. Of these patients, 594 were judged as having true fractures based on medical records and radiographic examinations. The sensitivity and PPV were 62.5 (95% confidence interval [CI], 59.4–65.6) and 59.7(95% CI, 56.6–62.8) respectively. In the receiver operating characteristic analysis, area under the curve (AUC) was 0.706 (95% CI, 0.688–0.724). @*Conclusion@#Our findings demonstrate the validity of our operational definitions to identify VFs more accurately using claims data. This algorithm to identify VF is likely to be useful in future studies for diagnosing osteoporotic VF.

Performance Evaluation of the Beckman Coulter DxN VERIS Hepatitis B Virus (HBV) Assay in Comparison With the Abbott RealTime HBV Assay

The detection and quantification of hepatitis B virus (HBV) DNA plays an important role in diagnosing and monitoring HBV infection as well as in assessing the therapeutic response. We compared the analytical performance of a random access, fully automated HBV assay—DxN VERIS Molecular Diagnostics System (Beckman Coulter, Brea, CA, USA)—with that of Abbott RealTime HBV assay (Abbott Laboratories, Des Plaines, IL, USA). The between-day precision of the VERIS assay ranged from 0.92% (mean 4.68 log IU/mL) to 4.15% (mean 2.09 log IU/mL) for pooled sera from HBV patients. HBV DNA levels measured by the VERIS HBV assay correlated with the calculated HBV DNA levels (r²=0.9994; P < 0.0001). The lower limit of quantification was estimated as 8.76 IU/mL (Probit analysis, 95% confidence interval: 7.32–12.00 IU/mL). Passing-Bablok regression analysis showed good concordance between the VERIS and RealTime assays for 187 chronic HBV samples (y=−0.2397+0.9712x; r=0.981), as well as for 20 drug-resistant HBV genotype C positive samples (y=−0.5415+0.9954x; r=0.961). The VERIS assay demonstrated performance similar to the RealTime assay and is suitable for high-throughput HBV DNA monitoring in large hospital laboratories.

Ethanol ablation as a treatment strategy for benign cystic thyroid nodules: a comparison of the ethanol retention and aspiration techniques

PURPOSE: We compared the efficacy and safety of two ethanol ablation techniques-ethanol aspiration and ethanol retention-for benign cystic thyroid nodules. METHODS: From October 2008 to September 2013, 113 patients who were treated using the ethanol aspiration technique (February 2008 to December 2010) and 108 patients who were treated using the ethanol retention technique (January 2011 to September 2013) were enrolled (male:female ratio, 53:168; mean age, 48.1 years; range, 18 to 80 years). The patient sample had 94 cystic and 127 predominantly cystic thyroid nodules. The volume reduction ratio (VRR) at the last follow-up, improvements in symptoms and cosmetic scores, vascularity, pain, and major complications were evaluated and compared between the ethanol aspiration group and ethanol retention group. We also performed a subgroup analysis according to the proportion of the solid component, in which VRR, symptom and cosmetic scores, and therapeutic success were compared. RESULTS: No statistically significant difference in VRR was found between the ethanol retention group and the ethanol aspiration group (83.2%±32.8% vs. 86.1%±18.4%, P=0.416) while patients who underwent the retention technique were more likely to experience pain after treatment (P=0.001). VRR, symptom and cosmetic scores, and therapeutic success did not significantly differ between techniques in either group in the subgroup analysis. CONCLUSION: The ethanol aspiration technique may be preferable to the ethanol retention technique for treating benign cystic and predominantly cystic thyroid nodules, because a comparable VRR can be expected with less pain.

Comparison of Six Commercial Diagnostic Tests for the Detection of Dengue Virus Non-Structural-1 Antigen and IgM/IgG Antibodies

ELISAs and rapid diagnostic tests (RDTs) are widely used for diagnosing dengue virus (DENV) infection. Using 138 single blood samples, we compared the ability to detect non-structural (NS)-1 antigen and anti-DENV IgM/IgG antibodies among (1) DENV Detect NS1 ELISA, DENV Detect IgM capture ELISA and DENV Detect IgG ELISA (InBios International, Inc.); (2) Anti-Dengue virus IgM Human ELISA and Anti-Dengue virus IgG Human ELISA (Abcam); (3) Dengue virus NS1 ELISA, Anti-Dengue virus ELISA (IgM) and Anti-Dengue virus ELISA (IgG) (Euroimmun); (4) Asan Easy Test Dengue NS1 Ag 100 and Asan Easy Test Dengue IgG/IgM (Asan Pharm); (5) SD BIOLINE Dengue Duo (Standard Diagnostics); and (6) Ichroma Dengue NS1 and Ichroma Dengue IgG/IgM (Boditech Med). For NS1 antigen detection, InBios and Euroimmun showed higher sensitivities (100%) than the RDTs (42.9–64.3%). All tests demonstrated variable sensitivities for IgM (38.1–90.5%) and IgG (65.7–100.0%). InBios and Boditech Med demonstrated higher sensitivity (95.6% and 88.2%, respectively) than the other tests for combined NS1 antigen and IgM antibody. Five NS1 antigen tests had good agreement (92.8–98.6%) without showing positivity for chikungunya. However, all IgG tests demonstrated potential false-positivity with variable ranges. Clinical laboratories should note performance variations across tests and potential cross-reactivity.

Determinants of Bone Mass and Insulin Resistance in Korean Postmenopausal Women: Muscle Area, Strength, or Composition?

PURPOSE: Muscle mass, strength, and composition determine muscle quantity and quality. However, data on muscle properties in relation to bone mass or insulin resistance are limited in Asian populations. This study aimed to investigate the relative importance of muscle measurements in regards to their relationship with lower bone mass and insulin resistance. MATERIALS AND METHODS: In this study, 192 postmenopausal women (age, 72.39±6.07 years) were enrolled. We measured muscle cross-sectional area (CSA) and attenuation at the gluteus maximus and quadriceps muscles through quantitative computed tomography. Muscle strength and physical performance were evaluated with the hand grip test and Short Physical Performance Battery (SPPB). Pearson correlation analysis and linear regression were performed to evaluate the relationship between muscle properties and homeostatic model assessment-insulin resistance (HOMA-IR) or bone mineral density (BMD). RESULTS: Muscle CSA, hand grip strength, and SPPB score held positive correlations with spine and hip BMDs, but not with insulin resistance. In contrast, muscle attenuation of the gluteus maximus or quadriceps was inversely related to HOMA-IR (r=−0.194, p=0.018 and r=−0.292, p<0.001, respectively), but not BMD. Compared with the control group, muscle CSA was significantly decreased in patients with osteoporosis; however, decreased muscle attenuation, indicating high fat infiltration, was found only in patients with diabetes. CONCLUSION: Muscle mass, strength, and physical performance were associated with low bone mass, and accumulation of intramuscular fat, a histological hallmark of persistently damaged muscles, may play a major role in the development of insulin resistance in Korean postmenopausal women.

Clinical Factors Related to the Response of IV Ferric Carboxymaltose Treatment in Patients with Restless Legs Syndrome

OBJECTIVES: Significant benefit of intravenous ferric carboxymaltose (FCM) for restless legs syndrome (RLS) has been demonstrated. However, clinical indicators to expect treatment response of RLS are not clarified. The aim of this study is to find out determinant factors to predict treatment outcome of FCM. METHODS: We enrolled consecutive 108 patients with RLS who visited sleep clinic and received FCM from April 2016 to November 2017. Obtained data were detailed history including international restless legs scale (IRLS) and questionnaires, comorbid diseases, medication. Complete blood cell count, serum iron, ferritin, and total iron-binding capacity were sampled before and after treatment. Treatment response was assessed about four weeks after FCM administration. Patients with more than 40% decrease on IRLS were classified into the responders. RESULTS: 99 patients (mean 54.5 y and 79 females) were included. 58 patients (58.6%) were classified to be responders. There were substantial differences in post-treatment IRLS and symptom reduction rate between responders (7.4±6.4, 77.5±18.6%) and non-responders (29.7±8.7, 7.4±10.3%). No significant differences were found in demographics, baseline IRLS, sleep, and mood status between two groups. Serum ferritin and transferrin saturation was significantly lower in responders (37.6 ng/mL, 25.0%) than non-responders (55.1 ng/mL, p=0.014 and 36.5%, p=0.001). Patients with a history of gastrectomy (n=8) showed an excellent response to FCM (83.8% of symptom reduction). Comorbid lumbosacral radiculopathy had lower response rate (29.4%). CONCLUSIONS: Peripheral iron compromised state and gastrectomy history may indicate good response to intravenous FCM in patients with RLS. Patients with lumbosacral radiculopathy tend to be poor responders to intravenous FCM.

Current State of Vocational Rehabilitation Program for Individuals with Disabling Mental Illness in Korea / 정신신체의학

OBJECTIVES: There has been long lasting trend of deinstitutionalization and public health centered care in management of individuals with disabling mental illness. We aimed to investigate current vocational rehabilitation state and effectiveness of system in korea. METHODS: We carried basic survey via telephone and e-mail beforehand to figure out how many and which institutions are operating vocational rehabilitation programs to psychiatric patients. A questionnaire packages were sent to total of 108 institutions in Korea which were operating occupation rehabilitation program. RESULTS: Of 108 institutions, 40.74% were returned with answers. The person in charge of vocational rehabilitation at each institution was mainly mental health social worker(48.8%), and the budget under \1,000,000 was the majority(61.5%) among surveyed institutions. The most commonly used vocational rehabilitation programs was case management(23.1%), followed by psychosocial rehabilitation program(21.2%), and on-the-job training(17.9%). The most effective program was case management(27.4%), followed by psychosocial rehabilitation program(19.8%), on-the-job training(17.9%). The main barrier of occupation rehabilitation to be conducted widely was ‘worries about being excluded from beneficiary of National Basic livelihood Protection Act’. CONCLUSIONS: Our results suggest that, in spite of high demand in vocational rehabilitation programs, government financial support is still lacking.

T-Cell Non-Hodgkin Lymphomas: Spectrum of Disease and the Role of Imaging in the Management of Common Subtypes

T-cell non-Hodgkin lymphomas (NHLs) are biologically diverse, uncommon malignancies characterized by a spectrum of imaging findings according to subtype. The purpose of this review is to describe the common subtypes of T-cell NHL, highlight important differences between cutaneous, various peripheral and precursor subtypes, and summarize imaging features and the role of imaging in the management of this diverse set of diseases.

Innovative Techniques for Image-Guided Ablation of Benign Thyroid Nodules: Combined Ethanol and Radiofrequency Ablation

In the treatment of benign thyroid nodules, ethanol ablation (EA), and radiofrequency ablation (RFA) have been suggested for cystic and solid thyroid nodules, respectively. Although combining these ablation techniques may be effective, no guidelines for or reviews of the combination have been published. Currently, there are three ways of combining EA and RFA: additional RFA is effective for treatment of incompletely resolved symptoms and solid residual portions of a thyroid nodule after EA. Additional EA can be performed for the residual unablated solid portion of a nodule after RFA if it is adjacent to critical structures (e.g., trachea, esophagus, and recurrent laryngeal nerve). In the concomitant procedure, ethanol is injected to control venous oozing after aspiration of cystic fluid prior to RFA of the remaining solid nodule.

Localization of Oncogenic Osteomalacia by Systemic Venous Sampling of Fibroblast Growth Factor 23

PURPOSE: Tumor-induced osteomalacia (TIO) is characterized by hypophosphatemia caused by a phosphaturic mesenchymal tumor. While surgical resection of the tumor leads to a cure, identification of the responsible tumor is challenging. Recently, several studies showed that systemic sampling of fibroblast growth factor 23 (FGF23) is helpful for localization of tumors. The present study aimed to evaluate the clinical utility of this method in Korean patients. MATERIALS AND METHODS: Six patients compatible with TIO who were admitted to our hospital between 2006 and 2015 were analyzed. Systemic venous sampling of FGF23 was performed to detect blind lesions or to confirm a suspicious lesion identified in previous imaging studies. RESULTS: Venous sampling helped confirming the tumor in five of the six patients. Three patients underwent surgery after sampling, and in two patients, the lesions were detected after 3 years by means of 68Ga-DOTATOC positron emission tomography with computed tomography. In one patient, there was a local elevation of serum FGF23 without any related lesion on additional imaging. CONCLUSION: Our data strengthened the value of venous sampling of FGF23 in predicting the location of tumors and suggested that it can be more effective in the presence of the relevant lesion in subsequent imaging analyses.

RE: Management of Low-Risk Papillary Thyroid Microcarcinoma

No abstract available.

Human Leukocyte Antigen-C Genotype and Killer Immunoglobulin-like Receptor-Ligand Matching in Korean Living Donor Liver Transplantation

BACKGROUND: The interaction between killer immunoglobulin-like receptors (KIRs) and HLA class I regulates natural killer (NK) cell cytotoxicity and function. The impact of NK cell alloreactivity through KIR in liver transplantation remains unelucidated. Since the frequency of HLA-C and KIR genotypes show ethnic differences, we assessed the impact of HLA-C, KIR genotype, or KIR-ligand mismatch on the allograft outcome of Korean liver allografts. METHODS: One hundred eighty-two living donor liver transplant patients were studied. Thirty-five patients (19.2%) had biopsy-confirmed acute rejection (AR), and eighteen (9.9%) had graft failure. The HLA-C compatibility, KIR genotypes, ligand-ligand, and KIR-ligand matching was retrospectively investigated for association with allograft outcomes. RESULTS: Homozygous C1 ligands were predominant in both patients and donors, and frequency of the HLA-C2 allele in Koreans was lower than that in other ethnic groups. Despite the significantly lower frequency of the HLA-C2 genotype in Koreans, donors with at least one HLA-C2 allele showed higher rates of AR than donors with no HLA-C2 alleles (29.2% vs 15.7%, P=0.0423). Although KIR genotypes also showed ethnic differences, KIR genotypes and the number of activating KIR/inhibitory KIR were not associated with the allograft outcome. KIR-ligand mismatch was expected in 31.6% of Korean liver transplants and had no impact on AR or graft survival. CONCLUSIONS: This study could not confirm the clinical impact of KIR genotypes and KIR-ligand mismatch. However, we demonstrated that the presence of HLA-C2 allele in the donor influenced AR of Korean liver allografts.

Effects of Single Vitamin D₃ Injection (200,000 Units) on Serum Fibroblast Growth Factor 23 and Sclerostin Levels in Subjects with Vitamin D Deficiency

BACKGROUND: Vitamin D deficiency remains common in all age groups and affects skeletal and non-skeletal health. Fibroblast growth factor 23 is a bone-derived hormone that regulates phosphate and 1,25-dihydroxyvitamin D homeostasis as a counter regulatory factor. 1,25-Dihydroxyvitamin D stimulates fibroblast growth factor 23 synthesis in bone, while fibroblast growth factor 23 suppresses 1,25-dihydroxyvitamin D production in the kidney. The aim of this study was to evaluate the effects of vitamin D₃ intramuscular injection therapy on serum fibroblast growth factor 23 concentrations, and several other parameters associated with bone metabolism such as sclerostin, dickkopf-1, and parathyroid hormone. METHODS: A total of 34 subjects with vitamin D deficiency (defined by serum 25-hydroxyvitamin D levels below 20 ng/mL) were randomly assigned to either the vitamin D injection group (200,000 units) or placebo treatment group. Serum calcium, phosphate, urine calcium/creatinine, serum 25-hydroxyvitamin D, fibroblast growth factor 23, sclerostin, parathyroid hormone, and dickkopf-1 levels were serially measured after treatment. RESULTS: Comparing the vitamin D injection group with the placebo group, no significant changes were observed in serum fibroblast growth factor 23, parathyroid hormone, or dickkopf-1 levels. Serum sclerostin concentrations transiently increased at week 4 in the vitamin D group. However, these elevated levels declined later and there were no statistically significant differences as compared with baseline levels. CONCLUSION: Serum fibroblast factor 23, sclerostin, parathyroid hormone, and dickkopf-1 levels were not affected significantly by single intramuscular injection of vitamin D₃.

Thyroid Radiofrequency Ablation: Updates on Innovative Devices and Techniques

Radiofrequency ablation (RFA) is a well-known, effective, and safe method for treating benign thyroid nodules and recurrent thyroid cancers. Thyroid-dedicated devices and basic techniques for thyroid RFA were introduced by the Korean Society of Thyroid Radiology (KSThR) in 2012. Thyroid RFA has now been adopted worldwide, with subsequent advances in devices and techniques. To optimize the treatment efficacy and patient safety, understanding the basic and advanced RFA techniques and selecting the optimal treatment strategy are critical. The goal of this review is to therefore provide updates and analysis of current devices and advanced techniques for RFA treatment of benign thyroid nodules and recurrent thyroid cancers.

Site-Specific Difference of Bone Geometry Indices in Hypoparathyroid Patients

BACKGROUND: Hypoparathyroid patients often have a higher bone mineral density (BMD) than the general population. However, an increase in BMD does not necessarily correlate with a solid bone microstructure. This study aimed to evaluate the bone microstructure of hypoparathyroid patients by using hip structure analysis (HSA). METHODS: Ninety-five hypoparathyroid patients >20 years old were enrolled and 31 of them had eligible data for analyzing bone geometry parameters using HSA. And among the control data, we extracted sex-, age-, and body mass index-matched three control subjects to each patient. The BMD data were reviewed retrospectively and the bone geometry parameters of the patients were analyzed by HSA. RESULTS: The mean Z-scores of hypoparathyroid patients at the lumbar spine, femoral neck, and total hip were above zero (0.63±1.17, 0.48±1.13, and 0.62±1.10, respectively). The differences in bone geometric parameters were site specific. At the femoral neck and intertrochanter, the cross-sectional area (CSA) and cortical thickness (C.th) were higher, whereas the buckling ratio (BR) was lower than in controls. However, those trends were opposite at the femoral shaft; that is, the CSA and C.th were low and the BR was high. CONCLUSION: Our study shows the site-specific effects of hypoparathyroidism on the bone. Differences in bone components, marrow composition, or modeling based bone formation may explain these findings. However, further studies are warranted to investigate the mechanism, and its relation to fracture risk.

Medical Problems during Participation of Medical Congress - A Long Trip to Val D'Isere from Korea / 신경중재치료의학

Since the 3rd WIN meeting in 1982 more than 500 participants join the meeting in Val D'Isere every year [1]. One of our authors has attended the meeting more than 10 times. He experienced many physical illnesses while travelling from South Korea to Val D'Isere in France, which is located in the Alps mountain near the border between France and Italy. In order to get there, it is necessary to take airplane, train, and/or bus with a heavy suitcase. During the trip which usually takes more than 15 hours, he experienced headache, gastrointestinal trouble, sleep disturbance and other additional physical illnesses. Therefore, we reviewed the itinerary to Val D'Isere and presented physical illnesses which occurred during a long trip for an academic activity by specialized professionals such as university hospital professors. In addition, we discussed the mechanism of such illnesses and offered possible solutions including medical treatment.

Paroxetine-induced Hypoglycemia in Type 2 Diabetic Patient / 이화의대지

Selective serotonin reuptake inhibitors are commonly prescribed drugs for the treatment of depression in the patients with diabetes. Here, we report a case of paroxetineinduced severe recurrent hypoglycemia that developed in a 35-year-old woman with poorly controlled type 2 diabetes complicated by diabetic nephropathy and neuropathy. She discontinued her daily insulin therapy 2 months after the introduction of paroxetine, but hypoglycemic events were sustained. After discontinuation of paroxetine, no more hypoglycemic events occurred.

Statins Increase Mitochondrial and Peroxisomal Fatty Acid Oxidation in the Liver and Prevent Non-Alcoholic Steatohepatitis in Mice

BACKGROUND: Non-alcoholic fatty liver disease is the most common form of chronic liver disease in industrialized countries. Recent studies have highlighted the association between peroxisomal dysfunction and hepatic steatosis. Peroxisomes are intracellular organelles that contribute to several crucial metabolic processes, such as facilitation of mitochondrial fatty acid oxidation (FAO) and removal of reactive oxygen species through catalase or plasmalogen synthesis. Statins are known to prevent hepatic steatosis and non-alcoholic steatohepatitis (NASH), but underlying mechanisms of this prevention are largely unknown. METHODS: Seven-week-old C57BL/6J mice were given normal chow or a methionine- and choline-deficient diet (MCDD) with or without various statins, fluvastatin, pravastatin, simvastatin, atorvastatin, and rosuvastatin (15 mg/kg/day), for 6 weeks. Histological lesions were analyzed by grading and staging systems of NASH. We also measured mitochondrial and peroxisomal FAO in the liver. RESULTS: Statin treatment prevented the development of MCDD-induced NASH. Both steatosis and inflammation or fibrosis grades were significantly improved by statins compared with MCDD-fed mice. Gene expression levels of peroxisomal proliferator-activated receptor α (PPARα) were decreased by MCDD and recovered by statin treatment. MCDD-induced suppression of mitochondrial and peroxisomal FAO was restored by statins. Each statin's effect on increasing FAO and improving NASH was independent on its effect of decreasing cholesterol levels. CONCLUSION: Statins prevented NASH and increased mitochondrial and peroxisomal FAO via induction of PPARα. The ability to increase hepatic FAO is likely the major determinant of NASH prevention by statins. Improvement of peroxisomal function by statins may contribute to the prevention of NASH.

Hepatic Sarcoidosis in a Patient with Chronic Hepatitis B Virus Infection

Sarcoidosis is a systemic inflammatory granulomatous disease affecting multiple organs, including liver, spleen, heart, eyes, and skin. Liver involvement is reported in 11.5% of cases and many studies have reported on the association between hepatitis C virus infection and sarcoidosis. However, the role of hepatitis B virus (HBV) infection as a trigger for sarcoidosis has never been reported. We describe a case of hepatic sarcoidosis in a patient with chronic hepatitis B infection, with a possible link between the two. It is the first case report of a patient with interferon-alpha-naive chronic HBV infection presenting with hepatic sarcoidosis accompanied by portal hypertension and liver cirrhosis.