Cryptococcal Meningitis Complicated by a Brain Abscess and an Abdominal Pseudocyst Following Ventriculoperitoneal Shunting / 대한내과학회지

Ventriculoperitoneal (VP) shunt insertion is the standard treatment for hydrocephalus; shunt-associated infection is the most common complication after surgery. However, fungal infections are unusual. We present a case of cryptococcal meningitis complicated by a brain abscess and an infected intra-abdominal pseudocyst that developed 14 weeks after VP shunt insertion to treat hydrocephalus in a 74-year-old patient. Cryptococcal central nervous system (CNS) infection has a high mortality rate; however, diagnosis is challenging. Therefore, prompt diagnosis and treatment are required when a cryptococcal CNS infection is suspected in patients with VP shunts.

Cryptococcal Meningitis Complicated by a Brain Abscess and an Abdominal Pseudocyst Following Ventriculoperitoneal Shunting / 대한내과학회지

Ventriculoperitoneal (VP) shunt insertion is the standard treatment for hydrocephalus; shunt-associated infection is the most common complication after surgery. However, fungal infections are unusual. We present a case of cryptococcal meningitis complicated by a brain abscess and an infected intra-abdominal pseudocyst that developed 14 weeks after VP shunt insertion to treat hydrocephalus in a 74-year-old patient. Cryptococcal central nervous system (CNS) infection has a high mortality rate; however, diagnosis is challenging. Therefore, prompt diagnosis and treatment are required when a cryptococcal CNS infection is suspected in patients with VP shunts.

Long Pentraxin 3 as a Predictive Marker of Mortality in Severe Septic Patients Who Received Successful Early Goal-Directed Therapy

PURPOSE: Pentraxin 3 (PTX3) has been suggested to be a prognostic marker of mortality in severe sepsis. Currently, there are limited data on biomarkers including PTX3 that can be used to predict mortality in severe sepsis patients who have undergone successful initial resuscitation through early goal-directed therapy (EGDT). MATERIALS AND METHODS: A prospective cohort study was conducted among 83 severe sepsis patients with fulfillment of all EGDT components and the achievement of final goal. Plasma PTX3 levels were measured by sandwich ELISA on hospital day (HD) 0, 3, and 7. The data for procalcitonin, C-reactive protein and delta neutrophil index were collected by electric medical record. The primary outcome was 28-day all-cause mortality. RESULTS: 28-day all-cause mortality was 19.3% and the median (interquartile range) APHCH II score of total patients was 16 (13–19). The non-survivors (n=16) had significantly higher PTX3 level at HD 0 [201.4 (56.9–268.6) ng/mL vs. 36.5 (13.7–145.3) ng/mL, p=0.008]. PTX3 had largest AUC(ROC) value for the prediction of mortality among PTX3, procalcitonin, delta neutrophil index, CRP and APACHE II/SOFA sore at HD 0 [0.819, 95% confidence interval (CI) 0.677–0.961, p=0.008]. The most valid cut-off level of PTX3 at HD 0 was 140.28 ng/mL (sensitivity 66.7%, specificity 73.8%). The PTX3 and procalcitonin at HD 0 showed strong correlation (r=0.675, p<0.001). However, PTX3 at HD 0 was the only independent predictive marker in Cox's proportional hazards model (≥140 ng/mL; hazard rate 7.16, 95% CI 2.46–15.85, p=0.001). CONCLUSION: PTX3 at HD 0 could be a powerful predictive biomarker of 28-day all-cause mortality in severe septic patients who have undergone successful EGDT.

Change in Renal Function among HIV-Infected Koreans Receiving Tenofovir Disoproxil Fumarate-Backbone Antiretroviral Therapy: A 3-Year Follow-Up Study

PURPOSE: Tenofovir disoproxil fumarate (TDF) is commonly prescribed as a fixed-dose, co-formulated antiretroviral drug for HIV-1 infection. The major concern of long-term TDF use is renal dysfunction. However, little is known about the long-term patterns of changes in renal function in HIV-infected Koreans receiving TDF. MATERIALS AND METHODS: We prospectively followed 50 HIV-infected Koreans, performing laboratory tests every 3 months during the first year and every 6 months for the next 2 years. Urine N-acetyl-β-D-glucosaminidase (NAG) and plasma cystatin-C were measured using samples collected in the first year. Data on renal function were retrospectively collected on HIV-infected patients receiving first-line TDF (n=40) and in antiretroviral therapy (ART)-naïve patients (n=24) for 3 years. Renal function was evaluated as estimated glomerular filtration rate (eGFR) from serum creatinine [Modification of Diet in Renal Disease (MDRD)] and cystatin-C. RESULTS: The eGFR (cystatin-C) showed significant changes from 0 to 48 wks (p=0.002), with the lowest levels at 24 wks (84.3±18.8 mL/min vs. 90.3±22.5 mL/min, p=0.021 by post hoc test). Urine NAG levels did not differ at 0, 12, 24, and 48 wks, although eGFR (MDRD) significantly decreased from 0 (98.7±18.9 mL/min/1.73 m²) to 144 wks (89.0±14.7 mL/min/1.73 m²) (p=0.010). The first-line TDF group had significantly lower eGFR (MDRD) than the ART-naïve group at 144 wks (89.7 mL/min/1.73 m² vs. 98.4 mL/min/1.73 m², p=0.036). Thirteen (26%) participants experienced a decrease in renal impairment of 10 mL/min/1.73 m² in eGFR (MDRD) at 144 wks. CONCLUSION: These data suggest that clinically meaningful renal injury can develop in HIV-infected Koreans receiving long-term TDF.

The Simple Predictors of Pseudomembranous Colitis in Patients with Hospital-Acquired Diarrhea: A Prospective Observational Study

BACKGROUND/AIMS: As the incidence rate of and mortality from pseudomembranous colitis (PMC) are increasing worldwide, it is important to study the simple predictive risk factors for PMC among patients with hospital-acquired diarrhea (HAD). This study focused on identifying the clinical risk factors that can easily predict PMC. METHODS: The presumed HAD patients were prospectively recruited at the Hallym University Kangdong Sacred Heart Hospital. RESULTS: Age of 70 and older (adjusted odds ratio [OR], 1.76; 95% confidence interval [CI], 1.12 to 0.75), use of proton pump inhibitors (adjusted OR, 4.07; 95% CI, 2.512 to 6.57), use of cephalosporins (adjusted OR, 2.99; 95% CI, 1.82 to 4.94), and underlying cancer (adjusted OR, 1.72; 95% CI, 1.04 to 2.82) were independent risk factors for PMC in the multivariate logistic regression analysis. The prevalence of PMC was very low in the patients with HAD who exhibited no risk factors. CONCLUSIONS: The risk factors for PMC in patients with HAD included cephalosporin use, proton pump inhibitor use, old age, and cancer. Considering the strongly negative predictive values of these risk factors, endoscopic evaluation can be delayed in patients with HAD without risk of developing PMC.

A Case of Primary Endobronchial Actinomycosis Presenting as a Complicated Parapneumonic Effusion

Endobronchial actinomycosis is a rare but important and challenging diagnosis to make. We report a case of 57 year-old man who presented with a fever and a right-sided chest pain diagnosed as an endobronchial actinomycosis. Chest computed tomography showed a segmental obstruction and consolidations in right middle lobe combined with an ipsilateral multiloculated pleural effusion. Bronchoscopic biopsy of a mass obstructing the medial segmental bronchus of right middle lobe revealed actinomycosis. This is the first reported case of primary endobronchial actinomycosis that presented with a chest pain and a complicated parapneumonic effusion. Primary endobronchial actinomycosis can be a cause of complicated parapneumonic effusion.

Effects of 2-deoxy-D-glucose and quercetin on the gene expression of bone sialoprotein and osteocalcin during the differentiation in irradiated MC3T3-E1 osteoblastic cells / 대한구강악안면방사선학회지

PURPOSE: To investigate the effects of 2-deoxy-D-glucose (2-DG) and quercetin (QCT) on gene expression of bone sialoprotein (BSP) and osteocalcin (OC) during the differentiation in irradiated MC3T3-E1 osteoblastic cells. MATERIALS AND METHODS: When MC3T3-E1 osteoblastic cells had reached 70-80% confluence, cultures were transferred to a differentiating medium supplemented with 5 mM 2-DG or 10 micrometer QCT, and then irradiated with 2, 4, 6, and 8 Gy. At various times after irradiation, the cells were analyzed for the synthesis of type I collagen, and expression of BSP and OC. RESULTS: The synthesis of type I collagen in cells exposed to 2 Gy of radiation in the presence of 2-DG or QCT showed no significant difference compared with the control group within 15 days post-irradiation. When the cells were irradiated with 8 Gy, 2-DG facilitated the irradiation mediated decrease of type I collagen synthesis, whereas such decrease was inhibited by treating with QCT. During MC3T3-E1 osteoblastic cell differentiation, the mRNA expression of BSP and OC showed the peak value at 14 days and 21 days, respectively. 2-DG or QCT treatment alone decreased the level of BSP mRNA, but increased the OC mRNA level only at early time of differentiation (day 7). In the cells irradiated with 2, 4, 8 Gy, the mRNA expression of BSP and OC decreased at 7 days after the irradiation. The cells were treated with various dose of radiation in the presence of 2-DG or QCT, the mRNA level of both BSP and OC increased although this increase was observed at low dose of radiation (2 Gy) and at the early stage of differentiation. However, when the cells were exposed to 4, 6, or 8 Gy, the increase of BSP and OC mRNAs was detected only in cells co-incubated with QCT. CONCLUSION: This study demonstrates that 2-DG and QCT affect differently the expression of bone formation related factors, type I collagen, BSP, and OC in the irradiated MC3T3-E1 osteoblasic cells, according to the dose of radiation and the times of differentiation. Overall, the present findings suggest that 2-DG and QCT could have the regulatory roles as radiation-sensitizer and -protector, respectively.

Positional relationship between mandibular third molar and mandibular canal in cone beam computed tomographs / 대한구강악안면방사선학회지

PURPOSE: To provide diagnostic information by evaluation of the positional relationship between the mandibular third molar and the mandibular canal. MATERIALS AND METHODS: Eighty-nine mandibular third molars were classified as mesioangular, horizontal, vertical, distoangular groups. The distances between the mandibular third molar and the mandibular canal were measured in cone-beam computed tomographs. The height and width ratios of distances from the mandibular third molar and the mandibular canal to the mandibular inferior border and to the lingual cortical plate were calculated. RESULTS: The vertical and buccolingual distances between the mandibular third molar and the mandibular canal were 0.03 mm, 2.96 mm in the mesioangular, 0.37 mm, 3.38 mm in the horizontal, -1.50 mm, 1.38 mm in the vertical, -1.10 mm, 4.20 mm in the distoangular group. There were significant differences in vertical (P0.05). The height and width ratios of distances on the mandibular third molar were 47.1%, 36.1% in the mesioangular, 47.4%, 34.4% in the horizontal, 37.0%, 46.7% in the vertical, 40.9%, 37.4% in the distoangular group. There were significant differences between the mesioangular and the vertical group, and the horizontal and the vertical group in height ratio (P0.05). CONCLUSION: The mesioangular group showed the nearest distance between the mandibular third molar and the mandibular canal vertically. The root apex of the mandibular third molar was positioned more buccally in the vertical group than in the mesioangular group.

Bone change of mandibular condyle using cone beam computed tomography / 대한구강악안면방사선학회지

PURPOSE: To assess bone changes of mandibular condyle using cone beam computed tomography (CBCT) in temporomandibular disorder (TMD) patients. MATERIALS AND METHODS: 314 temporomandibular joints (TMJs) images of 163 TMD patients were examined at the Department of Oral and Maxillofacial Radiology, Chonbuk National University. The images were obtained by PSR9000N (Asahi Roentgen Co., Japan) and reconstructed by using Asahivision software (Asahi Roentgen Co., Japan). The CBCT images were examined three times with four weeks interval by three radiologists. Bone changes of mandibular condyle such as flattening, sclerosis, erosion and osteophyte formation were observed in sagittal, axial, coronal and 3 dimensional images of the mandibular condyle. The statistical analysis was performed using SPSS 12.0. Intra- and interobserver agreement were performed by 3 radiologists without the knowledge of clinical information. RESULTS: Osteophyte (2.9%) was found more frequently on anterior surface of the mandibular condyle. Erosion (31.8%) was found more frequently on anterior and medial surfaces of the mandibular condyle. The intraobserver agreement was good to excellent (k=0.78-0.84), but interobserver agreement was fair (k=0.45). CONCLUSION: CBCT can provide high qualified images of bone changes of the TMJ with axial, coronal and 3 dimensional images.

Metastatic gastric adenocarcinoma to the mandible / 대한구강악안면방사선학회지

Metastatic tumors to the jaw bones are uncommon. The most common metastatic tumors to the jaw bones are the breast, lung and kidney. In the jaw bones, the common location of the lesions is the mandible, and the posterior area of the mandible is more commonly affected. The radiographic appearance is quite variable. In this report, a very rare case of metastatic gastric adenocarcinoma to the mandible is presented. The patient had undergone a gastrectomy 3 years ago.

Diagnostic accuracy of artificially induced vertical root fractures: a comparison of direct digital periapical images with conventional periapical images / 대한구강악안면방사선학회지

PURPOSE: To compare the diagnostic accuracy for the detection of root fractures in CMOS-based digital periapical images with conventional film-based periapical images. MATERIALS AND METHODS: Sixty extracted single-root human teeth with closed apices were prepared endodontically and divided into two groups; artificially induced vertical root fracture group and control group. All radiographs were obtained using the paralleling technique. The radiographs were examined by 4 observers three times within a 4 week interval. Receiver operating characteristic (ROC) analysis was carried out using data obtained from four observers. Intra- and inter-examiner agreements were computed using kappa analysis. RESULTS: The area under the ROC curve (Az) was used as an indicator of the diagnostic accuracy of the imaging system. Az values were as follows: direct-digital images; 0.93, film-based images; 0.92, and inverted digital images; 0.91. There was no significant difference between imaging modalities (P< 0.05). The kappa value of interobserver agreement was 0.42 (range: 0.28-0.60) and intra-observer agreement was 0.57 (range: 0.44-0.75). CONCLUSION: There is no statistical difference in diagnostic accuracy for the detection of vertical root fractures between digital periapical images and conventional periapical images. The results indicate that the CMOS sensor is a good image detector for the evaluation of vertical root fractures.