Development of colon cancer in a patient with longstanding colonic diffuse ganglioneuromatosis: a case report

Colonic diffuse ganglioneuromatosis is an extremely rare disease in which multiple tumors derived from the ganglion cells, nerve fibers, and supporting cells are distributed in the colon. It is generally considered to be a benign neoplastic condition and is occasionally associated with rare hereditary conditions such as neurofibromatosis type I or multiple endocrine neoplasia type 2B. Here, we report a case of a patient in whom colon cancer developed 12 years after the initial diagnosis of colonic diffuse ganglioneuromatosis, which suggests a possible association between colonic diffuse ganglioneuromatosis and colorectal cancer.

Refractory Macrophage Activation Syndrome in a Patient with Systemic Lupus Erythematosus Treated with Tocilizumab / 대한내과학회지

Macrophage activation syndrome (MAS) is a secondary hemophagocytic lymphohistiocytosis caused by autoimmune diseases, such as systemic lupus erythematosus (SLE). It is characterized by fever, cytopenia, coagulopathy, hepatosplenomegaly, elevated liver enzyme, and high ferritin, typically combined with hemophagocytic histiocyte proliferation in the bone marrow. Here, we report a case of MAS in a patient with SLE treated successfully by tocilizumab. She was transferred to our hospital due to persistent fever of unknown origin. Initial blood tests revealed cytopenia, elevated liver enzyme, and high ferritin. Bone marrow histology revealed the presence of hemophagocytic histiocytes. The patient was initially treated with high dose corticosteroids; however, fever and cytopenia were not controlled. Additional treatments with cyclosporine, intravenous immunoglobulin, and rituximab were applied consecutively, but the fever and cytopenia persisted. Symptom resolution was finally achieved following treatment with tocilizumab, resulting in rapid improved of fever, and resolution of pancytopenia within 2 months.

Serum Total Bilirubin Levels Provide Additive Risk Information over the Framingham Risk Score for Identifying Asymptomatic Diabetic Patients at Higher Risk for Coronary Artery Stenosis

BACKGROUND: The diagnosis of coronary artery disease (CAD) is often delayed in patients with type 2 diabetes. Serum total bilirubin levels are inversely associated with CAD. However, no studies have examined whether this can be used as a biochemical marker for identifying asymptomatic diabetic patients at higher risk for having obstructive CAD. METHODS: We performed a cross-sectional study of 460 consecutive asymptomatic patients with type 2 diabetes. All patients underwent coronary computed tomographic angiography, and their serum total bilirubin levels were measured. Obstructive CAD was defined as > or =50% diameter stenosis in at least one coronary artery. RESULTS: Serum total bilirubin tertiles showed an inverse association with the prevalence of obstructive CAD. In multivariate logistic regression analysis, the odds ratio for the highest versus the lowest tertile of total bilirubin was 0.227 (95% confidence interval [CI], 0.130 to 0.398), and an increment of 1 micromol/L in serum total bilirubin level was associated with a 14.6% decrease in obstructive CAD after adjustment for confounding variables. Receiver operating characteristic curve analysis showed that the area under the curve for the Framingham Risk Score (FRS) plus serum total bilirubin level was 0.712 (95% CI, 0.668 to 0.753), which is significantly greater than that of the FRS alone (P=0.0028). CONCLUSION: Serum total bilirubin level is inversely associated with obstructive CAD and provides additive risk information over the FRS. Serum total bilirubin may be helpful for identifying asymptomatic patients with type 2 diabetes who are at higher risk for obstructive CAD.

Utility of Fully Covered Esophageal Metal Stent in Percutaneous Endoscopic Necrosectomy / 대한췌담도학회지

Necrotizing pancreatitis is associated with high rates of morbidity and mortality. Managing necrotizing pancreatitis is challenging, and minimally invasive treatment modalities recently replaced traditional open necrosectomy. Percutaneous catheter drainage and endoscopic necrosectomy are now widely used because they are less invasive, safer, and can more effectively remove necrotic materials. Various methods and novel techniques have been introduced to manage walled-off necrosis. Herein, we report a case series of patients with necrotizing pancreatitis who were successfully treated using fully covered esophageal metal stent and endoscopic necrosectomy via the percutaneous approach. Percutaneous endoscopic necrosectomy using a fully covered esophageal stent is an effective endoscopic treatment for patients with walled-off necrosis that extends along both sides of the paracolic gutter, reduces the number of necrosectomy sessions, and improves disease status faster than conventional treatment.

Pancreatic Lymphoma Masquerading as Autoimmune Pancreatitis / 대한췌담도학회지

Accurate diagnosis of autoimmune pancreatitis (AIP) is important to clinicians since it is difficult to differentiate AIP from pancreatic malignancies. Furthermore, unlike pancreatic malignancies, AIP has dramatic response to steroids. A 61-years-old man presented with acute pancreatitis. Imaging studies showed two separate pancreatic masses, irregular narrowing of main pancreatic duct, and a renal mass that highly suggested AIP. Endoscopic ultrasound-guided core needle biopsy of the pancreatic masses and ultrasound-guided biopsy of the renal mass revealed peripheral T-cell lymphoma. The patient is currently undergoing chemotherapy. We present a case of pancreatic lymphoma masquerading as AIP with literature review.

Potentially Inappropriate Medications in Elderly Outpatients by the 2012 Version of Beers Criteria: A Single Tertiary Medical Center Experience in South Korea

BACKGROUND: The American Geriatric Society released the 2012 updated version of the Beers criteria with intentions to improve care of older adults by reducing their exposure to potentially inappropriate medications (PIMs). However, there have been no reports on the prevalence of PIMs prescriptions according to the 2012 version of Beers criteria in South Korea. METHODS: This is a retrospective study using medical records and code analysis of each PIM to survey the prevalence of PIMs prescriptions and common PIMs used for elderly patients. Locating the PIMs was carried out in all outpatients who visited Asan Medical Center from May 2012 to April 2013. Selection of PIMs was based on the 2012 updated version of the Beers criteria. RESULTS: A total of 652,192 outpatients older than 65 years visited our medical center during the study period and were analyzed. Among them, 33,810 (5.19%) received at least one PIM and 125,498 cases of PIM prescriptions were written. The percentage of the patients who received at least two kinds of PIMs concurrently was 33.14%. Common PIMs were tramadol (24.15%), clonazepam(11.51%), ibuprofen (10.02%), megesterol (9.80%), and amitriptyline (9.51%). CONCLUSION: Our study investigated the prevalence of PIMs prescription for Korean elderly outpatients in a single tertiary medical center. Compared to previous reports using the older version of the Beers criteria, our study showed a change in the priority of common PIMs.

Computational Flow Dynamics of the Severe M1 Stenosis Before and After Stenting / 신경중재치료의학

PURPOSE: Computational flow dynamic (CFD) study has not been widely applied in intracranial artery stenosis due to requirement of high resolution in identifying the small intracranial artery. We described a process in CFD study applied to symptomatic severe intracranial (M1) stenosis before and after stenting. MATERIALS AND METHODS: Reconstructed 3D angiography in STL format was transferred to Magics (Materialise NV, Leuven, Belgium) for smoothing of vessel surface and trimming of branch vessels and to HyperMesh (Altair Engineering Inc., Auckland, New Zealand) for generating tetra volume mesh from triangular surface-meshed 3D angiogram. Computational analysis of blood flow in the blood vessels was performed using the commercial finite element software ADINA Ver 8.5 (ADINA R & D, Inc., Lebanon, MA). The distribution of wall shear stress (WSS), peak velocity and pressure in a patient was analyzed before and after intracranial stenting. RESULTS: Computer simulation of wall shear stress, flow velocity and wall pressure before and after stenting could be demonstrated three dimensionally by video mode according to flow vs. time dimension. Such flow model was well correlated with angiographic finding related to maximum degree of stenosis. Change of WSS, peak velocity and pressure at the severe stenosis was demonstrated before and after stenting. There was no WSS after stenting in case without residual stenosis. CONCLUSION: Our study revealed that CFD analysis before and after intracranial stenting was feasible despite of limited vessel wall dimension and could reveal change of WSS as well as flow velocity and wall pressure.