Underwater Endoscopic Mucosal Resections of Non-ampullary Small Duodenal Tumors

Conventional endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been reported to be effective therapeutic options in sporadic non-ampullary duodenal tumors, but the rate of perforation is higher than that of other gastrointestinal lesions. Underwater EMR (UW EMR) has been reported to be a safe alternative to conventional EMR and ESD for superficial non-ampullary duodenal adenomas. We reviewed the medical chart and endoscopic report of patients who underwent endoscopic resection between August 2018 and February 2020. A total of 12 duodenal tumors were resected by UW EMR. The mean specimen and lesion sizes were 6.7 mm (2~16 mm) and 5.3 mm (2~10 mm), respectively. Of the 12 lesions, nine (75.0%) were located in the 2nd portion, and three (25.0%) were in the bulb. The mean procedural time was 7.8 minutes (3.2~18.7 minutes). Histologic results showed 10 dysplasia (nine low-grade, one high-grade) and two neuroendocrine tumors. UW EMR showed favorable efficacy and safety within small dysplastic lesions compared to previous studies’ results. Furthermore, it might be considered a treatment option with caution in patients with the duodenal subepithelial tumor within the third layer.

Basic Knowledge that Doctors Starting ERCP Should Know / 대한췌담도학회지

The first endoscopic retrograde cholangiopancreatography (ERCP) wad performed in 1968. With tremendous progress in techniques, instruments and devices, ERCP has played an important role in modern medicine for the diagnosis and management of various pancreaticobiliary diseases. ERCP has a potential risk of various complications even in the hands of the experts. The incidence of all ERCP-related complications is known to be about 4–10%, and that of fatal complications to be less than 0.5%. In order to prevent and minimize its side effects, the everyone who performs ERCP needs to fully understand various techniques and also recognize and deal with ERCP-related complications. In this review, we have summarized the must-know points in techniques and complications of ERCP for the beginners.

Basic Knowledge that Doctors Starting ERCP Should Know / 대한췌담도학회지

The first endoscopic retrograde cholangiopancreatography (ERCP) wad performed in 1968. With tremendous progress in techniques, instruments and devices, ERCP has played an important role in modern medicine for the diagnosis and management of various pancreaticobiliary diseases. ERCP has a potential risk of various complications even in the hands of the experts. The incidence of all ERCP-related complications is known to be about 4–10%, and that of fatal complications to be less than 0.5%. In order to prevent and minimize its side effects, the everyone who performs ERCP needs to fully understand various techniques and also recognize and deal with ERCP-related complications. In this review, we have summarized the must-know points in techniques and complications of ERCP for the beginners.

Endoscopic Removal of Gastric Lipoma with Hemorrhage Using Endoscopic Submucosal Dissection / 대한내과학회지

Most upper gastrointestinal lipomas occur in the duodenal second portion, and gastric lipomas are rare. Most lipomas are usually asymptomatic, but symptoms such as abdominal pain, intussusception, ulceration, and intestinal obstruction may occur depending on the size and location and, rarely, can cause bleeding. Endoscopic polypectomy, endoscopic mucosal resection, and surgical resection are the treatments of choice for lipomas with intestinal obstruction or bleeding. Upper gastrointestinal bleeding from lipoma is mostly of duodenal origin and very rarely from the stomach. Here, we report a case of successful treatment of gastric lipoma with massive bleeding by endoscopic resection.

Endoscopic Removal of Gastric Lipoma with Hemorrhage Using Endoscopic Submucosal Dissection / 대한내과학회지

Most upper gastrointestinal lipomas occur in the duodenal second portion, and gastric lipomas are rare. Most lipomas are usually asymptomatic, but symptoms such as abdominal pain, intussusception, ulceration, and intestinal obstruction may occur depending on the size and location and, rarely, can cause bleeding. Endoscopic polypectomy, endoscopic mucosal resection, and surgical resection are the treatments of choice for lipomas with intestinal obstruction or bleeding. Upper gastrointestinal bleeding from lipoma is mostly of duodenal origin and very rarely from the stomach. Here, we report a case of successful treatment of gastric lipoma with massive bleeding by endoscopic resection.

Comparison of Image Quality between Swept-Source and Spectral-Domain Optical Coherence Tomography According to Ocular Media Opacity

PURPOSE: To compare the image quality between swept-source optical coherence tomography (SS-OCT) and spectral domain optical coherence tomography (SD-OCT), especially in eyes with media opacity. METHODS: Forty eyes without media opacity and 60 eyes with media opacity (30 eyes with cataract, 20 eyes with vitreous opacity, and 10 eyes with corneal opacity) were included in this study. SD-OCT and SS-OCT 6 x 6 macular scans were taken by a single operator. For image quality analysis, a total of 200 OCT images were subjectively graded by two trained retina specialists and measured quantitatively using the image quality factor (QF) built into the OCT devices. RESULTS: Compared to conventional SD-OCT, SS-OCT had statistically significantly better subjective and objective grades in the normal group, as well as each of the media opacity groups (p-value < 0.001). In both the subjective and objective grades, there was no significant difference according to the types of media opacity (QF: p = 0.188, subject grading scale [SGS]: p = 0.635) and the degree of media opacity (Group I: 20 < or = QF < 50, Group II: 0 < or = QF < 20; QF: p = 0.088, SGS: p = 0.051) in the superiority of image quality of SS-OCT to SD-OCT. CONCLUSIONS: In this media opacity patient population, swept-source OCT is a superior diagnostic tool when compared with SD-OCT in both objective and subjective assessments, even in the ocular media opacity. This result may be useful in diagnosis and progression detection of retinal disease in media opacity eyes.

Evaluation of the Cortical Vitreous Using Swept-Source Optical Coherence Tomography in Normal Eyes

PURPOSE: To observe the shape of posterior vitreous spaces using swept-source optical coherence tomography (SS-OCT) in normal eyes. METHODS: The posterior vitreous of 80 eyes of 80 volunteers without ocular disease was imaged. The DRI OCT-1 Atlantis (Topcon, Oakland, NJ, USA) was used to acquire scans of the posterior vitreous over an 18 × 18-mm2 area using the 12-mm horizontal line scan protocol. The size of the premacularis bursa was measured by the aliper function of the OCT. RESULTS: A boat-shape bursa was found in most cases. The prevalence of detected bursa fell with further increases in the extent of posterior vitreous detachment. The mean width of the bursa premacularis was 7,679.1 µm and the mean depth was 471.4 µm. CONCLUSIONS: Deep range imaging optical coherence tomography will provide improvement for in vivo anatomic characterization of the cortical vitreous, and allow better visualization of the dimensions of the bursa premacularis.

Evaluation of the Cortical Vitreous Using Swept-Source Optical Coherence Tomography in Normal Eyes

PURPOSE: To observe the shape of posterior vitreous spaces using swept-source optical coherence tomography (SS-OCT) in normal eyes. METHODS: The posterior vitreous of 80 eyes of 80 volunteers without ocular disease was imaged. The DRI OCT-1 Atlantis (Topcon, Oakland, NJ, USA) was used to acquire scans of the posterior vitreous over an 18 × 18-mm2 area using the 12-mm horizontal line scan protocol. The size of the premacularis bursa was measured by the aliper function of the OCT. RESULTS: A boat-shape bursa was found in most cases. The prevalence of detected bursa fell with further increases in the extent of posterior vitreous detachment. The mean width of the bursa premacularis was 7,679.1 µm and the mean depth was 471.4 µm. CONCLUSIONS: Deep range imaging optical coherence tomography will provide improvement for in vivo anatomic characterization of the cortical vitreous, and allow better visualization of the dimensions of the bursa premacularis.

Macular Choroidal Thickness and Volume Measured by Swept-source Optical Coherence Tomography in Healthy Korean Children

PURPOSE: To evaluate the thickness and volume of the choroid in healthy Korean children using swept-source optical coherence tomography. METHODS: We examined 80 eyes of 40 healthy children and teenagers ( or =18 years) and compared adult measurements with the findings in children. RESULTS: The mean age of the children and teenagers was 9.47 +/- 3.80 (4 to 17) vs. 55.04 +/- 12.63 years (36 to 70 years) in the adult group (p < 0.001, Student's t-test). Regarding the Early Treatment Diabetic Retinopathy Study subfields, the inner temporal subfield was the thickest (247.96 microm). The inner and outer nasal choroid were thinner (p = 0.004, p = 0.002, respectively) than the surrounding areas. The mean choroidal volumes of the inner and outer nasal areas were smaller (p = 0.004, p = 0.003, respectively) than those of all the other areas in each circle. Among the nine subfields, all areas in the children, except the outer nasal subfield, were thicker than those in adults (p < 0.05). Regression analysis showed that age, axial length, and refractive error correlated with subfoveal choroidal thickness (p < 0.05). CONCLUSIONS: Overall macular choroidal thickness and volume in children and teenagers were significantly greater than in adults. The nasal choroid was significantly thinner than the surrounding areas. The pediatric subfoveal choroid is prone to thinning with increasing age, axial length, and refractive error. These differences should be considered when choroidal thickness is evaluated in children with chorioretinal diseases.

Comparison of Ocular Biometry and Postoperative Refraction in Cataract Patients between Galilei-G6(R) and IOL Master(R)

PURPOSE: To compare the axial lengths, anterior chamber depths, and keratometric measurements and to predict postoperative refractions of Dual Scheimpflug analyzer Galilei G6(R) and intra ocular lens (IOL) Master(R). METHODS: A total of 50 eyes in 50 patients who received cataract surgery were included in the present study. The axial length, anterior chamber depth, and keratometry were measured using 2 types of partial coherence interferometries (Galilei G6(R) and IOL Master(R)). The SRK/T formula was used to calculate IOL power and the predictive error which subtracts predictive refraction from postoperative refraction was compared between the ocular biometry devices. RESULTS: Axial lengths were 23.36 +/- 0.80 mm and 23.36 +/- 0.90 mm measured by Galilei G6(R) and IOL Master(R), respectively. Axial length measured by Galilei G6(R) was not statistically significant compared with IOL Master(R) (p = 0.321). The anterior chamber depth and keratometry were 3.22 +/- 0.35 mm and 44.29 +/- 1.40 D measured by Galilei G6(R) and 3.11 +/- 0.46 mm and 44.39 +/- 1.41 D measured by IOL Master(R), respectively. The differences of anterior chamber depth and keratometry between the 2 devices were statistically significant (p < 0.001 and p = 0.028, respectively). The mean absolute prediction errors were 0.45 +/- 0.37 D and 0.49 +/- 0.39 D in Galilei G6(R) and IOL Master(R), respectively and was not statistically significantly different (p = 0.423). CONCLUSIONS: The ocular biometric measurements and prediction of postoperative refraction using Galilei G6(R) were as accurate as with IOL Master(R).

Mechanical ventilation-associated pneumothorax presenting with paroxysmal supraventricular tachycardia in patients with acute respiratory failure / 영남의대학술지

The prevalence of pneumothorax cases among Intensive Care Unit patients who require mechanical ventilation ranges from 4%-15%. A pneumothorax remains one of the most serious complications of positive pressure ventilation. It can be diagnosed in a critically ill patient through a physical examination or radiographic studies that include chest radiographs, ultrasonography, or computed tomography scanning. However, in a critically ill patient, the diagnosis of a pneumothorax is often complicated by other diseases and by difficulties in imaging sick and unconscious patients. Although electrocardiogram changes associated with a pneumothorax have been described for many years, there has been no report of such among patients who require mechanical ventilation. In this paper, we report 2 cases of a spontaneous pneumothorax with paroxysmal supraventricular tachycardia in patients who required invasive mechanical ventilation due to acute respiratory failure.

Soft Tissue Malignant Myoepithelioma in the Extremities / 대한골관절종양학회지

PURPOSE: We report the diagnosis, treatment outcomes and prognosis of the patients with soft tissue malignant myoepithelioma in the extremities. MATERIALS AND METHODS: We retrospectively reviewed 6 patients with soft tissue malignant myoepithelioma in the extremities who were treated at our institution between 2008 and 2014. Two patients received unplanned excision at another hospital and remaining 4 patients underwent the biopsy procedures and received wide excision at our hospital. RESULTS: There were 3 men and 3 women with mean age of 41 (33-54) years. The average follow up was 28 (9-45) months. Among the 6 patients, only 4 patients underwent biopsy procedures under the impression of malignant soft tissue sarcoma. Surgical margins for these 4 patients were negative. Two patients who had unplanned excision received another re-excision and one of them showed no residual tumor in the resected specimen. Local recurrences were developed in all patients and distant metastasis in 4 patients. All 4 patients who developed distant metastasis died due to disease progression. Among the 2 patients who developed local recurrence only, one patient has another local recurrence after re-operation and remaining one patient is no evidence of disease for 2 years after resection of locally recurred mass. CONCLUSION: Soft tissue malignant myoepithelioma in the extremities is a rare disease and shows an aggressive behavior. Appropriate biopsy under the impression of soft tissue malignancy is necessary and complete surgical resection with wide margins is the recommended treatment of choice.

Rosai-Dorfman Disease as a Solitary Lesion of the Tibia / 대한골관절종양학회지

Rosai-Dorfman disease (RDD) is an idiopathic histioproliferative disorder of lymph node and extranodal site. Bone involvement is very rare. We report a case of extranodal RDD of the tibia in 32-year old male. The patient presented with pain with no evidence of lymphadenopathy. Clinico-radiologic diagnosis was metastatic carcinoma or Langerhans cell histiocytosis, but, histopathologic examination confirmed the diagnosis with RDD. We performed curettage on the osteolytic lesion of tibia. In South Korea, there was no report about RDD of the extremity and we want to report this case with review of the literature.

Intravitreal Bevacizumab Injection for the Treatment of Choroidal Neovascularization Secondary to Candida Chorioretinitis

PURPOSE: To report a case of choroidal neovascularization (CNV) secondary to candida chorioretinitis initially treated with an intravitreal bevacizumab injection. CASE SUMMARY: A 50-year-old female presented at our clinic with decreased vision and metamorphopsia in her left eye of 5 days duration. She received an anti-fungal treatment 2 months prior due to the presence of endogenous candida choroiditis in both eyes. Fluorescein angiography and optical coherence tomography (OCT) revealed juxtafoveal CNV in her left eye. Three monthly intravitreal injections of bevacizumab were administered as the initial loading dosage. Her visual symptoms improved and CNV regression was observed on OCT. No recurrence or complications were observed during the 6 month follow-up. CONCLUSIONS: Based on the present study results we suggest that intravitreal bevacizumab injection can be used to effectively treat CNV and improve visual symptoms during the treatment of juxtafoveal CNV associated with candida choroiditis.

Plain Radiologic Findings and Chronological Changes of Incipient Phase Osteosarcoma Overlooked by Primary Physicians

BACKGROUND: We assessed the plain radiographic characteristics of 10 cases of osteosarcomas during the initial painful period that had been overlooked by a primary physician. In addition, we evaluated chronologic changes in radiographic findings from initial symptomatic period to the time of accurate diagnosis. METHODS: The clinical records were reviewed for clinical parameters including age, sex, location, presenting symptoms, initial diagnosis, duration from initial symptoms to definite diagnosis, and initial and follow-up plain radiographic findings of the lesion. RESULTS: Initial clinical diagnoses included a sprain in 6, growing pain in 2, stress fracture in 1, and infection in 1 patient. Initial plain radiographic findings were trabecular destruction (100%), cortical disruption (60%), periosteal reaction (60%), and soft tissue mass (10%). Intramedullary matrix changes were osteosclerosis in 6 and osteolysis in 4 patients. On progression, 4 cases with minimal sclerosis changed to osteoblastic lesion in 3 patients and osteolytic lesion in 1. Four cases with faint osteolytic foci transformed into osteolytic lesion in 3 and mixed pattern in 1. CONCLUSIONS: Notable plain radiologic findings of incipient-stage osteosarcoma include trabecular disruption along with faint osteosclerosis or osteolysis. In symptomatic patients with trabecular destruction, additional imaging study including magnetic resonance imaging should be performed to exclude osteosarcoma in the incipient phase, even without radiologic findings suggesting malignant tumor, such as cortical destruction or periosteal reaction.

Maritime Remote Medical Advice Performed by Emergency Medical Information Center in South Korea

PURPOSE: Seafarers injured at sea need appropriate and prompt medical advice. Since 2002, the Busan emergency medical information center (BEMIC) has provided remote medical advice to vessels on the distant ocean via telephone, e-mail, facsimile and radio-transmission. METHODS: Seventy-four cases had requested remote medical advices to BEMIC from Jan 2005 to Jul 2005, and they were studied retrospectively. We analyzed patients' general characteristics, type of disease or injury, dispositions, and so forth. The cases were classified into three groups according to disposition. Class I was defined as a case which required simple treatment. Class II involved medical or surgical treatment with close observation. Class III required transfer to the nearest harbor instantly due to severe or uncertain condition. RESULTS:The nationalities of subjects were Korean (32.4%), Southeast Asians (35.1%), Chinese (24.3%) and others. The most common symptom was abdominal pain (24.3%). The patients'disease types were acute disease (53.4%), trauma (20.3%), burn (13.7%), chronic disease (8.2%) and others. There were 8 voluntary medication cases, which were performed by seamen before taking medical advice. The dispositions were class I (6.8%), class II (39.7%), and class III (53.5%), respectively. A cross-sectional study between the types and the dispositions was performed, revealing a statistical significance (p<0.001). CONCLUSION: Despite the lack of any kind of direct support from ship companies or governments, the remote medical advice service has performed. Enhancing educational programs based on this data is necessary in order to provide effective education of seafarers.

Lung Injury Induced by Major Burns does not Affect Fentanyl Clearance / 대한마취과학회지

BACKGROUND: Major burns can alter the pharmacokinetics of opiate analgesics, which are commonly used perioperatively. Fentanyl undergoes a significant amount of pulmonary pharmacokinetic transition. This study was conducted to compare the pharmacokinetics of fentanyl in major burns, with and without lung injury, during the subacute hyperdynamic phase of recovery. METHODS: Twelve adults, with total body surface area (TBSA) 51.0 +/- 11.8% burns, aged 34.9 +/- 9.6 years, with a lung injury related to the burn, were studied at 15.4 +/- 9.4 days after the injury. Another 8 patients, aged 39.8 +/- 10.5 years, with TBSA 46.3 +/- 19.4%, at 19.3 +/- 10.9 days, without lung injury, served as controls. Fentanyl 200microgram was given intravenously over 10 seconds. Blood samples (n = 20) were collected at predetermined intervals. A two-compartment model was used for pharmacokinetic analyses of the fentanyl concentrations, as determined by LC/MS. The cardiac index (CI) was also measured using an esophageal Doppler monitor. RESULTS: There were no differences in the patient characteristics between the two groups. Those with burns had a significantly higher cardiac index (4.1 +/- 2.4 L/min/m2), clearance (Cl), central (V1) and total volume of distribution (Vd), but there were no differences between those with and without lung injury (30.2 +/- 14.3 vs. 30.1 +/- 5.8 ml/min/kg, 0.8 +/- 0.3 vs. 0.6 +/- 0.2 L/kg, 5.8 +/- 1.7 vs. 5.2 +/- 2.1 L/kg, respectively). Prolonged distribution (t1/2alpha) and elimination half-lives (t1/2beta) were noted in those with burns, but there were no differences between the two groups (3.2 +/- 1.3 vs. 3.3 +/- 1.3 minutes, 2.6 +/- 1.4 vs. 2.0 +/- 0.7 hours, respectively). CONCLUSIONS: The increased Cl of fentanyl in those with burns is primarily dependent upon the resultant increased hepatic blood flow. The pulmonary kinetics is a saturable process, which is not affected by a single bolus of fentanyl. The lung injury induced by major burns would have no influence on the elimination kinetics of fentanyl.

Aberrant Promoter Methylation of Death-Associated Protein Kinase in Serum DNA from Lung Cancer Patients / 결핵

BACKGROUND: Promoter methylation of tumor suppressor genes is one of the key epigenetic changes in many human cancers. The aim of this study was to evaluate the promoter methylation status of the Death-associated protein(DAP) kinase gene, which played an important role in lung cancer, in the serum DNA of primary lung cancer patients. METHODS: This study investigated the aberrant methylation of DAP kinase in the serum of 65 primary lung cancer patients by methylation-specific PCR (MSP). RESULTS: Methylation in the serum was detected in 29 of 65(44.6%) for DAP kinase. There was no statistical association between methylation of DAP kinase and age, smoking history, histologic type, or stage. Methylation of DAP kinase was found more frequently in men (p=0.044). CONCLUSIONS: This study suggests that the aberrant methylation of the DAP kinase promoter is readily detectable in the serum DNA of lung cancer patients using MSP analysis.

Clinical Characteristics and Treatment Outcomes of Patients with Pulmonary Tuberculosis at a Private General Hospital / 결핵

BACKGROUND: Until the early 1990's in Korea, treatment outcomes of patients with pulmonary tuberculosis in the private sector were reported to be inferior to those of the public health center under the National Tuberculosis Programme. The purpose of this study was to analyze the clinical characteristics and the treatment efficacy of the patients with pulmonary tuberculosis recently diagnosed at a private general hospital. MATERIALS and METHODS: The study included all pulmonary tuberculosis patients diagnosed at Samsung Medical Center and notified to the public health center from August 2000 to January 2001. RESULTS: Of the 232 patients included in the study during a 6-month period, 188 were (81.0%) initial treatment cases and 44 (19.0%) were re-treatment cases. Eighty-three (35.8%) patients had smear-positive sputa, and 27 (11.6%) had smear-negative, culture-positive sputa. Initial sputum examinations were not performed in 47 (20.3%) patients. A six-month, short-course treatment using isoniazid, rifampin, ethambutol and pyrazinamide was prescribed for 31.4% of the patients under the initial treatment. The success rate (cured plus treatment completed) of the initial treatment for the smear-positive patients was 69.1%. Eleven (13.3%) of the 83 patients with smear-positive pulmonary tuberculosis discontinued their treatment without notice. CONCLUSIONS: To improve the treatment efficacy and decrease the default rates of the patients with pulmonary tuberculosis in the private sector, further efforts are required in line with the Korean Academy of Tuberculosis and Respiratory Disease Treatment Guidelines and in the implementation of an appropriate model of public-private mix for tuberculosis control in Korea.

The Expression of MUC1 and CD44s in Non-small Cell Lung Cancer / 결핵

BACKGROUND: MUC1 mucin is a heavily glycosylated large glycoprotein and is expressed aberrantly in carcinoma. CD44 is polymorphic family of cell surface glycoproteins participating in cell-cell adhesion and modulat ion of the cell-matrix interaction. MUC1 mucin and CD44 expression have been implicated in a tumor invasion and metastasis in certain malignancies. In this study, the expression of MUC1 and the standard form of CD44(CD44s) was examined in non-small cell lung cancer (NSCLC). METHODS: Immunohistochemical staining using monoclonal antibodies including MUC1 glycoprotein and CD44s was performed on 80 NSCLC surgical specimens. The association between MUC1 and CD44s expression and the histological type and tumor stage was investigated. RESULTS: Depolarized MUC1 expression in more than 10% of cancer cells was found in 12 (27.9%) out of 43 squamous cell carcinomas (SCCs) and 12 (32.4%) out of 37 adenocarcinomas (ACs). It was not associated with the tumor histological type and the TNM-stage in SCCs. Depolarized MUC1 expression correlated with the N-stage in ACs (p=0.036). CD44s was expressed in 36 (83.7%) out of 43 SCCs and 14(37.8%) out of 37ACs. Reduced CD44s expression correlated with the N-stage (p=0.031) and the TNM-stage (p=0.0006) in SCCs. CONCLUSIONS: Depolarized MUC1 expression was related to the nodal stage in NSCLC adenocarcinoma. Reduced CD44s expression was related to nodal involvement and the TNM-stage in squamous cell carcinoma. This suggests that MUC1 and CD44s expression in NSCLC might play important roles in tumor progression and can be used as prognostic variables.