Guidewire Impaction in the Main Pancreatic Duct in a Patient with Chronic Pancreatitis:A Case Report / 대한소화기학회지

The guidewire is an essential accessory in ERCP. Although rare, guidewires can cause complications, such as subcapsular hepatic hematoma, perforation, knotting, fracture, and impaction, during ERCP. This report describes a guidewire impaction during the endoscopic treatment of a patient with symptomatic chronic pancreatitis. The methods used to treat guidewire impaction are not well known. In the present case, the impacted guidewire was retrieved by inserting another guidewire and dilating the space adjacent to it. Endoscopists should check for the free movement of the guidewire before stent deployment. Additionally, it is important to ask for help from experienced senior staff to overcome any challenges during the procedure. In conclusion, endoscopists should be aware of the possibility of a guidewire impaction during ERCP.

Tenofovir alafenamide treatment may not worsen the lipid profile of chronic hepatitis B patients: A propensity score-matched analysis

Background/Aims@#Tenofovir alafenamide (TAF) has shown less favorable effect on lipids compared to tenofovir disoproxil fumarate (TDF) in clinical trials. However, data regarding these outcomes in patients with chronic hepatitis B (CHB) are scarce. Therefore, this study aimed to evaluate the effect of TAF on the lipid in patients with CHB. @*Methods@#A total of 237 TAF-treated CHB patients compared with TDF, inactive CHB, and non-hepatitis B virus (HBV)-infected control groups using propensity score matching (PSM). @*Results@#Following PSM, each analysis was conducted on cohorts via the matching of 70:140 (TAF:TDF), 89:89 (TAF:inactive CHB), 140:560 (TAF:non-HBV infected control), and 368:1,472 (TDF:non-HBV-infected control). A significant decrease in the total cholesterol (TC) level was noted at 48 weeks in the TDF group compared to the TAF group (176.3±32.9 vs. 156.7±27.7, P<0.001) and the non-HBV-infected control group (175.0±29.5 vs. 156.2±28.3, P<0.001). However, no significant change in TC was observed in the TAF group and inactive CHB or non-HBV-infected control groups at 48 weeks. For the subgroup analyses of TAF vs. non-HBV-infected control subjects and inactive CHB patients whose detailed lipid profile information were available, no between-group differences in TC, low-density lipoprotein (LDL)-cholesterol, highdensity lipoprotein (HDL)-cholesterol, TC/HDL ratio, and LDL/HDL ratio were observed at 48 weeks. @*Conclusions@#TDF seems to have a lipid-lowering effect compared to the non-HBV-infected control and TAF-treated groups. However, in real practice, TAF might not worsen the lipid profiles of subjects compared to non-HBV-infected controls and patients with inactive CHB.

Cognitive improvement effect of gintonin might be associated with blood-brain barrier permeability enhancement: dynamic contrastenhanced MRI pilot study

Along with the multiple neuroprotective effect, recent studies suggest that gintonin might increase the blood brain barrier permeability. We evaluated the effect of gintonin on the vascular permeability changes in different brain segments, using dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI). In this 8-week, randomized, open label pilot study, ten participants with subjective memory impairment but preserved cognitive function assigned to gintonin-enriched fraction (GEF) 300 mg/day or placebo groups. Korean versions of the Alzheimer's disease assessment scale (ADAS-K) and DCE-MRI parameters including Ktrans and Vp in different brain segments were evaluated at baseline and at 8 weeks after treatment. Nine participants completed the study protocol. No adverse events occurred during the observation period for 8 weeks in both groups. Following gintonin administration, increment trends of the brain permeability that did not reach a statistical significance were observed in the left hippocampus (Ktrans and Vp , both, p = 0.062), left thalamus and in left putamen (Ktrans , p = 0.062), and left insula and right amygdala (Vp , p = 0.062), but not in the control placebo group. The increment of the Ktrans value in the left thalamus from the baseline was highly correlated with the change of the ADAS scores (r = −0.900, p = 0.037). Gintonin might enhance the blood-brain barrier (BBB) permeability in the brain structures involved in cognitive functions. Further efficacy exploration for the synergistic effect of gintonin's BBB permeability enhancement to its other cognitive enhancing mechanisms are warranted.

Low-level viremia and cirrhotic complications in patients with chronic hepatitis B according to adherence to entecavir

Background/Aims@#Low-level viremia (LLV) after nucleos(t)ide analog treatment was presented as a possible cause of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB). However, detailed information on patients’ adherence in the real world was lacking. This study aimed to evaluate the effects of LLV on HCC development, mortality, and cirrhotic complications among patients according to their adherence to entecavir (ETV) treatment. @*Methods@#We performed a retrospective observational analysis of data from 894 consecutive adult patients with treatment-naïve CHB undergoing ETV treatment. LLV was defined according to either persistent or intermittent episodes of <2,000 IU/mL detectable hepatitis B virus DNA during the follow-up period. Good adherence to medication was defined as a cumulative adherence ≥90% per study period. @*Results@#Without considering adherence in the entire cohort (n=894), multivariate analysis of the HCC incidence showed that LLV was an independent prognostic factor in addition to other traditional risk factors in the entire cohort (P=0.031). Good adherence group comprised 617 patients (69.0%). No significant difference was found between maintained virologic response and LLV groups in terms of the incidence of liver-related death or transplantation, HCC, and hepatic decompensation in good adherence group, according to multivariate analyses. @*Conclusions@#In patients with treatment-naïve CHB and good adherence to ETV treatment in the real world, LLV during treatment is not a predictive factor for HCC and cirrhotic complications. It may be unnecessary to adjust their antiviral agent for patients with good adherence who experience LLV during ETV treatment.

Efficacy of tenofovir-based rescue therapy for chronic hepatitis B patients with resistance to lamivudine and entecavir

BACKGROUND/AIMS: Tenofovir disoproxil fumarate (TDF) monotherapy for 48 weeks provided a virological response comparable to that of TDF and entecavir (ETV) combination therapy in patients infected with ETV-resistant hepatitis B virus (HBV). Little long-term data in routine clinical practice are available regarding the optimal treatment of patients with ETV-resistant HBV. METHODS: We investigated the long-term antiviral efficacy of combination therapy of TDF+lamivudine (LAM) or TDF+ETV compared to that of TDF monotherapy in 73 patients with resistance to both LAM and ETV. RESULTS: Patients were treated with TDF monotherapy (n=12), TDF+LAM (n=19), or TDF+ETV (n=42) for more than 6 months. The median duration of TDF-based rescue therapy was 37 months. Virologic response (VR) was found in 63 patients (86.3%). The rates of VR among the three groups (TDF monotherapy, TDF+LAM, and TDF+ETV) were not statistically different (log-rank P=0.200) at 12 months (59.3%, 78.9%, and 51.8%, respectively) or at 24 months (88.4%, 94.7%, and 84.2%). In addition, treatment efficacy of TDF-based combination or TDF monotherapy was not statistically different with ETV-resistant strains or exposure to other antiviral agents. In multivariate analysis, only lower baseline HBV DNA level was an independent predictor for VR (hazard ratio, 0.723; 95% confidence interval, 0.627-0.834; P<0.001). CONCLUSIONS: TDF monotherapy was as effective as combination therapy of TDF+LAM or TDF+ETV in maintaining long-term viral suppression in chronic hepatitis B patients with resistance to both LAM and ETV. HBV DNA level at the start of TDF rescue therapy was the only independent predictor of subsequent VR.

Differential Effects of Quercetin and Quercetin Glycosides on Human α7 Nicotinic Acetylcholine Receptor-Mediated Ion Currents

Quercetin is a flavonoid usually found in fruits and vegetables. Aside from its antioxidative effects, quercetin, like other flavonoids, has a various neuropharmacological actions. Quercetin-3-O-rhamnoside (Rham1), quercetin-3-O-rutinoside (Rutin), and quercetin-3-(2(G)-rhamnosylrutinoside (Rham2) are mono-, di-, and tri-glycosylated forms of quercetin, respectively. In a previous study, we showed that quercetin can enhance α7 nicotinic acetylcholine receptor (α7 nAChR)-mediated ion currents. However, the role of the carbohydrates attached to quercetin in the regulation of α7 nAChR channel activity has not been determined. In the present study, we investigated the effects of quercetin glycosides on the acetylcholine induced peak inward current (I(ACh)) in Xenopus oocytes expressing the α7 nAChR. I(ACh) was measured with a two-electrode voltage clamp technique. In oocytes injected with α7 nAChR copy RNA, quercetin enhanced I(ACh), whereas quercetin glycosides inhibited I(ACh). Quercetin glycosides mediated an inhibition of I(ACh), which increased when they were pre-applied and the inhibitory effects were concentration dependent. The order of I(ACh) inhibition by quercetin glycosides was Rutin≥Rham1>Rham2. Quercetin glycosides-mediated I(ACh) enhancement was not affected by ACh concentration and appeared voltage-independent. Furthermore, quercetin-mediated I(ACh) inhibition can be attenuated when quercetin is co-applied with Rham1 and Rutin, indicating that quercetin glycosides could interfere with quercetin-mediated α7 nAChR regulation and that the number of carbohydrates in the quercetin glycoside plays a key role in the interruption of quercetin action. These results show that quercetin and quercetin glycosides regulate the α7 nAChR in a differential manner.

Comparison of tenofovir plus lamivudine versus tenofovir monotherapy in patients with lamivudine-resistant chronic hepatitis B

BACKGROUND/AIMS: Tenofovir disoproxil fumarate (TDF) exhibits similar antiviral efficacy against treatment-naïve and lamivudine (LAM)-resistant chronic hepatitis B (CHB). However, there are few clinical reports on the antiviral effects of TDF-LAM combination therapy compared to TDF monotherapy in patients with LAM-resistant CHB. METHODS: We investigated the antiviral efficacy of TDF monotherapy vs. TDF-LAM combination therapy in 103 patients with LAM-resistant CHB. RESULTS: The study subjects were treated with TDF alone (n=40) or TDF-LAM combination therapy (n=63) for ≥6 months. The patients had previously been treated with TDF-based rescue therapy for a median of 30.0 months (range, 8-36 months). A virologic response (VR) was achieved in 99 patients (96.1%): 95.0% (38/40) of patients in the TDF monotherapy group and 96.8% (61/63) of patients in the TDF-LAM combination therapy group. The VR rates were not significantly different between the TDF monotherapy and TDF-LAM combination therapy groups (88.9 vs. 87.3% at month 12, and 94.4 vs. 93.7% at month 24, log-rank p=0.652). Univariate and multivariate analyses revealed that none of the pretreatment factors were significantly associated with VR. CONCLUSIONS: TDF monotherapy was as effective as TDF-LAM combination therapy for maintaining viral suppression in the vast majority of patients with LAM-resistant CHB, which suggests that TDF add-on therapy with LAM is unnecessary.

Clinical Outcomes of Monovision Induced by Presbyopic Correcting Conductive Keratoplasty

PURPOSE: To evaluate the efficacy, safety, and satisfaction of patients who underwent conductive keratoplasty (CK). METHODS: CK was performed in 20 patients between April and December 2009. Surgeries were performed on the dominant eye with emmetropia as the postoperative goal and on the non-dominant eye with mild myopia as the postoperative goal. Patients' satisfaction, refractive change, and visual acuity were evaluated for at least 3 months after the surgery. RESULTS: Preoperatively, the mean manifest refraction spherical equivalent (MRSE) of the non-dominant and dominant patient eyes was 0.56 +/- 0.48 D and 0.88 +/- 0.25 D, respectively. Postoperatively, the mean MRSE of the non-dominant and dominant patient eyes was -1.65 +/- 0.56 D and -0.06 +/- 0.36D at 1 month, -1.33 +/- 0.40 D and 0.17 +/- 0.37 D at 3 months, and -1.10 +/- 0.44 D and 0.31 +/- 0.33 D at 6 months, respectively, indicating significant effect regression. Eleven out of 20 patients (55%) were disappointed with the results of CK. CONCLUSIONS: Conductive keratoplasty led to significant regression of refractive effects during follow-up. Monovision with CK is suggested to be a temporary refractive procedure in patients with presbyopia.

A Case of Mediastinal Tuberculous Lymphadenitis Mimicking a Submucosal Tumor of the Esophagus / 대한내과학회지

Esophageal involvement in tuberculosis is rare, and the clinical presentation may mimic an esophageal submucosal tumor. A 30-year-old woman presented with dysphagia for 1 month. At esophagoscopy, a 3-cm subepithelial mass with normal covering mucosa was found 28~25 cm from the upper incisors. We diagnosed the lesion as a submucosal tumor of the esophagus and performed endoscopic ultrasonography 1 week after the first examination. The second endoscopy showed a large, linear ulceration on the same subepithelial mass. The histologic examination obtained following an endoscopic biopsy revealed chronic granulomatous inflammation, and a molecular nested PCR study for Mycobacterium tuberculosis was positive. The final diagnosis was mediastinal tuberculous lymphadenitis with invasion into the esophagus. We suggest the use of molecular biology techniques when there is a strong clinical suspicion of tuberculosis and difficulty in arriving at a definite diagnosis.

A Case of Gastric Non-Hodgkin's Lymphoma That Developed in a Patient with Behcet's Disease / 대한소화기내시경학회지

Behcet's disease is chronic, relapsing, multi-systemic inflammatory vasculitis. Unlikely the other autoimmune diseases, gastric non-Hodgkin's lymphoma has rarely been reported in a patient with Behcet's disease. We report here on a 40-year-old man who had Behcet's disease for several years and who suffered recurrent oral ulcer, genital ulcer and skin lesion. The patient was treated with azathioprine and intermittent oral steroid. He complained of epigastric pain for 1 month, and he had a large ulcerative lesion seen on endoscopic evaluation. We confirmed the lesion was a gastric, diffuse, large B cell lymphoma by endoscopic biopsy. The patient was treated with the rituximab-CHOP regimen, and he has achieved a complete remission for 3 years. We report here on a case of gastric non-Hodgkin's lymphoma in a patient with Behcet's disease and who also had an ileocecal valve ulcer.

Abrasion of abutment screw coated with TiN

STATEMENT OF PROBLEM: Screw loosening has been a common complication and still reported frequently. PURPOSE: The purpose of this study was to evaluate abrasion of the implant fixture and TiN coated abutment screw after repeated delivery and removal with universal measuring microscope. MATERIAL AND METHODS: Implant systems used for this study were Osstem and 3i. Seven pairs of implant fixtures, abutments and abutment screws for each system were selected and all the fixtures were perpendicularly mounted in liquid unsaturated polyesther with dental surveyor. After 20 times of repeated closing and opening test, the evaluation for the change of inner surface of implant and TiN-coated abutment screw, and weight loss were measured. Mann-Whitney test with SPSS statistical software for Window was applied to analyze the measurement of weight loss. RESULTS: TiN-coated abutment screws of Osstem and 3i showed lesser loss of weight than non-coated those of Osstem and 3i (P < .05, Mann-Whitney test). CONCLUSION: Conclusively, TiN coating of abutment screw showed better resistance to abrasion than titanium abutment screw. It was concluded that TiN coating of abutment screw would reduce the loss of preload with good abrasion resistance and low coefficient of friction, and help to maintain screw joint stability.

A Case of Colonic Duplication Cyst Mimicking Gastrointestinal Stromal Tumor

Duplications of the gastrointestinal tract are rare congenital malformations that are usually present during the first decade of life. However, a smaller number of cases may remain occult until adulthood. Overall, the colon is the least common site of congenital gastrointestinal duplications. Colonic duplications can present with symptoms of diverticulitis and can be confused with acquired giant cysts or masses. We present a rare case of a duplication cyst of the colon in a female adult. Although the preoperative evaluations, including an abdominal CT scan and colonoscopy, were suggestive of a gastrointestinal tumor of the colon, the final diagnosis was a colonic duplication cyst based on the histopathologic examination of the resected specimen. Even if intestinal duplication cysts are uncommon, they should be considered in the differential diagnosis of intestinal masses.

A case of jejuno-jejunal intussusception caused by a small intestinal lipoma / 대한내과학회지

Intussusception is a prolapse of a segment of the intestine into the lumen of the adjacent intestine. The majority of intussusceptions occur in infancy and early childhood. Intussusception arising in adulthood represents only about 5% of all intussusceptions and is usually caused by a malignant small bowel lesion acting as an apex for intussusception. Lipoma is not a common tumor in the gastrointestinal tract, and gastrointestinal lipomas may be submucosal or subserosal. Most of them are asymptomatic, although they may cause abdominal pain, bowel obstruction, and gastrointestinal bleeding. Intestinal intussusception caused by lipoma is uncommon and is particularly rare when the lipoma is located in the small intestine. We report an unusual case of intussusception in an adult male patient, which was caused by a lipomatous lesion located in the proximal jejunum acting as a lead point.

A Case of Nodular Fasciitis in the Upper Eyelid

PURPOSE: To report a rare case of nodular fasciitis in the upper eyelid. CASE SUMMARY: A 42-year-old woman presented with rapid enlarging mass, 15x12 mm in size at left upper eyelid. Orbit CT disclosed an enhanced, well-circumscribed preseptal lid mass. The histopathologic and immunohistochemical analyses after excisional biopsy were consistent with nodular fasciitis. There was no recurrence of the tumor after excision. CONCLUSIONS: For rapidly enlarging lid mass, nodular fasciitis should be considered as a differential diagnosis of sarcoma.

Risk Factors for Lymph Node Metastasis after Endoscopic Resection for Early Colorectal Cancer

BACKGROUND/AIMS: Although endoscopic resection is widely used for the treatment of early colorectal cancer, the risk factors for lymph node metastasis are not clear. This study was designed to determine the risk factors for lymph node metastasis in patients with colorectal cancer who are treated by endoscopic resection. METHODS: The medical records of patients with histologically-proven early colorectal cancers who were treated by endoscopic resection between January 2002 and September 2008 were retrospectively reviewed. Information regarding the demographic data of patients and the clinicopathologic characteristics were recorded and analyzed. RESULTS: Twenty-nine patients who underwent subsequent surgical treatment after endoscopic resection for early colorectal cancer were enrolled in this study. Six patients (20.7%) had lymph node metastases on surgical pathologic examination. The predictive factors for lymph node metastasis were tumor morphology (non-polypoid flat tumors [p=0.019]), absence of background adenomas (p=0.033), and deep submucosal invasion > or = 2,000 um (p=0.012). Unexpectedly, the presence of vascular invasion was not associated with lymph node metastasis. CONCLUSIONS: The presence of vascular invasion might not be an absolute indication for additional surgical treatment of early colorectal cancer; however, deep submucosal invasion, accompanied by a gross tumor with a non-polypoid flat morphology, and the absence of background adenomas are potential risk factors for lymph node metastasis.

Hemobilia from Pancreatic Arteriovenous Malformation: Successful Treatment with Transportal Coil Embolization of Draining Veins / 대한소화기학회지

Pancreatic arteriovenous malformations (AVM) are extremely rare diseases frequently complicated by gastrointestinal hemorrhage. While surgical resection of affected lesion is preferred for the treatment of pancreatic AVM, angiographic intervention can be used as an alternative treatment, especially in surgically high-risk patients. We experienced a patient with pancreatic AVM manifested by hemobilia and biliary sepsis. Superior mesenteric and common hepatic arteriography showed pancreaticoduodenal AVM composed of nidus supplied by numerous fine feeding arteries and of draining veins encircling the common bile duct (CBD). Hemobilia was controlled by transportal coil embolization of draining veins of AVM around the CBD. Herein, we report this case with the review of literatures.

An Ampulla of Vater Carcinoid Tumor that Presented with Upper Gastrointestinal Bleeding / 대한소화기내시경학회지

A Carcinoid tumor of the ampulla of Vater is extremely rare, accounting for less than 0.3% of all gastrointestinal carcinoids. Most reported cases have arisen from the gallbladder. An ampullary carcinoid most commonly presents with jaundice or upper abdominal discomfort, and bleeding from the tumor is exceedingly rare. A diagnosis is most frequently made postoperatively due to submucosal spread of the tumor. As the metastatic potential cannot be predicted by tumor size, a Whipple pancreaticoduodenectomy rather than local excision is considered the treatment of choice. We herein report a case of a primary carcinoid tumor located at the ampulla of Vater that presented as gastrointestinal bleeding; the tumor was diagnosed by an endoscopic biopsy after a papillary sphinterotomy.

Phacoemulsification in Patients with Ahmed Glaucoma Valve Implant

PURPOSE: To investigate the effects of phacoemulsification in glaucomatous eyes with a functioning Ahmed glaucoma valve insertion. METHODS: This retrospective analysis followed 28 eyes from 26 patients with a functioning Ahmed glaucoma valve who had clear corneal phacoemulsification from December 1999 to February 2006. Intraocular pressure (IOP), best corrected visual acuity (BCVA), number of glaucoma medications and additional glaucoma surgeries were measured. RESULTS: The mean IOP before phacoemulsification was 17.4 mmHg +/- 5.8 (SD). Postoperative IOP was 13.6 +/- 4.4 mmHg, 13.7 +/- 4.0 mmHg, 14.1 +/- 4.0 mmHg and 15.4 +/- 3.8 mmHg at 1, 2, 6, and 12 months, respectively. The change in the number of glaucoma medications significantly changed at 1 month (p0.05) postoperatively. The IOP significantly changed at 1 week, 1 month, 2 months, and 6 months (p0.05) postoperatively. No eyes required additional surgery. BCVA improved in 23 eyes; the mean improvement was 3.7 +/- 2.9 Snellen lines at 2 months postoperatively. CONCLUSIONS: Phacoemulsification in glaucomatous eyes with a functioning Ahmed glaucoma valve improved BCVA and maintained control of IOP.

Clinical Outcomes of Lamivudine Therapy in HBeAg Positive Chronic Hepatitis B with Minimally Elevated ALT / 대한간학회지

BACKGROUND/AIMS: The aim of this study was to compare the efficacy of lamivudine therapy between chronic hepatitis B (CHB) patients, whose ALT levels less than 2 times the upper limit of normal (ULN) and patients whose ALT levels are more than 2 times ULN. METHODS: We retrospectively analyzed 508 consecutive patients with HBeAg-positive CHB who were treated with lamivudine for 1 year or more. Forty-six patients (Group A) with pretreatment ALT levels less than 2 times ULN were retrospectively compared with 462 patients (Group B) whose ALT levels are more than 2 times ULN. RESULTS: HBeAg seroconversion was achieved in 15 (32.6%) of group A and 162 (35.1%) of group B. The cumulative rates of HBeAg seroconversion in group A and B were 19% and 21% at 12 months; 35% and 31% at 24 months; and 38% and 39% at 36 months, respectively. HBV breakthrough was observed in 20 (43.5%) of group A and 192 (41.6%) of group B. The cumulative breakthrough rates of group A and B were 18% and 12% at 12 months; 33% and 29 % at 18 months; 45% and 42% at 24 months, respectively. Post-treatment relapse in group A and B occurred in 56% (5/9) and 41% (44/108), respectively. Therefore, the rates of the HBeAg seroconversion, breakthrough, and post-treatment relapse were not significantly different between these two groups. CONCLUSIONS: Lamivudine therapy in HBeAg-positive CHB patients whose ALT levels are minimally elevated is as effective as in treatment of the patients whose pretreated ALT levels are twice more than ULN.

The Effect of Irrigating Solution on the Corneal Endothelial Structures during Phacoemulsification

PURPOSE: To determine the effects of BSS Plus(R) and Optiplus(R) irrigating solution on the corneal endothelium in patients undergoing phacoemulsification with posterior chamber lens implantation. METHODS: The study comprised 42 eyes irrigated with BSS Plus(R) and 37 eyes irrigated with Optiplus(R) solution. Cell density of the corneal endothelial cell, coefficient variation of the cell area, hexagonality, and central corneal thickness were measured. RESULTS: There was no significant difference between the two solutions in their effect on corneal endothelial cell density, coefficient variation of the cell area, hexagonality, and central corneal thickness postoperatively after one day, one month, and two months (p>0.05). CONCLUSIONS: There were no differences in the effects of BSS Plus(R) and Optiplus(R) on the measured parameters of the corneal endothelium over the first two postoperative months.