Two-Stage Peroral Endoscopic Myotomy for Sigmoid-Type Achalasia

Peroral endoscopic myotomy (POEM) has been recently considered as the first treatment option for achalasia. The standard POEM procedures are often successful in most patients, but sometimes technical challenges are encountered. We report a new technique that is divided between two tunneling sites in the esophagus for sigmoid-type achalasia. A 40-year-old male patient with dysphagia for 10 years was diagnosed with a sigmoid-shaped esophagus at our hospital. We devised a two-stage myotomy technique to treat sigmoidtype achalasia. The myotomy was first performed in the upper part of the greater flexion area and then in the lower part of the flexion. We termed this method “two-stage POEM”, which was successfully performed without any complications. This new POEM method can also be used to improve symptoms in patients with achalasia who have a structural deformity that may result in a high change of treatment failure.

Endoscopic Submucosal Dissection Followed by Concurrent Chemoradiotherapy in Patients with Early Esophageal Cancer with a High Risk of Lymph Node Metastasis

Endoscopic submucosal dissection is recommended as an alternative therapy for early esophageal cancer. However, achieving curative resection in this procedure remains controversial since precise prediction of lymph node metastasis can be difficult. Here, we present the preliminary results of endoscopic submucosal dissection followed by concurrent chemoradiotherapy for early esophageal cancer with a high risk of lymph node metastasis. From May 2006 to January 2014, six patients underwent concurrent chemoradiotherapy after endoscopic submucosal dissection with a median follow-up period of 63 months. No complications were encountered during concurrent chemoradiotherapy. Although local recurrence did not occur in all patients, two patients were diagnosed with metachronous cancer. Overall, the survival rate was 100%. Thus, endoscopic submucosal dissection followed by concurrent chemoradiotherapy may be a feasible treatment for early esophageal cancer in patients with a high risk of lymph node metastasis. Future prospective large-scale studies are warranted to confirm our results.

Huge Intramural Duodenal Hematoma Complicated with Obstructive Jaundice following Endoscopic Hemostasis / 대한소화기학회지

Intramural hematoma of the duodenum is a relatively unusual complication associated with the endoscopic treatment of bleeding peptic ulcers. Intramural hematomas are typically resolved spontaneously with conservative treatment alone. We report a case of an intramural duodenal hematoma following endoscopic hemostasis with epinephrine injection therapy, which was associated with transient obstructive jaundice in a patient undergoing hemodialysis. The patient developed biliary sepsis due to obstruction of the common bile duct secondary to the huge hematoma. He was treated with fluoroscopy-guided drainage catheter insertion, which spontaneously resolved the biliary sepsis through conservative treatment in 6 weeks. Fluoroscopy-guided drainage may impact the treatment of intramural hematomas that involve life-threatening complications.

Management of Le Fort I fracture

Among the classification of maxillary fracture, the Le Fort classification is the best-known categorization. Le Fort (1901) completed experiments that determined the maxilla areas of structural weakness which he designated as the “lines of weakness”. According to these results, there are three basic fracture line patterns (transverse, pyramidal and craniofacial disjunction). A transverse fracture is a Le Fort I fracture that is above the level of the apices of the maxillary teeth section, including the entire alveolar process of the maxilla, vault of the palate and inferior ends of the pterygoid processes in a single block from the upper craniofacial skeleton. Le Fort fractures result in both a cosmetic and a functional deficit if treated inappropriately. In this article, authors review the management of a Le Fort I fracture with a case-based discussion.

Pulmonary Placental Transmogrification Presenting as a Small Lung Nodule / 대한내과학회지

Pulmonary placental transmogrification (PT) is a rare lung disease that takes on the histologic appearance of placental chorionic villi. We herein report a case of PT in a 66-year-old woman who presented with a single nodule on chest radiography performed during a routine health examination. She had no complaints of any symptoms. Chest radiography showed a focal ill-defined nodular opacity in the right lower lobe; chest computed tomography revealed a 17-mm lobulated, focal irregular mass with fissural retraction in the right lower lobe, suggestive of lung cancer. Pathology of a percutaneous needle aspiration biopsy revealed papillary structures resembling placental villi. These were lined by cytotrophoblast-like cells and syncytiotrophoblasts. This characteristic pathologic finding led to a diagnosis of PT. PT of the lung is found mainly in bullous or cystic lesions. However, this patient presented with a single nodule on chest radiography.

A Case of Invasive Pulmonary Aspergillosis with Direct Invasion of the Mediastinum and the Left Atrium in an Immunocompetent Patient / 결핵및호흡기질환

We report a case of invasive pulmonary aspergillosis invading the mediastinum and the left atrium. A 70-year-old woman was hospitalized for dyspnea. She had been well controlled for her diabetes mellitus and hypertension. The chest X-ray disclosed mediastinal widening, and the computed tomography scan of the chest showed that there was a large mediastinal mass and this lesion extended into the left atrium and right bronchus. The cardiac echocardiography showed that a huge mediastinal cystic mass compressed in the right atrium and a hyperechoic polypoid lesion in the left. The pathology from the bronchoscopic biopsy observed abundant fungal hyphae which was stained with periodic acid-Schiff and Gomori's methenamine silver. Despite the treatment with antifungal agents, she died from cardiac tamponade after three months. Invasive pulmonary aspergillosis, which involves the mediastinum and the heart, is very rare in immunocompetent patients.

A Case of Invasive Pulmonary Aspergillosis with Direct Invasion of the Mediastinum and the Left Atrium in an Immunocompetent Patient / 결핵및호흡기질환

We report a case of invasive pulmonary aspergillosis invading the mediastinum and the left atrium. A 70-year-old woman was hospitalized for dyspnea. She had been well controlled for her diabetes mellitus and hypertension. The chest X-ray disclosed mediastinal widening, and the computed tomography scan of the chest showed that there was a large mediastinal mass and this lesion extended into the left atrium and right bronchus. The cardiac echocardiography showed that a huge mediastinal cystic mass compressed in the right atrium and a hyperechoic polypoid lesion in the left. The pathology from the bronchoscopic biopsy observed abundant fungal hyphae which was stained with periodic acid-Schiff and Gomori's methenamine silver. Despite the treatment with antifungal agents, she died from cardiac tamponade after three months. Invasive pulmonary aspergillosis, which involves the mediastinum and the heart, is very rare in immunocompetent patients.

Life-Threatening Acute Fulminant Myocarditis Following a Coffee Diet Program / 대한구급학회지

Myocarditis is an inflammatory disease of the myocardium caused by various infectious or noninfectious triggers. Although viral infections are important causes of myocarditis, some drugs or toxins can also cause myocarditis. We report a case of life-threatening fulminant myocarditis which followed an extensive coffee diet program. Despite medical treatment, the patient was not able to maintain hemodynamic stability. She was supported by extracorporeal membrane oxygenation and completely recovered 3 months later.

What is the Clinical Significance of Cerebrospinal Fluid Biomarkers in Parkinson's disease? Is the Significance Diagnostic or Prognostic?

The clinical diagnostic criteria of Parkinson's disease (PD) have limitations in detecting the disease at early stage and in differentiating heterogeneous clinical progression. The lack of reliable biomarker(s) for early diagnosis and prediction of prognosis is a major hurdle to achieve optimal clinical care of patients and efficient design of clinical trials for disease-modifying therapeutics. Numerous efforts to discover PD biomarkers in CSF were conducted. In this review, we describe the molecular pathogenesis of PD and discuss its implication to develop PD biomarkers in CSF. Next, we summarize the clinical utility of CSF biomarkers including alpha-synuclein for early and differential diagnosis, and prediction of PD progression. Given the heterogeneity in the clinical features of PD and none of the CSF biomarkers for an early diagnosis have been developed, research efforts to develop biomarkers to predict heterogeneous disease progression is on-going. Notably, a rapid cognitive decline followed by the development of dementia is a risk factor of poor prognosis in PD. In connection to this, CSF levels of Alzheimer's disease (AD) biomarkers have received considerable attention. However, we still need long-term longitudinal observational studies employing large cohorts to evaluate the clinical utility of CSF biomarkers reflecting Lewy body pathology and AD pathology in the brain. We believe that current research efforts including the Parkinson's Progression Markers Initiative will resolve the current needs of early diagnosis and/or prediction of disease progression using CSF biomarkers, and which will further accelerate the development of disease-modifying therapeutics and optimize the clinical management of PD patients.

Mycosis in Jillin Province, China / 대한의진균학회지

In the past 15 years, from 1986 to 2000, 2,763 cases of superficial mycoses had been diagnosed and treated in Jillin Province. Other mycoses included 1,450 cases of tinea versicolor, 497 cases of candidiasis, 142 cases of sporotrichosis, 1 case of chromomycosis, and 47 cases of aspergillosis. Among the 2,763 cases of superficial mycoses, 762 cases were tinea cruris, 246 cases were tinea manus, 661 cases were tinea pedis, and 156 cases were onychomycosis. From the region, there was a high incidence of sporotrichosis in the middle and the west part of our province, and there was rather low incidence of it in the eastern mountain areas. We separated Sporothrix schenckii from the natural environment. Sporothrix schenckii was separated from the plants and the soil in both the region of high incidence and low incidence. Therefore, the reason why there's a low incidence in the eastern mountain areas is still unknown. Pathogenic fungi were separated, and we found 2,038 strains of T. rubrum, which came first in the pathogenic fungi of dermatophytoses. Coming next were T. mentagiophytes, M. canis, E. floccosum, M. gypseum and T. violaseum. Sporothrix schenckii was separated from all of the 142 cases of sporotrichosis. Candida albicans A, Candida albicans B, Candida tropicalis and Candida parapsilosis were separated from candidiasis; Exophiala jeanselmei was separated chromomycosis; A. fumigatus, A. niger, and A. favus were separated from aspergillosis. The problem we should pay attention to is; In the 1980's, M. canis came third in the pathogenic fungi of dermatophytoses, first in that of tinea capitis, which took 84.2% in the pathogenic fungi of tinea capitis. But from the beginning of 1990's, the number had declined. By the end of 1990's, M. canis just took 9.6 percent in the pathogenic fungi of tinea capitis. And the separation rate of M. canis from cat had obviously declined. Whether it's getting to vanish like M. ferrugineum also needs paying attention to.

Effect of Propranolol on Portal Vein Pressure in Patients with Chronic Liver Disease: Evaluation by Perrectal Portal Scintigraphy / 대한핵의학회잡지

PURPOSE: Propranolol is known to decrease portal pressure by reducing blood flow of portal vein. Per-rectal portal scintigraphy with Tc-99m pertechnetate has been introduced to evaluate the portal circulation and early diagnosis of liver cirrhosis. We evaluated the effects of propranolol on portal circulation by using per-rectal portal scintigraphy. MATERIALS AND METHODS: We analyzed the portal hemodynamics by per-rectal portal scintigraphy in 51 patients with liver cirrhosis, 10 chronic hepatitis and 10 normal subjects. 38 patients with cirrhosis underwent per-rectal portal scintigraphy before and after propranolol medication. Per-rectal portal scintigraphy was performed after per-rectal administration of 370 MBq of Tc-99m pertechnetate. The shunt index was calculated as the ratio, expressed as a percentage of heart radioactivity to the sum of heart and liver radioactivity during the first 30 seconds. RESULTS: The shunt index in 40 patients with cirrhosis (59.8+/-27.2%) was significantly higher than that of normal control (5.0+/-1.2%, p<0.01) and chronic hepatitis (11.4+/-3.5%, p<0.01). Shunt index was significantly different according to Child's classification and the degree of esophageal varix (p<0.01). After propranolol medication, shunt index was significantly decreased from 59.9+/-27.3% to 51.3+/-15.3% (p<0.01) in 38 patients with liver cirrhosis. There was no significant difference of the amount of shunt index reduction after propranolol according to Childs' classification and the degree of esophgageal varix. CONCLUSION: The effect of propranolol on portal circulation was demonstrated as decreasing shunt index on per-rectal portal scintigraphy in patients with liver cirrhosis. Per-rectal portal scintigraphy may be useful to evaluate the portal circulation and to predict the effect of propranolol in patients with liver cirrhosis.

A Case of Scleredema Preceded by Upper Respiratory Infection / 감염

Scleredema is a rare connective tissue disease of unknown etiology and characterized by non-pitting thickening of subcutaneous tissue of the neck, face, head, upper trunk and arms. We present a 28 year-old man with extensive skin changes following upper respiratory infection, who have not any concurrent disorders such as diabetes mellitus. Histopathological findings of skin showed normal epidermis with a widening of spaces between collagen bundles by infiltration of acid mucopolysaccharide in the dermis.