A Case of Myocardial Infarction Occurred after Endoscopic Submucosal Dissection under Bridging Therapy with Low Molecular Weight Heparin

Myocardial infarction (MI) is a complication that can occur after endoscopic submucosal dissection (ESD). However, very few reports are available about this complication. A 71-year-old male, who had two drug eluting stents inserted due to ischemic heart disease, was referred to the Division of Gastroenterology for ESD of a lesion suspicious of early gastric cancer. ESD was performed after dual antiplatelet agents were discontinued and bridging therapy with low molecular weight heparin (LMWH) was initiated. However, MI occurred immediately after the ESD procedure. A coronary angiogram did not show any significant stent thrombosis or restenosis. The patient recovered spontaneously. Here, we report a case of MI that occurred after ESD under bridging therapy with LMWH.

A Case of Pulmonary Thromboembolism in a Patient with Idiopathic Thrombocytopenic Purpura / 대한내과학회지

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune blood disorder characterized by thrombocytopenia. Common clinical manifestations include bleeding events. Rarely, thrombotic complications may develop in ITP. A 43-year-old man was admitted with dyspnea. His platelet count at admission was 48,000/mm3. The patient had a history of ITP diagnosed 12 years earlier and had been treated with low-dose steroids. Two months before admission, he had been diagnosed with deep vein thrombosis and treated only with clopidogrel due to severe thrombocytopenia. Chest computed tomography showed filling defects in both pulmonary arteries. In the workup for precipitating factors, only lupus anticoagulant was positive. The concomitant administration of warfarin and methylprednisolone was used to treat the pulmonary thromboembolism and ITP, respectively. Six months later, the lupus anticoagulant test remained positive. The patient was confirmed to have a pulmonary thromboembolism due to antiphospholipid syndrome, which might be related to the underlying ITP. After 10 months, his symptoms and radiological findings had improved.

A Case of Elevated Prothrombin Time-International Normalized Ratio (PT-INR) Associated with Concurrent Use of Erlotinib and Warfarin / 대한내과학회지

Erlotinib, an orally active epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), is indicated for EGFR mutation-positive patients with poor performance status. Erlotinib is also used as a second-line agent in patients who show disease progression after failure of first-line therapy. Warfarin is administered in patients with advanced cancer for the prevention or treatment of venous thromboembolism. Both erlotinib and warfarin are metabolized in the human liver primarily by the CYP3A4 enzyme system. Thus, erlotinib may inhibit the metabolism of warfarin and clinicians should pay attention to the possible interaction between the two drugs when they are administered concurrently. We report the case of a 50-year-old man who showed changes in the prothrombin time-international normalized ratio (PT-INR) after coadministration of erlotinib and warfarin.

An Endobronchial Lipoma Treated by Bronchoscopic Excision / 대한내과학회지

A 68-year-old man presented with partial atelectasis of the right middle lobe on chest X-ray. Computed tomography of the chest revealed a hypodense mass in the middle lobe. Bronchoscopy showed a round mass obstructing the right middle lobe bronchus, and a biopsy specimen revealed only chronic inflammation. The tumor was removed using rigid bronchoscopy, and a diagnosis of endobronchial lipoma was made. An endobronchial lipoma is a very rare benign tumor that may cause parenchymal lung damage due to bronchial obstruction and subsequent pneumonia. We report this case to emphasize the role of endoscopic treatment in the management of endobronchial lipoma.

Study on Genipin: A New Alternative Natural Crosslinking Agent for Fixing Heterograft Tissue

BACKGROUND: In cardiac surgery, especially in the reconstruction of vascular structures and intracardiac defects, glutaraldehyde has usually been used as the reagent for fixing porcine or bovine pericardial tissues. But the well-known problem of calcification or cytotoxicity of glutaraldehyde motivates the search for a replacement. The aim of this study is to investigate the physical, mechanical, and biochemical characteristics of bovine pericardial tissues fixed with genipin, which is known to be a less toxic and more natural fixing reagent. MATERIALS AND METHODS: Bovine pericardial tissues were fixed with different concentrations and conditions of glutaraldehyde and genipin. To determine the physical, mechanical, and biochemical differences among different concentrations and conditions, we divided the tissue into 18 groups by concentration, the addition of organic solvents, and the timing of adding the organic solvents, and compared the characteristics of each group. RESULTS: Tensile strength, physical activity, and thermal stability tests revealed that the tissues fixed with glutaraldehyde were better with regard to mechanical strength and biochemical durability. However, the difference was not significant statistically. CONCLUSION: Genipin can be used as an alternative crosslinking agent for pericardial tissue, considering given its physical, mechanical, biochemical characteristics and low cytotoxicity comparable to glutaraldehyde. However, further studies are needed on the immune reaction and the long term changes in genipin-fixed tissues in the human body.

Association between Seasonal Changes in Vitamin D and Bone Mineral Density / 대한폐경학회지

OBJECTIVES: Vitamin D deficiency, which causes secondary hyperparathyroidism, is considered to be a major contributor to osteoporosis. Because the serum 25-hydroxyvitamin D (25-OHD) level depend on sun exposure and, varies by season, the level of serum 25-OHD in each season at which vitamin D status can lead to changes in bone mineral density (BMD) is not known. METHODS: A total of 2,878 women who underwent periodic health examinations at Ajou University Hospital were included in this study. We measured the serum 25-OHD concentrations using radioimmunoassay and BMDs using dual energy x-ray absorptiometry (DXA). The differences in serum 25-OHD levels among groups as a function of age, season, and BMD were tested by one-way ANOVA. RESULTS: The serum 25-OHD level was not different based on age, but by season, with higher levels in the summer and autumn than in the winter and spring. However, the 25-OHD level did not have a significant relationship with BMD in any season. CONCLUSION: The serum 25-OHD level represents vitamin D status at the time of testing, which is not associated with long-term changes in BMD. When the 25-OHD levels are used to make clinical decisions related to the treatment of osteoporosis, careful interpretation is required.

A Case of Hemicranial Pneumocephalus Secondary to Removal of a Central Venous Catheter / 대한내과학회지

The presence of pneumocephalus associated with insertion, maintenance, and removal of intravenous catheters is a rare radiographic finding, but may be clinically relevant. Various pathways have been proposed to explain the development of pneumocephalus, but none are well understood. We present a patient with hemicranial pneumocephalus secondary to removal of a central venous catheter as determined by computed tomography, and we propose a possible mechanism of the pneumocephalus.

Myeloid Sarcoma in Patients with RUNX1/RUNX1T1 Positive AML and a c-kit Mutation / 대한내과학회지

t (8;21)(q22;q22) is the most frequently detected cytogenetic abnormality in patients with acute myeloid leukemia (AML) and accounts for 8-21% of de novo AML. The translocation involves two genes, RUNX1 (formerly AML1) on 21q22 and RUNX1T1 (ETO) on 8q22. RUNX1/RUNX1T1 translocation confers a favorable prognosis, but a subset of patients has a precipitous course with a high incidence of relapse. This patient subset is associated with the presence of a c-kit mutation. c-kit is a proto-oncogene, which encodes a type III transmembrane tyrosine kinase, which elicits a variety of cellular responses essential for the development of bone marrow stem cells. The expression of the c-kit mutation in AML is < 2%, whereas AML with RUNX1/RUNX1T1 shows higher rates of c-kit mutation and is associated with extramedullary leukemia and poor clinical outcome. We report cases of myeloid sarcoma in patients with RUNX1/RUNX1T1-positive AML and a c-kit mutation.

Synchronous development of KIT positive acute myeloid leukemia in a patient with gastrointestinal stromal tumor

We report a case of synchronous occurrence of KIT-positive acute myeloid leukemia (AML) and gastrointestinal stromal tumor (GIST). A 63-year-old woman was hospitalized for dizziness, and abdominal computed tomography revealed an exophytic gastric mass and hepatic metastasis. The patient was diagnosed with GIST and was administered imatinib (400 mg/day) for the metastatic unresectable tumor. After 2 weeks of imatinib treatment, the patient developed pancytopenia, which persisted even after the drug was discontinued, thereby necessitating bone marrow biopsy. Biopsy examination indicated AML, and karyotyping revealed a complex karyotype. We did not observe point mutations at residues D816 and N822 of KIT. Therefore, the patient received standard induction chemotherapy, but on the 18th day after completion of chemotherapy, she died of septic shock and multi-organ failure. Since KIT plays an important role in both GIST and AML, we consider that both these malignancies may have been associated with each other.

Anti-calcification Effects in Decellularized and Variously Fixed Bovine Pericardium / 대한흉부외과학회지

BACKGROUND: Our goal was to evaluate anti-calcification effects of decellularization and diverse fixing methods including preincubation of the bovine pericardium with ethanol. We also assessed changes in mechanical properties. MATERIAL AND METHOD: Harvested bovine pericardium was decellularized with 0.25% sodim dodecysulfate and then treated with 5 methods of fixation: (1) 0.5% glutaraldehyde (GA) for 14 days, (2) 0.5% GA for 5 days, 2% GA for 2 days and 0.25% GA for 7 days, (3) 0.5% GA for 5 days, 2% GA for 2 days, 0.25% GA for 7 days, and then 70% ethanol for 2 days, (4) 0.5% GA for 5 days, a mixture of 2% GA and 70% ethanol for 2 days, and 0.25% GA for 7 days, (5) 0.5% GA for 5 days, a mixture of 2% GA, 65% ethanol, and 5% octanediol for 2 days and then 0.25% GA for 7 days. All treated bovine pericardia were tested for histological variables, lipid content, and mechanical properties including tensile strength and thermal stability. A total 10 kinds of differently treated bovine pericardia were implanted into rat subdermis and harvested 8 weeks later. Harvested pericardia were evaluated for calcium content. RESULT: No protein denaturation was observed microscopically after decellularization. There was a 32% mean decrease in tensile strength index after decellularization in the bovine pericardium group fixed. Octanediol preincubation attenuated the decrease in tensile strength and maintained thermal stability. TG and cholesterol were not affected by decellularization but were decreased by organic solvent. Calcium content was decreased after decellularization, and organic solvent preincubation decreased calcification in the non-decellularized bovine pericardium group. CONCLUSION: Decellularization and organic solvent preincubation have anti-calcification effects but decellularization may cause mechanical instability. A method of decellularization and fixation that does not cause damage to matrices will be needed for evaluation of the next step in using tissue-engineering for replacement of cardiac valves.

Anticalcification Treatment of Glutaraldehyde-fixed Bovine Pericardium with Amino Acids (The Effect of Ethanol, Glutamic Acid and Homocysteic Acid Treatment) / 대한흉부외과학회지

BACKGROUND: Glutaraldehyde-fixed heterografts are prone to calcification after long-term implantation in human, and this is one of the limiting factors for the longevity of the heterografts used in cardiovascular surgery. The aim of the study was to evaluate the anticalcification effect of an ethanol and amino acids treatment on glutaraldehyde- fixed bovine pericardium. MATERIAL AND METHOD: Bovine pericardial tissues were divided into 5 groups. Group 1 consisted of tissues fixed with glutaraldehyde, group 2 consisted of commercially available bovine pericardial valve tissues (Carpentier-Edwards PERIMOUNT), group 3 consisted of glutaraldehyde-fixed tissues treated with ethanol, group 4 consisted of glutaraldehyde-fixed tissues treated with ethanol and L-glutamic acid, and group 5 consisted of glutaraldehyde-fixed tissues treated with ethanol and homocysteic acid. The tissue microstructure was examined by light and electron microscopy. Tissue samples of each group were implanted into rat subcutaneous tissue for 3~4 months and the calcium contents were measured after harvest. RESULT: The collagen fibers appeared to be well preserved in all the groups. The calcium contents of groups 2, 3, 4 and 5 (13.46+/-11.74, 0.33+/-0.02, 0.39+/-0.08 and 0.42+/-0.06micro/mg, respectively) were all significantly lower than that of group 1 (149.97+/-28.25micro/mg) (p <0.05). The calcium contents of groups 3, 4 and 5 were all significantly lower than that of group 2 (p <0.05). CONCLUSION: Treatment with ethanol alone or in combination with amino acids (L-glutamic acid or homocysteic acid) strongly prevented the calcification of glutaraldehyde-fixed bovine pericardium.

Biaxial Strain Analysis of Various Fixation Models in Porcine Aortic and Pulmonary Valves / 대한흉부외과학회지

BACKGROUND: The function of a bioprosthetic heart valve is determined largely by the material properties of the valve cusps. The uniaxial tensile test has been studied extensively. This type of testing, however, does not replicate the natural biaxial loading condition. The objective of the present study was to investigate the regional variability of the biaxial strain versus pressure relationship based on the types of fixation liquid models. MATERIAL AND METHOD: Porcine aortic valves and pulmonary valves were assigned to three groups: the untreated fresh group, the fixed with glutaraldehyde (GA) group, and the glutaraldehyde with solvent (e.g., ethanol) group. For each group we measured the radial and circumferential stretch characteristics of the valve as a function of pressure change. RESULT: Radial direction elasticity of porcine aortic and pulmonary valves were better than circumferential direction elasticity in fresh, GA fixed, and GA+solvent fixed groups (p=0.00). Radial and circumferential direction elasticity of pulmonary valves were better than aortic valves in GA fixed and GA+solvent fixed groups (p=0.00). Radial and circumferential direction elasticity of aortic valves were decreased after GA and GA+solvent fixation (p=0.00), except for circumferential elasticity of GA+solvent fixed valves (p=0.785). The radial (p=0.137) and circumferential (p=0.785) direction of elasticity of aortic valves were not significantly different between GA fixed and GA+solvent fixed groups. Radial (p=0.910) and circumferential (p=0.718) direction of elasticity of pulmonary valve also showed no significant difference between GA fixed and GA+solvent fixed groups. CONCLUSION: When fixing porcine valves with GA, adding a solvent does not cause a loss of mechanical properties, but, does not improve elasticity either. Radial direction elasticity of porcine aortic and pulmonary valves was better than circumferential direction elasticity.

Synchronized Synergism Using Ethanol, L-lysine and NaBH4 in Glutaraldehyde Treated Porcine Pericardium / 대한흉부외과학회지

BACKGROUND: Calcification is the most frequent cause of clinical failure of bioprosthetic tissues that are fabricated from Glutaraldehyde (GA)-fixed porcine valve or bovine pericardium. We recently used a multi-factorial approach of employing different mechanisms to investigate how to reduce the calcification of bioprosthetic tissues. The purpose of the present study was to evaluate the synchronized synergism using ethanol, L-lysine and NaBH4 in glutaraldehyde treated porcine pericardium from the standpoint of calcification and tissue elasticity. MATERIAL AND METHOD: Porcine pericardium was fixed with 0.625% GA (commercial fixation). An interim step of ethanol (80%; 1 day at room temperature) or L-lysine (0.1 M; 2 days at 37degrees C) or NaBH4 (0.1 M; 2 days at room temperature) was followed by completion of the GA fixation (2 days at 4degrees C and 7 days at room temperature). The tensile strength and thickness of the samples were measured. The treated pericardiums were implanted subcutaneously into three-week old Sprague-Dawley rats for 8 weeks. The calcium content was assessed by atomic absorption spectroscopy and the histology of the samples. RESULT: The amount of calcium in the pericardium pretreated with ethanol (13.6+/-10.0 ug/mg, p=0.008), L-lysine (15.3+/-1.0 ug/mg, p=0.002) and both (16.1+/-11.1 ug/mg, p=0.012) was significantly reduced compared with the control (51.2+/-8.5 ug/mg). However, NaBH4 pretreatment (65.7+/-61.8 ug/mg, p=0.653) and combined pretreatment that including ethanol, L-lysine and NaBH4 (92.9+/-58.3 ug/mg, p=0.288) were not significantly different from the controls (51.2+/-8.5 ug/mg). Both the combined pretreatment using ethanol and L-lysine (7.60+/-1.55, p=0.76) and the combined pretreatment that included ethanol, L-lysine and NaBH4 (7.47+/-1.85, p=0.33) increased the tensile strength/thickness ratio compared with that of the controls (4.75+/-1.88). CONCLUSION: The combined pretreatment using ethanol and L-lysine seemed to decrease the calcification of porcine pericardium fixed with glutaraldehyde, as compared to single pretreatment, and it increase the tissue elasticity, but to the degree that showed synchronized synergism. NaBH4 pretreatment seemed to increase the calcification of porcine pericardium, irrespective of whether single or combined pretreatment was used.

Ganglioneuroblastoma in a Patient with Crossed Testicular Ectopia / 대한비뇨기과학회지

Crossed testicular ectopia is a rare anomaly, in which both testes migrate toward the same hemiscrotum. Fewer than 100 cases of this condition have been reported in the literature worldwide. Occasionally, conditions initially suspected to be crossed testicular ectopia have proven to be other anomalies, including hypospadias, renal agenesis, and seminal vesicle cysts. In this case, we diagnosed ganglioneuroblastoma in a patient with testicular ectopia.

Comparison of the Surgical Outcome of Laparoscopic Cyst Marsupialization for Peripheral and Parapelvic Renal Cysts / 대한비뇨기과학회지

PURPOSE: The location of renal cysts is related with the symptoms and signs. Parapelvic cysts are a rare form of simple renal cysts, and they are much more commonly associated with the symptoms of obstruction, pain, infection and stone formation. We evaluated the surgical outcomes of laparoscopic renal cyst marsupialization for treating the peripheral and parapelvic types of renal cysts. MATERIALS AND METHODS: Between November 1993 and April 2007, 87 patients(91 cases) who presented with symptomatic renal cysts underwent laparoscopic renal cyst marsupialization. There were 76 cases in the peripheral cyst group and 15 cases in the parapelvic cyst group. The mean age was 59.2 years(age range: 20-77) for the patients with peripheral renal cysts and 62.9 years(age range: 47-79) for the patients with parapelvic cysts. RESULTS: The mean operative time was 108 minutes(30-280) for the patients with peripheral renal cysts and 144 minutes(80-270) for the patients with parapelvic cysts, and there was a significant difference(p=0.031). However for the other factors, including the time for the first oral intake, the time to remove the drain and the length of the hospital stay, there were no significant differences(p=0.671, 0.088, 0.268, respectively). Complications, including bleeding and leakage, were detected in 11 patients(14.4%) of the peripheral cyst group and in 4 patients(26.6%) of the parapelvic cyst group; there was a statistical difference(p=0.035). Both groups had a high success rate, 98.7% in the peripheral cyst group and 100% in the parapelvic cyst group. CONCLUSIONS: We found that laparoscopic renal cyst marsupialization was a standard treatment with a high success rate and a fast recovery time. However, performing this for parapelvic cysts showed a longer operative time and a higher complication rate as compared with peripheral cysts.

Antibiotic Resistance and Genotypic Characterization of Escherichia coli Isolated from Pig Farm Environment

The use of antibiotics, including therapeutically in human and veterinary medicine, or as prophylaxis of growth promotion in animal husbandry, ultimately exerts selective pressure favorable for the propagation of antibiotic resistant bacteria. In this study we have determined the resistance for antibiotics of E. coli from pig farm environment, and investigate genetic relatedness by random amplification of polymorphic DNA (RAPD). Six farms were randomly selected in Gyeongsanman-do and Busan provinces for collecting samples from feces, manure and underground water. A total of 88 isolates from feces, 74 isolates from manure and 1 isolate from underground water were analyzed by antibiotic resistance and RAPD. Antibiotic resistance testing was performed by disk diffusion method using 16 antibiotics. The highest percentage of antibiotic resistance of isolates from feces and manure was found to the following antibiotics; tetracycline (100% and 100%), sulfamethoxazole/trimethoprim (60.2% and 62.2%), streptomycin (50.0% and 68.9%), chloramphenicol (56.8% and 56.8%), ampicillin (50.0% and 81.1%) and cephalothin (50.0% and 51.4%). Of isolates from feces and manure, 22.7% and 20.3% showed multiple resistance to 4 and 5 antibiotics, respectively. The isolates from GE pig farm showed six RAPD patterns. A single pattern, RAPD-C, was predominat in feces isolates (50.0%) and manual isolates (46.7%), and the rest of feces isolates showed RADP-A, B and E pattern and manure isolates showed D and E pattern. One isolate from underground water showed F pattern. The appearance of multiresistant in E. coli isolates from pig farms environment is a problem of major concern of public health and RAPD may offer an useful tool of discrimination for the epidemiological investigation.

Malignant Peripheral Nerve Sheath Tumor of the Retroperitoneum in Patient with Neurofibromatosis / 대한비뇨기과학회지

A malignant peripheral nerve sheath tumor (MPNST), also known as a malignant neurilemmoma or malignant schwannoma, is significantly associated with neurofibromatosis type 1 (NF 1). NF 1 is characterized by multiple dermal neurofibromas, cafe-au-lait spots, MPNST and other abnormalities. MPNST is often metastatic, and is detected in the extremities, frequently in the head and neck, but rarely in the retroperitoneal and pelvic spaces. We experienced a case of MPNST in the retroperitoneal space of a 38-year-old male with NF 1, who also had metastatic lesions of the lung and liver.