The Effectiveness of Multidisciplinary Team-Based Education in the Management of Type 2 Diabetes / 임상당뇨병

BACKGROUND: Although clinicians, nurse specialists, pharmacists, and nutritionists expend significant time and resources in optimizing care for patients with diabetes, the effectiveness of integrated diabetes care team approach remains unclear. We assessed the effects of a multidisciplinary team care educational intervention on glycated hemoglobin (HbA1c) levels among diabetes patients. METHODS: We conducted a matched case-control study in Korean patients with type 2 diabetes, comparing the propensity scores pertaining to the effectiveness in reducing HbA1c levels between a group receiving an educational intervention and a control group. We included 40 pairs of patients hospitalized between June 2014 and September 2016. HbA1c values measured at baseline, 3 months, and 6 months were compared between the two groups. RESULTS: The educated group showed an improvement in HbA1c levels compared to the control group at 3 months (6.3 ± 2.3% vs. 9.5 ± 4.0%; P = 0.020) and at 6 months (7.5 ± 1.5% vs. 9.6 ± 3.0%; P = 0.106). There was a significant difference in the change in mean HbA1c from baseline to 3 months between the two groups (−35.7 ± 26.1% vs. −9.1 ± 20.5%; P = 0.013). CONCLUSION: A multidisciplinary team care education intervention was advantageous for improving glucose control in patients with type 2 diabetes, and may help to optimize glycemic control in clinical practice.

A case of rescuing a patient with acute cardiovascular instability from sudden and massive intraoperative pulmonary thromboembolism by extracorporeal membrane oxygenation / 고신대학교의과대학학술지

Intraoperative pulmonary thromboembolism is a high mortality situation. Early mortality in patients with pulmonary thromboembolism varies from 2% in normotensive patients to 30% in patients with cardiogenic shock. The use of extracorporeal cardiopulmonary resuscitation can improve survival and neurologic outcomes of cardiac arrest. We report a case of intraoperative massive pulmonary thromboembolism with circulatory collapse and cardiac arrest during anesthesia for pelvic bone fracture surgery, which were rescued by extracorporeal membrane oxygenation.

Low serum bilirubin level predicts the development of chronic kidney disease in patients with type 2 diabetes mellitus

BACKGROUND/AIMS: We evaluated whether serum bilirubin levels can predict the development of chronic kidney disease (CKD) in patients with type 2 diabetes mellitus (T2DM). METHODS: This was a retrospective observational longitudinal study of patients presenting at the Pusan National University Hospital. A total of 349 patients with T2DM and preserved kidney function (estimated glomerular filtration rate ≥ 60 mL/min/1.73 m²) were enrolled. The main outcome was the development of CKD stage 3 or greater. The patients were divided into four groups according to the quartiles of the total serum bilirubin levels at baseline. RESULTS: The group with the lowest range of total serum bilirubin level (Q1) showed the highest cumulative incidence of CKD stage 3 or greater than that of the other lower quartiles (Q1 vs. Q4; hazard ratio [HR], 6.75; 95% confidence interval [CI], 1.54 to 29.47; p = 0.011). In multivariate analysis, the risk of developing CKD stage 3 or greater was higher in the second lowest quartile of the serum bilirubin level than that in the highest quartile of the serum bilirubin level (Q2 vs. Q4; HR, 9.36; 95% CI, 1.33 to 65.73; p = 0.024). In the normoalbuminuria subgroup (n = 236), multivariate analysis showed that the risk of developing CKD stage 3 or greater was higher in the lowest quartile of the serum bilirubin level than that in the highest quartile of the serum bilirubin level (Q1 vs. Q4; HR, 7.36; 95% CI, 1.24 to 35.82; p = 0.019). CONCLUSIONS: Serum bilirubin might be an early clinical marker for predicting the progression of CKD in patients with T2DM and preserved renal function.

Comparison of two- and three-dimensional sonography for the prediction of the extrathyroidal extension of papillary thyroid carcinomas

BACKGROUND/AIMS: The purpose of this study was to compare the diagnostic validity of two-dimensional (2D) and three-dimensional (3D) ultrasonography (US) when predicting the extrathyroidal extension of papillary thyroid cancer. METHODS: All 2D data were interpreted in real time and 3D data were stored, rendered using tomographic ultrasound imaging (TUI), and then reviewed retrospectively. RESULTS: Extrathyroidal extension was present in 17 papillary thyroid cancers(24.3%) on pathology reports. The presence of contact was significantly associated with extrathyroidal extension on both 2D and 3D US (p = 0.007 and p = 0.003), and the sensitivity and specificity were not significantly different between 2D and 3D US (p = 1.000 and p = 0.754). The coexistence of protrusion and contact was not significantly associated with extrathyroidal extension on either 2D or 3D sonogram. CONCLUSIONS: Three-dimensional images rendered with TUI algorithms alone do not seem to be markedly superior to real-time 2D US in predicting the extrathyroidal extension of papillary thyroid cancer.

Ectopic ACTH syndrome caused by pulmonary carcinoid tumor mimicking long-standing sclerosing hemangioma

No abstract available.

Association of the Preoperative Neutrophil-to-ymphocyte Count Ratio and Platelet-to-Lymphocyte Count Ratio with Clinicopathological Characteristics in Patients with Papillary Thyroid Cancer

BACKGROUND: Several inflammatory biomarkers, especially a high preoperative neutrophil-to-lymphocyte count ratio (NLR) and platelet-to-lymphocyte count ratio (PLR), are known to be indicator of poor prognosis in several cancers. However, very few studies have evaluated the significance of the NLR and PLR in papillary thyroid cancer (PTC). We evaluated the association of the preoperative NLR and PLR with clinicopathological characteristics in patients with PTC. METHODS: This study included 1,066 female patients who underwent total thyroidectomy for PTC. Patients were stratified into 4 quartiles by preoperative NLR and PLR. And the combination of preoperative NLR and PLR was calculated on the basis of data obtained value of tertile as follows: patients with both an elevated PLR and an elevated NLR were allocated a score of 2, and patients showing one or neither were allocated a score of 1 or 0, respectively. RESULTS: The preoperative NLR and PLR were significantly lower in patients aged > or =45 years and in patients with Hashimoto's thyroiditis. The PLR was significantly higher in patients with tumor size >1 cm (P=0.021).When the patients were categorized into the aforementioned four groups, the group with the higher preoperative PLR was found to have a significantly increased incidence of lateral lymph node metastasis (LNM) (P=0.018). However, there are no significant association between the combination of preoperative NLR and PLR and prognostic factors in PTC patients. CONCLUSION: These results suggest that a preoperative high PLR were significant associated with lateral LNM in female patients with PTC.

Detection of Plasma BRAF(V600E) Mutation Is Associated with Lung Metastasis in Papillary Thyroid Carcinomas

PURPOSE: The BRAF(V600E) mutation represents a novel indicator of the progression and aggressiveness of papillary thyroid carcinoma (PTC). The purpose of this study was to determine the clinical significance of free circulating mutant BRAF(V600E) in predicting the advanced disease of PTC. MATERIALS AND METHODS: Seventy seven matched tumor and plasma samples obtained from patients with both benign and PTC were analyzed for BRAF(V600E) mutation using a peptide nucleic acid (PNA) clamp real-time polymerase chain reaction (PCR). RESULTS: The BRAF(V600E) mutation was absent in tumor DNA samples obtained from patients with benign follicular adenomas or adenomatous goiter. In contrast, 49 of 72 (68.1%) PTC tumors were positive for the BRAF(V600E) mutation. Among them, 3 (6.1%) patients with PTC were positive for BRAF(V600E) mutation in plasma and tumor. However, all 3 patients (100%) had lateral lymph node and lung metastasis. CONCLUSION: These findings suggest that the BRAF(V600E) mutation can be detected using a PNA clamp real-time PCR in the blood of PTC patients with lung metastasis. Future studies are warranted to determine clinical significance of serum BRAF(V600E) mutation in large prospective studies.

Association between Serum Fibroblast Growth Factor 21 and Coronary Artery Disease in Patients with Type 2 Diabetes

The aim of this study was to evaluate the association of plasma fibroblast growth factor (FGF)-21 with angiographically significant coronary artery disease (CAD) in patients with type 2 diabetes mellitus. Serum FGF-21 was measured in 120 patients undergoing coronary angiography. Patients were divided into 4 groups based on the presence/absence of type 2 diabetes mellitus and of significant CAD. The atherosclerotic burden was obtained by two angiographic scores: Gensini score (GS) and Extent score (ES). FGF-21 levels were higher in type 2 diabetes mellitus than in non-diabetic patients (P = 0.014). FGF-21 levels were significantly correlated with GS (r = 0.358, P < 0.001) and ES (r = 0.324, P < 0.001) in univariate analysis with all patients. After adjusting for several confounding factors, both GS and ES were associated with FGF-21 in all patients (r = 0.271, P = 0.014; r = 0.217, P = 0.041, respectively). However, FGF-21 lost significant correlation with both GS and ES with type 2 diabetes mellitus in the final model. The patients with type 2 diabetes mellitus and CAD feature had elevated FGF-21 levels. Despite of a limited role in diabetic patients, FGF-21 levels are independently associated with angiographic severity and extent of CAD.

Incidentally Detected Inoperable Malignant Pheochromocytoma with Hepatic Metastasis Treated by Transcatheter Arterial Chemoembolization

Malignant pheochromocytoma (PCC) is a rare condition. Although the liver is the second most frequent site of metastasis in malignant PCC, no definite treatments have been established. Herein, we report a case of liver metastasis of PCC that was successfully treated by transcatheter arterial chemoembolization (TACE). A 69-year-old man was admitted to the Department of Gastroenterology for evaluation of an incidental hepatic mass in August 2013. He had undergone right adrenalectomy in May 2005 and PCC had been confirmed on the basis of histopathological findings. Liver biopsy was performed, and metastatic PCC was diagnosed. The lesion appeared inoperable because of invasion of the portal vein and metastases in the lymph nodes along the hepatoduodenal ligament. Thus, TACE was performed instead. After TACE, symptoms including dizziness and cold sweating improved, and the patient's serum catecholamine levels decreased. On the basis of this case, we believe that TACE may be a useful treatment for liver metastasis in malignant PCC.

Short-Term Caloric Restriction Does Not Reduce Bone Mineral Density in Rats with Early Type 2 Diabetes

BACKGROUND: The effect of caloric restriction (CR) in the setting of diabetes on bone metabolism has not yet been fully studied. The aim of this study is to determine if short-term CR alters bone mass and metabolism in Otsuka Long-Evans Tokushima fatty (OLETF) rats, an animal model of type 2 diabetes. METHODS: Four groups (n=5) were created: OLETF rats with food ad libitum (AL), OLETF rats with CR, Long-Evans Tokusima Otsuka (LETO) rats with food AL, and LETO rats with CR. The CR condition was imposed on 24-week-old male rats using a 40% calorie reduction for 4 weeks. The effect of CR on femoral bone mineral density (BMD) was assessed by dual-energy X-ray absorptiometry. Serum markers were measured by immunoassay. RESULTS: After 4 weeks of CR, body weight decreased in both strains. The BMD decreased in LETO rats and was maintained in OLETF rats. After adjustment for body weight, BMD remained lower in LETO rats (P=0.017) but not OLETF rats (P=0.410). Bone-specific alkaline phosphatase levels decreased in LETO rats (P=0.025) but not in OLEFT rats (P=0.347). Serum leptin levels were reduced after CR in both strains, but hyperleptinemia remained in OLETF rats (P=0.009). CR increased 25-hydroxyvitamin D levels in OLETF rats (P=0.009) but not in LETO rats (P=0.117). Additionally, interleukin-6 and tumor necrosis factor-alpha levels decreased only in OLETF rats (P=0.009). CONCLUSION: Short-term CR and related weight loss were associated with decreases of femoral BMD in LETO rats while BMD was maintained in OLETF rats. Short-term CR may not alter bone mass and metabolism in type 2 diabetic rats.

The Side Effects of Sodium Glucose Cotransporter 2 (SGLT2) Inhibitor / 임상당뇨병

Anti-diabetic drugs for effectively lowering glucose with limited side effects are necessary in providing patient-centered diabetic management. Sodium glucose cotransporter 2 (SGLT 2) inhibitors provide a novel therapeutic approach for managing type 2 diabetic patients by lowering glucose levels by increasing urinary excretion of glucose independently of insulin secretion or action. Several SGLT 2 inhibitors were recently approved and available in the US, European and Korean markets. SGLT 2 improved glycemic control with low propensity of hypoglycemia. Through the clinical trials, most SLGT2 inhibitors were generally well tolerated. Genital tract infections were more frequent in most clinical studies of SGLT2 inhibitors and urinary tract infections were slightly increased in some studies. This review will describe the main safety issues that have been uncovered in clinical trials of SGLT 2 inhibitors.

Adiposity in the Relationship between Serum Vitamin D Level and Insulin Resistance in Middle-Aged and Elderly Korean Adults: The Korea National Health and Nutrition Examination Survey 2008

BACKGROUND: The role of adiposity in the relationship between serum vitamin D levels and insulin resistance has not yet been fully studied. This aim of this study is to clarify the role of adiposity in the relationship between serum vitamin D level and insulin resistance among middle-aged and elderly Korean adults. METHODS: We used data from 2,710 individuals aged > or =50 years based on national data from a representative sample of the fourth Korea National Health and Nutrition Examination Survey IV-2 in 2008. RESULTS: After adjustment for potential confounders, body mass index (BMI) was significantly associated with 25(OH) vitamin D (P=0.008). However, waist circumference was not significantly associated with 25(OH) vitamin D. In the stratified analyses, 25(OH) vitamin D was found to be negatively associated with fasting insulin and homeostasis model assessment estimate of insulin resistance (HOMA-IR) in participants with BMIs > or =25 kg/m2 (P=0.003 for both insulin and HOMR-IR) but was not found to be associated in those with BMIs <23 kg/m2. However, we observed a significant inverse in the association of 25(OH) vitamin D with fasting insulin and HOMA-IR in both the normal (P=0.001 and P<0.001 and the abdominally obese group (P=0.010 and P=0.009) in the stratified analyses according to abdominal obesity. CONCLUSION: Our results support that the idea that endogenously-produced vitamin D might be stored in subcutaneous fat deposits. In addition, the association of vitamin D with insulin resistance in middle-aged and elderly Korean adults was stronger when it was stratified by BMI than when abdominal obesity status.

Clinicopathologic Characteristics of Papillary Microcarcinoma in the Elderly / 대한갑상선학회지

BACKGROUND AND OBJECTIVES: Older patients show more aggressive features in papillary thyroid carcinoma (PTC). However, data about clinicopathologic features of older patients in papillary thyroid microcarcinoma (PTMC) are limited. Presently, we investigated the difference of clinicopathologic features in PTMC according to age. MATERIALS AND METHODS: A total of 820 PTMC patients (82 males, 10%; 738 females, 90%) who underwent total thyroidectomy at Pusan National University Hospital were enrolled. The patients were divided into three age groups: group 1 (44 years or younger, n=230), group 2 (45-64 years, n=513), and group 3 (65 years or older, n=77). RESULTS: Extrathyroidal extension was 33% in group 1, 32.2% in group 2, and 31.2% in group 3 (p=0.948). There was no significant difference of lymph node metastasis between the groups: N0 (59.1% vs. 67.8% vs. 70.1%), N1a (37.4% vs. 28.8% vs. 26%), and N1b (3.5% vs. 3.3% vs. 3.9%) (p=0.159). Of the 820 patients, 526 (64.1%) were diagnosed as early stage (stage I, II) PTMC and 294 (35.9%) were diagnosed as advanced stage (stage III, IV) PTMC. The proportion of patients with each stage was significantly different between the groups (p<0.001). However, there was no significantly difference in the stage over 45 years old. Of the 820 patients, 517 were evaluated BRAF(V600E) mutation. There was no difference in prevalence between each group. CONCLUSION: There was no statistically significant difference of clinicopathologic features between the groups, indicating that old age itself was not associated with unfavorable clinicopathologic features in PTMC.

Crohn's Duodeno-colonic Fistula Preoperatively Closed Using a Detachable Endoloop and Hemoclips: A Case Report / 대한소화기학회지

Duodeno-colonic fistula is an enterocolonic fistula that occurs as a complication of Crohn's disease. Symptoms of duodeno-colonic fistula are similar to those of Crohn's disease, such as weight loss and diarrhea. The treatment of choice is surgery, although medical treatment may also be considered. However, surgery is recommended when all available medical therapies have been ineffective. In this case, we report a secondary duodeno-colonic fistula due to Crohn's disease that was temporarily managed by an endoscopic procedure with a detached endoloop and hemoclips as a bridging therapy to final surgical repair.

A 47,X,+t(X;X)(p22.3;p22.3)del(X)(p11.23q11.2),Y Klinefelter Variant with Morbid Obesity

Klinefelter syndrome is the most common type of genetic cause of hypogonadism. This syndrome is characterized by the presence of 1 or more extra X chromosomes. Phenotype manifestations of this syndrome are small testes, fibrosis of the seminiferous tubules, inability to produce sperm, gynecomastia, tall stature, decrease of serum testosterone and increases of luteinizing hormone and follicle stimulating hormone. Most patients with Klinefelter syndrome are tall, with slender body compositions, and reports of obesity are rare. We report the case of a 35-yr-old man with hypogonadism and morbid obesity and diabetes mellitus. He had gynecomastia, small testes and penis, very sparse body hair and his body mass index was 44.85. He did not report experiencing broken voice and was able to have erections. We conducted a chromosome study. His genotype was 47,X,+t(X;X)(p22.3;p22.3)del(X)(p11.23q11.2). In this case, the patient was diagnosed as Klinefelter syndrome. He showed rare phenotypes like morbid obesity and average height and the phenotype may be caused by the karyotype and the excess number of X chromosome. Further studies of the relationship between chromosomes and phenotype are warranted.

Coagulopathy Caused by Concurrent Ciprofloxacin and Warfarin Use: What Other Factors Induce Coagulopathy?

BACKGROUND: To assess factors affecting the prolongation of the international normalized ratio (INR) with concurrent warfarin and ciprofloxacin use. METHODS: A retrospective case-control study was performed at a single, 2,000-bed tertiary hospital between January 2007 and December 2009. Thirty-three patients who were on warfarin and ciprofloxacin concurrently were enrolled. Demographics and clinical data were collected from medical records. RESULTS: Nine patients were assigned to the case group (prolonged INR) and 19 patients to the control group (normal INR). Activities of daily living (ADL) and total number of classes of medications taken demonstrated significant differences between the groups (15.33 vs. 7.11, p<0.001; 7.11 vs. 5.47, p=0.041). No bleeding complications occurred during this study. CONCLUSION: As ADL reflects patient performance status and general condition of an individual, we conclude that a poor general condition is associated with coagulopathy in persons concurrently using warfarin and ciprofloxacin.

Spontaneous Bacterial Peritonitis with Sepsis Caused by Enterococcus hirae

Selective intestinal decontamination (SID) with norfloxacin has been widely used for the prophylaxis of spontaneous bacterial peritonitis (SBP) because of a high recurrence rate and preventive effect of SID for SBP. However, it does select resistant gut flora and may lead to SBP caused by unusual pathogens such as quinolone-resistant gram-negative bacilli or gram-positive cocci. Enterococcus hirae is known to cause infections mainly in animals, but is rarely encountered in humans. We report the first case of SBP by E. hirae in a cirrhotic patient who have previously received an oral administration of norfloxacin against SBP caused by Klebsiella pneumoniae and presented in septic shock.

A Case of Intractable Bisphosphonate-Related Osteonecrosis of the Jaw Treated with Teriparatide / 대한골다공증학회지

Bisphosphonates are the most widely used medications for treating high bone turnover osteoporosis, Paget's disease of bone, multiple myeloma and metastatic carcinomas, etc. However, a destructive complication of bisphosphonate-related osteonecrosis of the jaw (BRONJ) can occur. The treatments of BRONJ are challenging and the currently recommended managements for BRONJ are still controversial. Our case demonstrated that teriparatide can be a treatment of choice for intractable BRONJ, which had not been cured for 2 years even with the proper surgical treatment and withdrawal of bisphosphonates.

Testicular Tuberculosis That Mimicked Testicular Cancer / 감염과화학요법

Next to lymphatic involvement, genitourinary tuberculosis is considered the second most common manifestation of extrapulmonary tuberculosis worldwide. However, testicular and spermatic cord involvement is uncommon. We report here on a case of testicular and spermatic cord tuberculosis that masqueraded as testicular cancer. A 25-year-old man was admitted to our hospital with painless right scrotal swelling for past 2 months. The abdominal CT scan showed a heterogenous testicular mass that was suspicious for being malignancy. He underwent right radical orchiectomy; testicular and spermatic cord tuberculosis was revealed on histopathological examination. This case highlights the importance of taking a thoughtful diagnostic approach for testicular and spermatic cord tuberculosis, including fine needle aspiration before performing surgical exploration.

A Case of Menetrier's Disease Showing Mucus Bridge Observed during Endoscopy / 대한소화기학회지

Menetrier's disease is a rare entity characterized by large, tortuous gastric mucosal folds. The mucosal folds in Menetrier's disease are often most prominent in the body and fundus. Histologically, massive foveolar hyperplasia (hyperplasia of surface and glandular mucous cells) is noted, which replaces most of the chief and parietal cells. Profuse mucus is usually observed during the endoscopy but there have been few cases that show interesting endoscopic findings such as mucus bridge or water pearl. Herein, we report a case of Menetrier's disease showing mucus bridge by excessive mucus observed during the endoscopy.