Development of a Complete Atrioventricular Block Associated with Intake of Evening Primrose Oil / 대한내과학회지

A complete atrioventricular block is seen in patients due to a variety of causes, including drugs. The resolution of a drug-induced atrioventricular block is often accomplished by drug discontinuation. We report a case of a complete atrioventricular block in a 31-year-old woman following a month of treatment with evening primrose oils. After excluding all other likely causes of conduction disorders, an adverse effect of the evening primrose oils seemed to be the most likely diagnosis. After discontinuation of the oils, no associated symptoms or conduction disturbances were observed for 4 months after discharge. We stress the reconsideration of taking medicines and functional foods continuously as most patients are not aware of the hazards they pose.

Infective Endocarditis in a Patient after Percutaneous Mitral Balloon Valvuloplasty / 대한내과학회지

Percutaneous mitral balloon valvuloplasty (PMBV) is the treatment of choice for mitral stenosis. Only a few reported cases have been reported in PMBV patients worldwide. In this study, a case of a 34 year-old female with infective endocarditis a year after PMBV is presented. The patient presented with fever, and peripheral vascular symptoms. Transthoracic echocardiography showed vegetation on the anterior mitral leaflets and Staphylococcus Viridans was isolated from blood cultures. The patient was successfully treated with Amoxicillin + Clavulate and Gentamicin. Further studies on the correlation between PMBV and infective endocarditis are needed.

A Case of Deep Vein Thrombosis after Coronary Angiography in a Patient Using Antidepressants and Anxiolytics

Deep vein thrombosis (DVT) is a rare but potentially serious complication of coronary angiography (CAG) affecting just under 5 in 10000 patients. Most of the cases regarding DVT after CAG reported in the literature were associated with procedure-related vascular complications or with risk factors for venous thromboembolism (VTE). Here, we describe the case of a 50-year-old woman during treatment for anxiety disorder, who developed significant DVT after CAG without a history of VTE and with no significant risk factors for VTE, which was treated with an anticoagulant. This case reminds us that clinicians should consider the possible occurrence of VTE after diagnostic CAG even in patients without significant risk factors.

A Case of Deep Vein Thrombosis after Coronary Angiography in a Patient Using Antidepressants and Anxiolytics

Deep vein thrombosis (DVT) is a rare but potentially serious complication of coronary angiography (CAG) affecting just under 5 in 10000 patients. Most of the cases regarding DVT after CAG reported in the literature were associated with procedure-related vascular complications or with risk factors for venous thromboembolism (VTE). Here, we describe the case of a 50-year-old woman during treatment for anxiety disorder, who developed significant DVT after CAG without a history of VTE and with no significant risk factors for VTE, which was treated with an anticoagulant. This case reminds us that clinicians should consider the possible occurrence of VTE after diagnostic CAG even in patients without significant risk factors.

A Case of Transient Hypertension after Blunt Abdominal Trauma / 대한내과학회지

Arterial hypertension following blunt abdominal trauma is a rare complication that can be induced by compression of the renal parenchyma due to a perirenal or subcapsular hematoma or adrenal hemorrhage. A 63-year-old woman was admitted after blunt abdominal trauma. Abdominal computed tomography (CT) revealed a right renal subcapsular hematoma and right adrenal gland hematoma. The patient developed hypertension during conservative treatment. Pheochromocytoma, renovascular hypertension, adrenal adenoma, thyroid disease, and other causes of secondary hypertension were excluded. On following the patient, her blood pressure normalized spontaneously without prescribing any antihypertensive medications. The renal subcapsular hematoma and adrenal hemorrhage regressed progressively as the blood pressure normalized. We report this case to make physicians aware that transient hypertension can develop in patients with blunt abdominal trauma, and to prevent the use of unnecessary antihypertensive medications.

A Reverse Dipping Pattern Predicts Cardiovascular Mortality In a Clinical Cohort

An abnormal dipping pattern in ambulatory blood pressure monitoring (ABPM) is a cardiovascular (CV) risk factor. However, its impact on CV mortality has not been investigated sufficiently in clinical practice to be considered a standard parameter. We assessed the association between abnormal dipping patterns and increased CV mortality in a tertiary hospital in Korea. Our retrospective cohort study included 401 patients who underwent ABPM between 1994 and 1996 in Hanyang University Hospital, Seoul, Korea. The patients were classified as risers ( or =0% drop, n=294). The follow-up period was 120 months. The frequency of CV mortality was 14.0% in risers and 5.8% in others. A Cox regression analysis found a significant association between dipping pattern and CV mortality, after adjusting for age, gender, body mass index, hypertension, diabetes mellitus, smoking and hypercholesterolemia. Risers were at greater risk of CV death than others (RR, 3.02, P=0.022), but there was no difference in event rates between dippers and non-dippers. The reverse dipping pattern may be more frequent in clinical settings than in the population at large, and it is strongly associated with increased risk of CV mortality in Korea.

Correlation between Proximal Abdominal Aortic Stiffness Measured by Ultrasound and Brachial-Ankle Pulse Wave Velocity

BACKGROUND AND OBJECTIVES: The proximal portion of the abdominal aorta (AA) is characterized by minimal arteriosclerosis compared with other aortic segments. To assess the clinical usefulness of this characteristic, the correlation between ultrasonographically measured proximal AA stiffness and brachial-ankle pulse wave velocity (baPWV) was examined. SUBJECTS AND METHODS: 285 subjects were analyzed, half with hypertension and half with normal blood pressure. Proximal AA was examined using ultrasonography; strain, distensibility, elastic modulus, and the stiffness index were determined. After adjustment for age, gender, body mass index (BMI), systolic blood pressure (SBP), and heart rate, the relationships between baPWV and all these parameters were tested. RESULTS: The mean age of the study subjects was 58.1+/-12.8 years and the mean BMI was 24.3+/-3.8 kg/cm2. 58.9% of the subjects were female. 42.8% were hypertensive subjects. Among the hypertensive subjects, 56.0% were taking antihypertensive medication. Adjusted partial correlation coefficients for the relationship between baPWV with strain, distensibility, elastic modulus, and the stiffness index of the proximal AA were -0.203 (p=0.01), -0.121 (p=0.129), 0.304 (p=0.0001), and 0.299 (p=0.0001), respectively, in normotensive subjects. In the multivariate analyses, such correlations were observed mainly in the normotensive group, whereas there was no association among hypertensive subjects regardless of antihypertensive medication status. CONCLUSION: baPWV is moderately correlated with the stiffness parameters for the proximal AA, mainly in normotensive subjects.

The Relationship Between Coronary Artery Calcification and Bone Mineral Density in Patients According to Their Metabolic Syndrome Status

BACKGROUND AND OBJECTIVES: The extent of coronary artery calcification (CAC) is closely related to total atherosclerotic plaque burden. However, the pathogenesis of CAC is still unclear. Conditions such as diabetes mellitus, renal failure, smoking, and chronic inflammation have been suggested to link vascular calcification and bone loss. In the present study, we hypothesized that bone loss can contribute to the pathogenesis of CAC in patients with the chronic inflammatory condition that accompanies metabolic syndrome (MetS). The objective of this study was to investigate the relationship between CAC and bone mineral density (BMD) in patients with MetS and in patients without MetS, by using coronary multidetector-row computed tomography (MDCT). SUBJECTS AND METHODS: Data from 395 consecutive patients was analyzed retrospectively. From the MDCT database, only those patients who underwent both coronary MDCT and dual-energy X-ray absorptiometry within an interval of one month, were selected. The presence of MetS was determined by the updated criteria as defined by the Third Adult Treatment Panel Report of the National Cholesterol Education Program. RESULTS: In patients with MetS, a significant correlation was found between CAC and age {odds ratio (OR)=1.139, 95% confidence interval (CI) 1.080 to 1.201, p<0.001}, CAC and male sex (OR=3.762, 95% CI 1.339 to 10.569, p=0.012), and CAC and T-score of L-spine (OR=0.740, 95% CI 0.550 to 0.996, p=0.047) using a forward multiple logistic regression analysis model including clinical variables of gender, age, lipid profile, body mass index, diabetes mellitus, hypertension, smoking, and BMD. But in patients without MetS, BMD by itself was not found to contribute to CAC. CONCLUSION: BMD was inversely correlated with CAC only in patients with MetS. This finding suggests that low BMD accompanied by MetS, may have significant clinical implications.

The Relationship Between Coronary Artery Calcification and Bone Mineral Density in Patients According to Their Metabolic Syndrome Status

BACKGROUND AND OBJECTIVES: The extent of coronary artery calcification (CAC) is closely related to total atherosclerotic plaque burden. However, the pathogenesis of CAC is still unclear. Conditions such as diabetes mellitus, renal failure, smoking, and chronic inflammation have been suggested to link vascular calcification and bone loss. In the present study, we hypothesized that bone loss can contribute to the pathogenesis of CAC in patients with the chronic inflammatory condition that accompanies metabolic syndrome (MetS). The objective of this study was to investigate the relationship between CAC and bone mineral density (BMD) in patients with MetS and in patients without MetS, by using coronary multidetector-row computed tomography (MDCT). SUBJECTS AND METHODS: Data from 395 consecutive patients was analyzed retrospectively. From the MDCT database, only those patients who underwent both coronary MDCT and dual-energy X-ray absorptiometry within an interval of one month, were selected. The presence of MetS was determined by the updated criteria as defined by the Third Adult Treatment Panel Report of the National Cholesterol Education Program. RESULTS: In patients with MetS, a significant correlation was found between CAC and age {odds ratio (OR)=1.139, 95% confidence interval (CI) 1.080 to 1.201, p<0.001}, CAC and male sex (OR=3.762, 95% CI 1.339 to 10.569, p=0.012), and CAC and T-score of L-spine (OR=0.740, 95% CI 0.550 to 0.996, p=0.047) using a forward multiple logistic regression analysis model including clinical variables of gender, age, lipid profile, body mass index, diabetes mellitus, hypertension, smoking, and BMD. But in patients without MetS, BMD by itself was not found to contribute to CAC. CONCLUSION: BMD was inversely correlated with CAC only in patients with MetS. This finding suggests that low BMD accompanied by MetS, may have significant clinical implications.

Non-Dipper Pattern is a Determinant of the Inappropriateness of Left Ventricular Mass in Essential Hypertensive Patients

BACKGROUND AND OBJECTIVES: Inappropriately high left ventricular mass (iLVM) is known to be related to cardiovascular prognosis. A non-dipper pattern has a greater mean left ventricular (LV) mass than the dipper pattern in hypertensive patients. However, the appropriateness of LV mass in dipper or non-dipper patterns has not been adequately investigated. The aim of this study was to define the relationship between nocturnal dipping and the appropriateness of LV mass. SUBJECTS AND METHODS: Using the ambulatory blood pressure monitoring (ABPM) database, the data of 361 patients who underwent ABPM and echocardiography was analyzed retrospectively. Appropriateness of LV mass was calculated as observed/predicted ratio of LV mass (OPR) using a Korean-specified equation. Nocturnal dipping was expressed as percent fall in systolic blood pressure (BP) during the night compared to the day. RESULTS: Daytime, nighttime and 24 hours BP in hypertensive patients was 140.4+/-14.8 mmHg, 143.7+/-15.2 mmHg and 129.4+/-20.0 mmHg, respectively. OPR was 106.3+/-19.9% and nocturnal dipping was 10.2+/-10.9 mmHg. In a multiple linear regression model, 24 hours systolic BP (beta=0.097, p=0.043) and nocturnal dipping (beta=-0.098, p=0.046) were independent determinants of OPR as well as age (beta=0.130, p=0.025) and body mass index (BMI) (beta=0.363, p25 kg/m2). CONCLUSION: The non-dipper pattern is independently associated with iLVM in hypertensive patients as well as obesity.

Esophageal Sinus Formation due to Cyanoacrylate Injection for Esophageal Variceal Ligation-induced Ulcer Bleeding in a Cirrhotic Patient / 대한소화기학회지

Intravariceal injection of N-butyl-2-cyanoacrylate is widely used for the hemostasis of bleeding gastric varices, but not routinely for esophageal variceal hemorrhage because of various complications such as pyrexia, bacteremia, deep ulceration, and pulmonary embolization. We report a rare case of esophageal sinus formation after cyanoacrylate obliteration therapy for uncontrolled bleeding from post-endoscopic variceal ligation (EVL) ulcer. A 50-year-old man with alcoholic liver cirrhosis presented with hematemesis. Emergent esophagogastroscopy revealed bleeding from large esophageal varices with ruptured erosion, and bleeding was initially controlled by EVL, but rebleeding from the post-EVL ulcer occurred at 17th day later. Although we tried again EVL and the injections of 5% ethanolamine oleate at paraesophageal varices, bleeding was not controlled. Therefore, we administered 1 mL cyanoacrylate diluted with lipiodol and bleeding was controlled. Three months after the endoscopic therapy, follow-up endoscopy showed medium to large-sized esophageal varices and sinus at lower esophagus. Barium esophagography revealed an outpouching in esophageal wall and endoscopic ultrasonography demonstrated an ostium with sinus. It is noteworthy that esophageal sinus can be developed as a rare late complication of endoscopic cyanoacrylate obliteration therapy.

The Relationship Between Ambulatory Arterial Stiffness Index and Blood Pressure Variability in Hypertensive Patients

BACKGROUND AND OBJECTIVES: Ambulatory arterial stiffness index (AASI) is well known as a predictor of cardiovascular mortality in hypertensive patients. Mathematically, AASI reflect the standard deviation (SD) of blood pressure (BP) variation. AASI is measured higher levels in non-dipper than dipper. Thus, AASI has a possibility of not only reflecting arterial stiffness but also BP variability and/or autonomic nervous dysfunction. SUBJECTS AND METHODS: Consecutive data from 418 untreated hypertensive patients were analyzed retrospectively. We examined the association between the 24-hour ambulatory BP monitoring (ABPM) parameters and AASI. RESULTS: AASI had a simple correlation with age (R=0.189, p<0.001), relative wall thickness (RWT) (R=0.115, p=0.019), left ventricular mass index (LVMI) (R=0.192, p<0.001), average systolic BP (SBP) (R=0.232, p<0.001), average pulse pressure (PP) (R=0.363, p<0.001), SD of diastolic BP (DBP) (R=-0.352, p<0.001), SD of PP (R=0.330, p<0.001), SD of heart rate (HR) (R=-0.268, p<0.001), and nocturnal dipping (R=-0.137, p=0.005). In multiple linear regression analysis model including clinical parameters and 24 hour-ABPM parameters, independent predictors of AASI were SD of PP (beta=1.246, p<0.001), SD of DBP (beta=-1.067, p<0.001), SD of SBP (beta=-0.197, p<0.001), and non-dipper (beta=0.054, p=0.033). CONCLUSION: AASI is closely correlated with BP variability. The result of this study shows that AASI is not only a parameter for arterial stiffness, but also a parameter for BP variability.

A Case of Peritoneal Dialysis Peritonitis Due to Methicillin-Resistant Staphylococcus auricularis / 대한신장학회지

Although coagulase-negative staphyloccus is the most common organism causing peritonitis in peritoneal dialysis (PD) patients, only one case of PD peritonitis due to Staphylococcus auricularis, the normal flora of external auditory meatus, has been reported over the world. Here we add a case of PD peritonitis caused by methicillin-resistant Staphylococcus auricularis, which was successfully treated with vancomycin. A 79-year-old male PD patient was admitted because of abdominal pain and cloudy peritoneal fluid. At admission, the exit site was clear, and no rebound tenderness was noted although the abdominal wall was diffusely tender. Gram stain of the peritoneal fluid did not reveal any organism, but white blood cell count was 1,210/mm3, with 80% polymorphonuclear cells and 10% lymphocytes. Empirical antibiotic therapy was started with intraperitoneal cefazolin and ceftazidime. Over the next few days, however, the peritoneal fluid was still turbid and showed an elevated cell count. Then, the result of peritoneal fluid culture identified that the organism was oxacillin-resistant Staphylococcus auricularis. Thus the antibiotics were switched into vancomycin, and intraperitoneal vancomycin 1 gm was administered three times at 5 days' intervals to achieve completely clear peritoneal fluid. Staphylococcus auricularis should be considered as a new potential skin organism causing PD peritonitis.