Clinical Outcomes of Multidisciplinary Team Care on the Regulation of Chronic Kidney Disease - Mineral and Bone Disorder (CKD-MBD) in Patients Undergoing Dialysis

BACKGROUND: Multidisciplinary team care (MTC) is a collaborative approach to treatment plan and ongoing care. We aimed to evaluate the clinical effect of MTC on the regulation of chronic kidney disease-mineral and bone disorder (CKD-MBD) complications in dialysis patients. METHODS: This retrospective observational study was approved by the institutional review board. Among patients who have undergone dialysis at admission, the patients admitted to the nephrology ward were allocated to MTC group, and the others to usual care (UC) group. The MTC group had collaborative care by nephrologists, nurses, pharmacists, and nutritionists. The endpoints were the regulation of corrected calcium (cCa) and phosphate (P), the percent of patients in target level of cCa-P product (cCa×P), and the prescription rate of non-calcium based P-binders. RESULTS: A total of 163 patients were included from January to December 2009. A significant difference was shown in the percentage of patients in target cCa×P level at admission (MTC vs. UC, 81.40% vs. 91.67%; P = 0.038), but there was no significant difference at discharge. During admission, the cCa and P levels of patients in only UC group were significantly changed. In addition, compared with UC group, patients in MTC group were more likely prescribed appropriate P-binders, when they had higher cCa×P levels than 55 mg²/dL² (P <0.001). CONCLUSION: It was found that MTC had beneficial effect on improving the regulation of CKD-MBD and the appropriate phosphate binder uses. Therefore, application of the MTC is anticipated to enhance quality of clinical care in chronic diseases.

Myxoid liposarcoma in a dog / 대한수의학회지

The pathological features of a mass in the back skin region of an 8-year-old castrated male dog are described herein. The cut section of the tumor was white to tan with a soft multilobulated mass containing hemorrhagic and necrotic foci and a mucinous-like composition. Microscopically, the tumor was composed of a mixture of lipocytes, lipoblasts, spindle cells and stellate cells and had a myxoid background. Oil red O staining revealed that the cytoplasm of neoplastic cells contained large numbers of lipid droplets. Immunohistochemically, tumor cells were positive for vimentin and S-100 protein. The skin mass was diagnosed as myxoid liposarcoma.

Clinicopathologic Features of Cases with Negative Pathologic Results after Endoscopic Submucosal Dissection / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic submucosal dissection (ESD) is accepted as a standard treatment of early gastric cancer (EGC) and gastric adenoma. Occasionally, tumorous lesion is not found and pathologic discrepancies can occur after ESD. The aim of this study was to analyze the factors affecting the negative pathologic results after ESD. METHODS: We retrospectively reviewed the data from all patients with gastric neoplasm (276 EGC and 516 gastric adenomas) who were treated with ESD during past 3 years and enrolled the patients who had negative pathologic results. RESULTS: Out of 792 patients treated with ESD, 27 patients (3.4%) were eligible for inclusion. Among the 27 patients, factors affecting the negative pathologic results were, most commonly, the focal lesion (n=13, 48.2%) which was small enough to be removed completely during pre-ESD biopsy, followed by pathologic discrepancies (n=11, 40.7%) between pathologists and lastly the operator factor (n=3, 11.1%) dissecting incorrect lesions. Of the focal lesions, the initial pathologic diagnoses were adenocarcinoma in 11 cases (84.6%). In cases with pathologic discrepancies, all the pretreatment diagnoses were adenoma with low grade dysplasia. In cases caused by operator factors, intestinal metaplasia was accompanied by elevated adenoma in all cases. CONCLUSIONS: To decrease negative pathologic results after ESD, an endoscopist should perform ESD after sufficient communication with pathologists, especially for adenoma with low grade dysplasia, and choose correct lesion, especially located at the antrum and associated with intestinal metaplasia. The possibility of total removal of small lesions even by forcep biopsy should be considered.

A Newly Developed Pericardial Tuberculoma During Antituberculous Therapy

Tuberculosis generally affects the respiratory tract. In developing nations, the pericardium is the most common location of extrapulmonary tuberculosis; however, tuberculous pericarditis rarely appears as a localized mass or tuberculoma. We present here a case of a 62-year-old woman with pericardial tuberculoma. She had a history of effusive tuberculous pericarditis and drainage. Because she had taken regular medication over a period of six months, the pericardial mass with an adjacent lung nodule newly detected on the chest radiogram was initially suspected of being invasive lung cancer. Prior to pathologic confirmation, precise information from imaging tests, including computed tomography, magnetic resonance imaging, and positron emission tomography-computed tomography are helpful when making decisions regarding which methods should be used for surgical approach and treatment. Through imaging, our case showed typical features of pericardial tuberculoma and a favorable clinical course after two months with a change in antituberculous therapy.

Clinical Features of Hyponatremia: Changes Related to Increasing Use of Thiazide-Combination Diuretics / 대한신장학회지

PURPOSE: In this study, the etiology and the change of clinical characteristics of hyponatremia, in relation to the increased used of thiazide diuretics, have been assessed. METHODS: To perform a retrospective cohort study, a total sum of 322 patients who have been admitted in a single tertiary referral hospital between 2004 and 2009, were included. RESULTS: The most common cause of hyponatremia was due to thiazide diuretics (37.6%). Among the 121 patients who suffered from thiazide induced hyponatremia, 60 (48.0%) patients took combination thiazide. The incidence of hyponatremia has shown a tendency to increase from 2004 to 2009 (trend test, p<0.001). The incidence of hyponatremia due to the use of combination types has also increased (trend test, p<0.001). Thiazide induced hyponatremia showed no difference when compared to hyponatremia due the other causes, except the fact that the portion of female patients was higher (73.6% vs 64.6%, p<0.001), mean age was older (74.7 vs 69.9 years-old, p<0.001), and incidence of cerebrovascular accident was also higher (19.8% vs 6.5%, p<0.001). CONCLUSION: The use of thiazide is increasing and hence thiazide-induced hyponatremia is also increasing. This is thought to be particularly related to the increase of thiazide-combined drugs. Thiazideinduced hyponatremia shows a higher incidence in old age, female sex and those who have a history of a cerebrovascular event. Hence more caution is needed when using thiazide diuretics as antihypertensives, and plasma sodium levels should be monitored carefully.

Dual Pulsed-Wave Doppler Tracing of Right Ventricular Inflow and Outflow: Single Cardiac Cycle Right Ventricular Tei Index and Evaluation of Right Ventricular Function

BACKGROUND AND OBJECTIVES: The reliability and usefulness of the right ventricular (RV) Tei index (RTX) remains controversial because it has not been possible to simultaneously measure RV inflow and outflow. However, dual pulsed-wave Doppler (DPD) enables flow velocities to be obtained at different sampling sites simultaneously. In this study we evaluated the feasibility and reliability of RTX values obtained by DPD (RTX(DPD)). SUBJECTS AND METHODS: Forty-one patients who underwent cardiac catheterization and echocardiography for RV volume or pressure overloading conditions were evaluated. Symptom-limited exercise treadmill testing with expired gas analysis was performed and maximal exercise capacity was measured. RESULTS: RTX by conventional flow Doppler (RTX(CFD), 0.262+/-0.164) was similar to RTX(DPD) (0.253+/-0.117, p=NS), whereas RTX by tissue Doppler echocardiography (RTX(TDE), 0.447+/-0.125) was significantly larger than RTX(DPD) (p<0.001). Based on multiple regression analysis, maximal exercise capacity was independently related to RTX(DPD) (beta=-0.60, p<0.001), mid-RV dimension (beta=-0.26, p=0.012), left ventricular ejection fraction (beta=0.22, p=0.023), and early diastolic tricuspid annular velocity (beta=0.21, p=0.048). CONCLUSION: It is feasible and reliable to evaluate RV function using RTX(DPD) values. However, to evaluate the clinical usefulness of RTX(DPD), additional studies are required with a large number of patients and long-term follow-up.

Flash Pulmonary Edema in a Patient With Unilateral Renal Artery Stenosis and Bilateral Functioning Kidneys

Flash pulmonary edema typically exhibits sudden onset and resolves rapidly. It generally is associated with bilateral renal artery stenosis or unilateral stenosis in conjunction with a single functional kidney. We describe a patient who presented with flash pulmonary edema treated by percutaneous therapy with stent implantation. Our case is unique in that the flash pulmonary edema occurred in the setting of unilateral renal artery stenosis with bilateral functioning kidneys.

Deglutition Syncope Associated With Ventricular Asystole in a Patient With Permanent Atrial Fibrillation

Deglutition syncope is a situational syncope that is diagnosed only by a detailed history. We report deglutition syncope in a 62-year-old man, who had permanent atrial fibrillation. The patient had no structural or functional abnormalities of the esophagus. During syncopal attacks, his electrocardiography showed ventricular asystole that was sustained for 12 seconds. The patient was successfully treated by implantation of a permanent pacemaker.

Intravascular Ultrasound-Guided Troubleshooting in a Large Hematoma Treated With Fenestration Using a Cutting Balloon

Intramural hematoma formation is not a well-studied complication of percutaneous coronary intervention. We describe a patient with stable angina who developed an intramural hematoma during elective percutaneous coronary intervention (PCI) in the right coronary artery (RCA). Total occlusion with dense dye staining developed a long way from the distal RCA, near the posterior descending artery bifurcation site. The true lumen was compressed by the enlarged, tense, false lumen. The patient was successfully treating with intravascular ultrasound-guided fenestration using a cutting balloon, and a stent was implanted in the distal RCA.

Compliance with Atovaquone-Proguanil against Malaria of Korean Travelers Abroad / 감염과화학요법

BACKGROUND: Recently, many Korean people travel abroad where malaria is prevalent. However, in Korea, relatively little is known about compliance of chemoprophylaxis against malaria. This study was performed to determine the factors influencing compliance of chemoprophylaxis against malaria in Korean travelers. MATERIALS AND METHODS: Face to face interview, telephone interview and e-mail correspondence were performed to 241 people who were prescribed with atovaquone-proguanil at the international travelers' clinic of National Medical Center between February 2007 and October 2007. RESULTS: Total of 55 people out of 235 reported one or more events of adverse reactions after chemoprophylaxis (total 76 events). However, in 38 adverse events the link between chemoprophylaxis and adverse events were very weak. Compliance of malaria chemoprophylaxis with atovaquone-proguanil was 53.9% in the study group. The predictive factors for non-compliance were package tour, travel of business affair and young age group. Conclusions: Compliance of malaria chemoprophylaxis in Korea travelers was low compared with Dutch and French studies. More efforts to increase compliance are needed, especially in travelers on package tour, business travel and people under age 40.

Compliance with Atovaquone-Proguanil against Malaria of Korean Travelers Abroad / 감염과화학요법

BACKGROUND: Recently, many Korean people travel abroad where malaria is prevalent. However, in Korea, relatively little is known about compliance of chemoprophylaxis against malaria. This study was performed to determine the factors influencing compliance of chemoprophylaxis against malaria in Korean travelers. MATERIALS AND METHODS: Face to face interview, telephone interview and e-mail correspondence were performed to 241 people who were prescribed with atovaquone-proguanil at the international travelers' clinic of National Medical Center between February 2007 and October 2007. RESULTS: Total of 55 people out of 235 reported one or more events of adverse reactions after chemoprophylaxis (total 76 events). However, in 38 adverse events the link between chemoprophylaxis and adverse events were very weak. Compliance of malaria chemoprophylaxis with atovaquone-proguanil was 53.9% in the study group. The predictive factors for non-compliance were package tour, travel of business affair and young age group. Conclusions: Compliance of malaria chemoprophylaxis in Korea travelers was low compared with Dutch and French studies. More efforts to increase compliance are needed, especially in travelers on package tour, business travel and people under age 40.

A Case of Kaposi Sarcoma of the Bronchi and Gastrointestinal Tract in an AIDS Patient

Kaposi sarcoma is a rare tumor originated from skin in patients with immune suppressive illness like as acquired immunodeficiency syndrome (AIDS) or organ transplantation. It may be widely disseminated internally such as digestive or respiratory organ. In Korean patients with AIDS, Kaposi sarcoma is rarely seen rather than western countries. The reason is unknown. Although few cases of Kaposi sarcoma in patients with AIDS had been described in the Korean literatures, multi-organ involved cases were extremely rare. We describe a case of old AIDS patient in whom Kaposi sarcoma had affected multi-organs including esophagus, stomach, duodenum, colon, bronchi and skin.

Prevalence of Infectious Diseases in the Homeless Admitted to a Tertiary Care Center / 감염과화학요법

BACKGROUND: Despite the expected high prevalence of several infectious diseases among the homeless, a majority of them have not received screening test and early treatment. MATERIALS AND METHODS: The subjects of this study were 269 homeless patients who had been hospitalized in the National Medical Center (Korea) between January 2002 and August 2004. Their medical histories and records were reviewed to analyze the prevalence and clinical characteristics of hepatitis B and C, syphilis, tuberculosis and HIV infection among them. RESULTS: The entire 269 homeless patients being hospitalized during the period of this study consist of 249 male patients and 19 female patients. For the prevalence of infectious diseases, HBV was seen in 15 of 228 patients (6.6%); HCV in 8 of 113 patients (7.1%); VDRL positive in 25 of 234 patients (10.7 %); HIV antibody positive in 2 of 130 (1.5%); and tuberculosis in 19 of 269 (7.1%). The number of patients who had the antibody to hepatitis B was 118 (51.7%). Of 28 patients hospitalized with the chief complaints of liver diseases and/or their complications, the number of cases infected with hepatitis B and C viruses was only 5 (17.9%). On the other hand, for patients with tuberculosis, 13 of 19 cases (68.4%) were hospitalized with the chief complaints associated with symptoms of pulmonary tuberculosis or enlarged lymph nodes. The number of patients with multiple infectious diseases was 9 in total. CONCLUSION: As expected, the prevalence of some infectious diseases were higher among the homeless inpatients, than non-homeless population. Proper screening tests in order to determine the presence of any infectious diseases among the patients and protect involved medical staff are necessary. Further, the government should take proactive measures to prevent the spread of infectious diseases in the aspect of public health.

Prevalence of Infectious Diseases in the Homeless Admitted to a Tertiary Care Center / 감염과화학요법

BACKGROUND: Despite the expected high prevalence of several infectious diseases among the homeless, a majority of them have not received screening test and early treatment. MATERIALS AND METHODS: The subjects of this study were 269 homeless patients who had been hospitalized in the National Medical Center (Korea) between January 2002 and August 2004. Their medical histories and records were reviewed to analyze the prevalence and clinical characteristics of hepatitis B and C, syphilis, tuberculosis and HIV infection among them. RESULTS: The entire 269 homeless patients being hospitalized during the period of this study consist of 249 male patients and 19 female patients. For the prevalence of infectious diseases, HBV was seen in 15 of 228 patients (6.6%); HCV in 8 of 113 patients (7.1%); VDRL positive in 25 of 234 patients (10.7 %); HIV antibody positive in 2 of 130 (1.5%); and tuberculosis in 19 of 269 (7.1%). The number of patients who had the antibody to hepatitis B was 118 (51.7%). Of 28 patients hospitalized with the chief complaints of liver diseases and/or their complications, the number of cases infected with hepatitis B and C viruses was only 5 (17.9%). On the other hand, for patients with tuberculosis, 13 of 19 cases (68.4%) were hospitalized with the chief complaints associated with symptoms of pulmonary tuberculosis or enlarged lymph nodes. The number of patients with multiple infectious diseases was 9 in total. CONCLUSION: As expected, the prevalence of some infectious diseases were higher among the homeless inpatients, than non-homeless population. Proper screening tests in order to determine the presence of any infectious diseases among the patients and protect involved medical staff are necessary. Further, the government should take proactive measures to prevent the spread of infectious diseases in the aspect of public health.

Severity of Coronary Atherosclerosis; Influence of Metabolic Syndrome Risk Factor Clustering and hs-CRP

BACKGROUND AND OBJECTIVES: Metabolic syndrome and high sensitivity C-reactive protein (hs-CRP) are known to be strong predictors of coronary atherosclerosis. Even though there have been many observations and much research concerning the association of coronary atherosclerosis with CRP and metabolic syndrome, certain problems still need to be resolved in order to produce clear mechanistic illustrations. Therefore, the correlations of metabolic syndrome, hs-CRP and the severity of coronary atherosclerosis were evaluated herein. SUBJECTS AND METHODS: 271 patients, aged between 29 and 87, who had undergone diagnostic coronary angiograms at the National Medical Center, between January, 2004 and June, 2006 were evaluated. Coronary angiograms were performed in patients who complained of typical chest pain and had risk factors associated with coronary atherosclerosis. The correlations of metabolic syndrome, hs-CRP and coronary atherosclerosis were analyzed in these patients. RESULTS: Positive relationships were found between the metabolic syndrome risk factor clustering and an increased level of hs-CRP (p<0.01). The severity of coronary atherosclerosis increased with the increasing number of metabolic syndrome risk factors. As metabolic syndrome risk factor clustering increased, the quantity of 1, 2 and 3 vessel diseases also increased (Odd ratios 1.61, 1.83 and 2.50; p=0.001, <0.001 and <0.001, respectively). In contrast to metabolic syndrome risk factor clustering, no definite relationship between the hs-CRP level and the severity of coronary atherosclerosis was observed. CONCLUSION: The more metabolic syndrome risk factors clustered, the greater the severity of coronary atherosclerosis. The extension of coronary atherosclerosis maybe predicted using evaluation of metabolic syndrome risk factor clustering in patients with angina.

Pacemaker malfunction related to insulation break according to position change in a patient with complete AV block / 대한내과학회지

A 53 year-old woman presented with intermittent dizziness and palpitation. She had received VVI type pacemaker due to complete AV block in 1990, and exchanged by VVIR type pacemaker thirteen years later. 1 year later, she suffered intermittent dizziness and palpitation in erect position, not in supine position. Intermittent pacing failure and sensing failure was observed in pacemaker test, especially in erect position, not in supine position. Pacing threshold was increased in erect position, but lead impedance was not changed. Insulation break was observed in bipolar lead by fluoroscope. Initially we tried a new lead implantation by cephalic access to prevent lead related complication, but failed. So, we implanted a new bipolar lead by subclavian access. Finally, she was treated by a new bipolar lead implantation.