A Case of Vancomycin-Induced Drug Reaction with Eosinophilia, Systemic Symptoms and Multiorgan Involvement Proven Using Lymphocyte Transformation Test

Drug-induced hypersensitivity syndrome (DiHS), also referred to as drug reaction with eosinophilia and systemic symptoms (DRESS), is a rare but potentially life-threatening condition induced by drug hypersensitivity that leads to significant morbidity and mortality and often occurs in patients undergoing combination antibiotic therapy. Due to a recent increase in the incidence of methicillin-resistant Staphylococcus aureus infections, the occurrence of vancomycin-induced DiHS/DRESS has increased rapidly. However, because of insufficient pharmacogenetic data on vancomycin-induced drug eruptions in Asians coupled with the risk of re-eliciting the symptoms by provocation tests, confirmation of the culprit drug in vancomycin-induced DiHS/DRESS is often challenging. Here, we report a case of vancomycin-induced DiHS/DRESS, where the causal relationship was confirmed using a lymphocyte transformation test (LTT). A 51-year-old woman was treated with combination antibiotics, including vancomycin, for infective pericarditis. The patient subsequently developed fever, facial edema, generalized rash followed by multiple internal organ involvement, including the kidney, lung, liver, and heart. Thus, based on the International Registry of Severe Cutaneous Adverse Reaction (RegiSCAR) criteria, the case was diagnosed as ‘definite’ DiHS/ DRESS, although the culprit drug was obscured by combination antibiotic therapy. The LTT confirmed that vancomycin, but not other glycopeptide antibiotics, specifically induced Tcell proliferation in this case. Collectively, our case suggests that clinicians can utilize LTT to identify the causative medication of DiHS/DRESS when the clinical information is limited to defining the culprit drug.

Effect of Stent Placement on Survival in Patients with Malignant Portal Vein Stenosis:A Propensity Score–Matched Study

Objective@#Percutaneous portal vein (PV) stent placement can be an effective treatment for symptoms associated with portal hypertension. This study aimed to evaluate the effect of PV stenting on the overall survival (OS) in patients with malignant PV stenosis. @*Materials and Methods@#Two groups of patients with malignant PV stenosis were compared in this retrospective study involving two institutions. A total of 197 patients who underwent PV stenting between November 2016 and August 2019 were established as the stent group, whereas 29 patients with PV stenosis who were treated conservatively between July 2013 and October 2016 constituted the no-stent group. OS was compared between the two groups before and after propensity score matching (PSM). Risk factors associated with OS were evaluated using the Cox proportional hazards model. Procedureassociated adverse events were also evaluated. @*Results@#The stent group finally included 100 patients (median age, 65 [interquartile range, 58–71] years; 64 male). The nostent group included 22 patients (69 [61–75] years, 13 male). Stent placement was successful in 95% of attempted cases, and the 1- and 2-year stent occlusion–free survival rate was 56% (95% confidence interval, 45%–69%) and 44% (32%–60%), respectively. The median stent occlusion–free survival time was 176 (interquartile range, 70–440) days. OS was significantly longer in the stent group than in the no-stent group (median 294 vs. 87 days, p < 0.001 before PSM, p = 0.011 after PSM).The 1- and 3-year OS rates before PSM were 40% and 11%, respectively, in the stent group. The 1-year OS rate after PSM was 32% and 5% in the stent and no-stent groups, respectively. Anemia requiring transfusion (n = 2) and acute thrombosis necessitating re-stenting (n = 1) occurred in three patients in the stent group within 1 week. @*Conclusion@#Percutaneous placement of a PV stent may be effective in improving OS in patients with malignant PV stenosis.

Prostatic Artery Embolization for Lower Urinary Tract Symptoms via Transradial Versus Transfemoral Artery Access: Single-Center Technical Outcomes

Objective@#To evaluate the safety and feasibility of prostatic artery embolization (PAE) via transradial access (TRA) compared with transfemoral access (TFA). @*Materials and Methods@#This retrospective study included 53 consecutive men with lower urinary tract symptoms (LUTS) who underwent PAE between September 2018 and September 2021. Thirty-one patients (mean age ± standard deviation:70.6 ± 8.4 years) were treated with TFA, including 14 patients treated before adopting TRA. Since December 2019, TRA has also been attempted with the procedure’s selection criteria of patent carpal circulation and a height ≤ 172 cm, with 22 patients treated via TRA (69.1 ± 9.6 years). Parameters of technical success (defined as successful bilateral embolization), clinical success (defined as LUTS improvement), procedural time, radiation dose, and adverse events were compared between the two groups using the Fisher’s exact test, independent sample t test, Wilcoxon signed-rank test, or Mann-Whitney test. @*Results@#All patients received at least one-side PAE. Technical success of PAE was achieved in most patients (TRA, 21/22; TFA, 30/31; p > 0.999). No technical problem-related conversion from TRA to TFA occurred. The clinical success rate was 85% (11/13) in patients with TRA, and 89% (16/18) in patients with TFA for follow-up > 2 weeks post-PAE (median, 3 months) (p > 0.999). The median procedure time was similar in both groups (TRA, 81 minutes vs. TFA, 94 minutes; p = 0.570). No significant dose differences were found between the TRA and TFA groups in the dose-area product (median Gycm2 , 95 [range, 44–255] for TRA and 84 [34–255] for TFA; p = 0.678) or cumulative air kerma (median mGy, 609 [236–1584] for TRA and 634 [217–1594] for TFA; p = 0.551). No major adverse events occurred in either of the groups. @*Conclusion@#PAE via TRA is a safe and feasible method comparable to conventional TFA. It can be safely implemented by selecting patients with patent carpal circulation and adequate height.

Endovascular Treatment of a Systemic-to-Pulmonary Artery Fistula: A Case Report

Systemic-to-pulmonary artery fistulas are rare. This condition may be congenital, post-traumatic, or post-inflammatory and can cause infection, hemorrhage, or pulmonary hypertension. Here, we report a case of an intercostal-to-pulmonary artery fistula, incidentally detected during the evaluation of dyspnea in a 67-year-old female. Retrograde transcatheter coil embolization in a dilated draining pulmonary artery was initially attempted. However, another draining pulmonary artery developed after 5 months. The intercostal arteries or systemic feeders were successfully embolized through a transarterial access. At the 10-month follow-up, the abnormally dilated vessels had regressed, and dyspnea had improved. Sequential or simultaneous retro- and antegrade transcatheter embolization may successfully treat pleural arterio-arterial fistulas.

Endovascular Treatment of a Systemic-to-Pulmonary Artery Fistula: A Case Report

Systemic-to-pulmonary artery fistulas are rare. This condition may be congenital, post-traumatic, or post-inflammatory and can cause infection, hemorrhage, or pulmonary hypertension. Here, we report a case of an intercostal-to-pulmonary artery fistula, incidentally detected during the evaluation of dyspnea in a 67-year-old female. Retrograde transcatheter coil embolization in a dilated draining pulmonary artery was initially attempted. However, another draining pulmonary artery developed after 5 months. The intercostal arteries or systemic feeders were successfully embolized through a transarterial access. At the 10-month follow-up, the abnormally dilated vessels had regressed, and dyspnea had improved. Sequential or simultaneous retro- and antegrade transcatheter embolization may successfully treat pleural arterio-arterial fistulas.

A Survey of Physician’s Awareness Regarding the Prescription and Side Effects of Topical Steroids / 대한피부과학회지

Background@#Topical steroids are the most commonly prescribed anti-inflammatory agents in dermatology, and patients often experience various adverse events of topical steroid application. Patients’ awareness of adverse effects and understanding of coping strategies for these unwanted events are pivotal elements for the safe use of topical steroids. @*Objective@#This study aimed to assess the prescribing pattern of topical steroids and patient education for safe use by dermatologists and non-dermatology specialists in Korea. @*Methods@#A questionnaire was sent to dermatologists, pediatricians, and other specialists through an online survey.A total of 444 answers were analyzed; then, the numbers were adjusted according to the nationwide proportion of specialists prescribing topical steroids. The total number of respondents was set to 720 after the adjustment. @*Results@#Dermatologists prescribed topical steroids to 49% of their patients, while other specialist doctors prescribed to 6.4% of the patients. Mid-potency steroids were most commonly prescribed (52.9%), followed by low/weak potency (37.6%), in adjusted analysis. Overall, 12.5% of all respondents and 14.5% of dermatologists reported adverse events due to topical steroids within the last month. The physicians spent 2.1 minutes on average (2.0 minutes for dermatologists) for patient education on proper use of topical steroids. The majority (79.1%) of physicians informed patients of the fact that the prescription contained steroids, while some were reluctant to disclose this information because of the negative perception about steroids in the general population. @*Conclusion@#This survey provides thorough information on the current status of prescription, counseling condition, doctors’ perception of patients’ knowledge of adverse events, and proper use of topical steroids.

Dysphagia in Wilson’s Disease: A Case Report of One-Year Follow-Up / 대한연하장애학회지

Wilson’s disease (WD) is a genetic disease caused by an ATP7B gene mutation. Although dysphagia is known as a neurological manifestation of WD, clinical case reports with post-treatment long-term follow-up are scarce. A 17-year-old male was admitted to hospital complaining of general weakness and swallowing difficulty. He was diagnosed with WD by genetic confirmation. Assessment of the videofluoroscopic swallowing study (VFSS) determined an initial videofluoroscopic dysphagia scale (VDS) score of 48. After 11 months treatment with D-penicillamine and neuromuscular electrical stimulation therapy (NMES) with oromotor exercises, the VDS score improved to 23, especially in the following areas: mastication, apraxia, premature bolus loss, triggering of pharyngeal swallow, and laryngeal elevation. Dysphagia is an early neurological symptom of WD, and is reversible when properly treated with early diagnosis. Thus, since WD is treatable, patients presenting with dysphagia should be indicative of high probability of the disease, and evaluated at the earliest. NMES treatment in combination with D-penicillamine helps to improve the deglutition function in both oral and pharyngeal phases. To investigate the characteristics of dysphagia and the specific clinical efficacy of NMES in WD, further studies with larger number of patients are required.

Pharmacological therapeutics in androgenetic alopecia

Androgenetic alopecia (AGA) is the most common type of hair loss and affects both men and women. Male pattern hair loss shows characteristic frontal recession and vertex baldness, whereas female pattern hair loss produces diffuse alopecia over the mid-frontal scalp. AGA is mediated by increased androgen susceptibility in affected scalp hairs. 5α-Reductase converts testosterone into dihydrotestosterone, a potent androgen, in the scalp. Both androgen receptors and 5α-reductase have higher expression levels in the balding scalp than in non-affected regions. Increased androgen susceptibility induces hair follicle miniaturization, which leads to the progressive loss of thicker terminal hairs in the balding scalp. Currently, topical minoxidil and oral 5α-reductase inhibitors, such as finasteride and dutasteride, are approved options for the pharmacological treatment of AGA. Topical minoxidil remains the mainstay of therapy for mild to moderate AGA in both men and women. The daily intake of 1-mg finasteride or 0.5-mg dutasteride shows better efficacy than topical minoxidil in regard to hair regrowth in male AGA. Anti-androgens can be used in female AGA wit clinical and biochemical evidence of hyperandrogenism. Patients may be overwhelmed and confused by the variety of treatment options for AGA management, including over-the-count drugs with low evidence quality. Therefore, physicians must be aware of the current guidelines for the management of AGA based on evidence-based approaches to select better options for patients.

Cumulative Therapeutic Effect of High-Voltage Microcurrent Therapy in Patients with Herniated Lumbar Disc

OBJECTIVE: This study aims to evaluate the efficacy of high-voltage microcurrent therapy in patients with herniated lumbar disc (HLD) presenting radicular or back pain.METHOD: This is a retrospective study with 33 patients who are complaining pain with HLD findings on magnetic resonance image. Microcurrent therapy was applied to leg or paralumbar area. Treatment was conducted for seven minutes with 250~1000 uA intensity as high as the patients could tolerate via stimulating probe with roller type and the frequency was 60 Hz with a sine wave pulse. The visual analogue scale (VAS) was measured just before and after the treatment.RESULTS: The degree of pain reduction (ΔVAS) was 1.6 points after treatment on average. The ΔVAS according to the diagnosis, stenosis, dermatome area, medication, pain site and caudal epidural block was not statistically significant. However, the ΔVAS according to the number of treatments (< 3, ≥ 3 times) showed a statistically significant difference (p=0.04).CONCLUSION: High-voltage microcurrent therapy may help reduce lumbar or lumbosacral radiating pain after the procedure. The effect was better when microcurrent was applied three times or more. This result suggests that the microcurrent would have cumulative effect on reducing radicular or back pain in patients with HLD.

Torticollis and Atlantoaxial Rotatory Subluxation after Chiropractic Therapy

Torticollis is an abnormal, asymmetric head or neck position which usually caused by imbalance of paracervical muscles. The traumatic torticollis can be caused by following events; atlantoaxial rotatory subluxation, atlantoaxial dislocation, cervical vertebral fractures, and injury to the cervical musculature. Especially, acute traumatic atlantoaxial rotatory subluxation usually presents limitation of cervical range of motion without pain or neurologic deficit. We report a case of a 58 year-old man who developed the acute atlantoaxial rotatory subluxation right after the chiropractic therapy, which induced the limitation of cervical range of motion to 52.5% of normal range. The magnetic resonance image revealed the facture of the odontoid process and the partial injury in transverse ligaments of the atlas. He underwent intramuscular botulinum toxin injection and 10 days of continuous cervical traction 15 hours a day using a 5 kg weight. The range of the cervical motion restored up to 90.2% of normal range.

Effects of Academic Relationships on Academic Burnout in Health Professions Students / 의학교육논단

There are several dimensions of academic burnout experienced by medical and health science college students. The purpose of this study was to examine the effects of academic relationships on academic burnout. Data was collected from 476 Eulji University students using an online survey over 4 days in April of 2018. Of the 264 respondents, 111 studied medicine (42.0%), 105 studied nursing (39.8%), and 48 studied clinical pathology (18.1%). The questionnaire was composed of the following sections: demographics (four questions), general life characteristics (seven questions), academic enthusiasm (eight questions), academic relationships (15 questions), and academic burnout sub-dimensions (partially revised Maslach Burnout Inventory-Student Survey Scale) (11 questions). T-tests and one-way analysis of variance were performed to illustrate the differences among the three departments. The effects of academic relationships and academic enthusiasm on academic burnout were analyzed using linear regression. Comparing the three departments, academic burnout was not found to be statistically significant (p=0.296). However, medical students' academic enthusiasm was significantly lower (p<0.001) and academic relationships were significantly higher (p<0.001) than nursing and clinical pathology students. The difference in academic burnout among the three departments was not significant. However, medical students have stronger academic relationships, while nursing and clinical pathology students were more focused on academics. Relationships and academic enthusiasm contribute to reducing academic burnout. Therefore, strategies need to be developed to deal with academic burnout considering relationship factors.

The Importance of Education regarding the Effects of Anticancer Treatment on Fertility and Ovarian Function in the Female Patients with Breast Cancer

OBJECTIVES: Female breast cancer patients generally have limited knowledge regarding issues related to preservation of ovarian function and fertility. The present study aimed to explore the change in the understanding of these issues when female breast cancer patients are educated and counseled about ovarian function and fertility after anticancer treatment.METHODS: One hundred nine young female breast cancer patients completed a questionnaire, which revealed their thoughts and opinions before and after receiving the education about ovarian function and fertility. Their responses were analyzed to determine the impact of the education on their perception and understanding of the aforementioned issues.RESULTS: The objective survey had four main themes: planning and desire for children, degree of baseline understanding of the effects of anticancer therapy on fertility and ovarian function, resultant change in cognition after education about cancer treatment and its relationship with fertility, and need for education regarding the types of therapies received and their effects on subsequent ovarian function and fertility before treatment.CONCLUSIONS: The preservation of ovarian function and fertility is an important factor that must be included in the discussion prior to initiation of anticancer therapy. Although the study results do not have high educational effectiveness or a high satisfaction with education, there is a need for information and education regarding the impact of anticancer treatment on preservation of ovarian function and fertility.

Diagnosis and Effect of Maxillary Expansion in Pediatric Sleep-Disordered Breathing / 대한소아치과학회지

The aim of this study was to analyze the changes and improvements in symptoms of sleep-disordered breathing (SDB) using semi-rapid maxillary expansion (SRME) in children with narrow maxilla and SDB symptoms. Subjects were 15 patients with sleep disorder (apnea-hypopnea index, AHI ≥ 1) and narrow maxillary arch between 7 and 9 years of age. Before the SRME was applied, all subjects underwent pediatric sleep questionnaires (PSQ), lateral cephalometry, and portable sleep monitoring before expansion (T0). All subjects were treated with SRME for 2 months, followed by maintenance for the next 3 months. All subjects had undergone PSQ, lateral cephalometry, and portable sleep monitoring after expansion (T1). Adenoidal-nasopharyngeal ratio (ANR), upper airway width and hyoid bone position were measured by lateral cephalometry. The data before and after SRME were statistically analyzed with frequency analysis and Wilcoxon signed rank test. As reported by PSQ, the total PSQ scale was declined significantly from 0.45 (T0) to 0.18 (T1) (p = 0.001). Particularly, snoring, breathing, and inattention hyperactivity were significantly improved (p = 0.001). ANR significantly decreased from 0.63 (T0) to 0.51 (T1) (p = 0.003). After maxillary expansion, only palatopharyngeal airway width was significantly increased (p = 0.035). There was no statistically significant difference in position of hyoid bone after expansion (p = 0.333). From analysis of portable sleep monitoring, changes in sleep characteristics showed a statistically significant decrease in AHI and ODI, and the lowest oxygen desaturation was significantly increased after SRME (p = 0.001, 0.004, 0.023).In conclusion, early diagnosis with questionnaires and portable sleep monitoring is important. Treatment using SRME will improve breathing of children with SDB.

Relationship between Upper Airway and Sleep-Disordered Breathing in Children with Mouth Breathing / 대한소아치과학회지

The most common cause of mouth breathing is obstacles caused by mechanical factors in upper airway. Mouth breathing could be consequently pathological cause of sleep-disordered breathing. Sleep-disordered breathing in children can cause growth disorders and behavioral disorders. The purpose of this study was to investigate relationship between upper airway and sleep-disordered breathing in children with mouth breathing.Twenty boys between 7 – 9 years old who reported to have mouth breathing in questionnaire were evaluated with clinical examination, questionnaires, lateral cephalometric radiographs, and portable sleep testing. This study assessed apnea-hypopnea index (AHI) and oxygen desaturation index (ODI) for the evaluation of sleep-disordered breathing and was done to investigate the correlation between these values and the upper airway width measured by lateral cephalometric radiographs.There was no significant correlation with the size of the tonsils (p = 0.921), but the adenoid hypertrophy was higher in the abnormal group than in the normal group (p = 0.008). In the classification according to AHI and ODI, retropalatal and retroglossal distance showed a statistically significant decrease in the abnormal group compared to the normal group (p = 0.002, p = 0.001). As AHI and ODI increased, upper airway width tended to be narrower. This indicates that mouth breathing could affect the upper airway, which is related to sleep quality.

Dysphagia Following Anterior Approach Cervical Spinal Surgery in a Patient with Ankylosing Spondylitis / 대한연하장애학회지

The known causes of dysphagia following cervical spine surgery include pre-vertebral soft tissue swelling, decreased posterior pharyngeal movement, and impaired upper esophageal sphincter opening. Some studies have suggested that dysphagia is associated with movement of the cervical vertebrae during swallowing. In the present case, a 59-year-old man with a limited cervical range of motion due to ankylosing spondylitis slipped and fell, resulting in a C7 vertebral body fracture. He underwent anterior cervical discectomy as well as C5-T1 anterior fusion and C5-T2 level postero-lateral fusion. After surgery, he showed signs and symptoms of aspiration. A video-fluoroscopic swallowing study (VFSS) revealed incomplete laryngeal elevation, cricopharyngeal dysfunction, and vallecular remnant. Aspiration was observed in the semisolid-swallowing test. The patient's dysphagia could be attributed to two main causes. First, the esophagus might have been compressed by thickened pre-vertebral soft tissue after surgery. Second, the cervical range of motion, which was already limited by ankylosing spondylitis, might have been limited further by the anterior fusion of the cervical spine. In conclusion, a preoperative evaluation, including VFSS, should be considered before cervical spinal surgery, particularly in patients with ankylosing spondylitis presenting with a limited cervical range of motion.

Effects of Parental Styles on Children's Dental Fear in Jeonju / 대한소아치과학회지

The aim of this study was to investigate difference of child's dental fear and agreement between parent/child dyads according to parental rearing style.The subjects were 801 children aged 8 and 11-year old and their parents in Jeonju city. The parents were asked to answer a questionnaire which included four parental rearing style and the Children's Fear Survey Schedule - Dental Subscale(CFSS-DS) at home. Also, the CFSS-DS was completed by 8 and 11 years old children in a classroom.Authoritative, permissive, authoritarian and neglectful parenting styles were 53.4%, 45.8%, 0.2% and 0.6% respectively. Authoritative and permissive parents reported 5.7 and 7.5 points higher than dental fear scores reported by their children. At 8 years old, children of authoritative parents were significantly 3.9 points higher than them of permissive parents(p = 0.002). Also, parent/child dyads showed moderate agreement assessing dental fear at aged 8.Parenting styles are related to children's dental fear, and especially 8-year-old girls in authoritative parenting styles have the highest dental fear. However, as age increased, the impact of parental styles on children's dental fear decreased.

Sacral Reconstruction with a 3D-Printed Implant after Hemisacrectomy in a Patient with Sacral Osteosarcoma: 1-Year Follow-Up Result

Pelvic reconstruction after sacral resection is challenging in terms of anatomical complexity, excessive loadbearing, and wide defects. Nevertheless, the technological development of 3D-printed implants enables us to overcome these difficulties. Here, we present a case of sacral osteosarcoma surgically treated with hemisacrectomy and sacral reconstruction using a 3D-printed implant. The implant was printed as a customized titanium prosthesis from a 3D real-sized reconstruction of a patient's CT images. It consisted mostly of a porous mesh and incorporated a dense strut. After 3-months of neoadjuvant chemotherapy, the patient underwent hemisacretomy with preservation of contralateral sacral nerves. The implant was anatomically installed on the defect and fixed with a screw-rod system up to the level of L3. Postoperative pain was significantly low and the patient recovered sufficiently to walk as early as 2 weeks postoperatively. The patient showed left-side foot drop only, without loss of sphincter function. In 1-year follow-up CT, excellent bony fusion was noticed. To our knowledge, this is the first report of a case of hemisacral reconstruction using a custom-made 3D-printed implant. We believe that this technique can be applied to spinal reconstructions after a partial or complete spondylectomy in a wide variety of spinal diseases.