The refit model for end-stage liver disease-Na is not a better predictor of mortality than the refit model for end-stage liver disease in patients with cirrhosis and ascites

BACKGROUND/AIMS: The modification of the Model for End-Stage Liver Disease (MELD) scoring system (Refit MELD) and the modification of MELD-Na (Refit MELDNa), which optimized the MELD coefficients, were published in 2011. We aimed to validate the superiority of the Refit MELDNa over the Refit MELD for the prediction of 3-month mortality in Korean patients with cirrhosis and ascites. METHODS: We reviewed the medical records of patients admitted with hepatic cirrhosis and ascites to the Konkuk University Hospital between January 2006 and December 2011. The Refit MELD and Refit MELDNa were compared using the predictive value of the 3-month mortality, as assessed by the Child-Pugh score. RESULTS: In total, 530 patients were enrolled, 87 of whom died within 3 months. Alcohol was the most common etiology of their cirrhosis (n=271, 51.1%), and the most common cause of death was variceal bleeding (n=20, 23%). The areas under the receiver operating curve (AUROCs) for the Child-Pugh, Refit MELD, and Refit MELDNa scores were 0.754, 0.791, and 0.764 respectively; the corresponding values when the analysis was performed only in patients with persistent ascites (n=115) were 0.725, 0.804, and 0.796, respectively. The significant difference found among the Child-Pugh, Refit MELD, and Refit MELDNa scores was between the Child-Pugh score and Refit MELD in patients with persistent ascites (P=0.039). CONCLUSIONS: Refit MELD and Refit MELDNa exhibited good predictability for 3-month mortality in patients with cirrhosis and ascites. However, Refit MELDNa was not found to be a better predictor than Refit MELD, despite the known relationship between hyponatremia and mortality in cirrhotic patients with ascites.

Elevated Hemoglobin A1c Levels Are Associated with Worse Survival in Advanced Pancreatic Cancer Patients with Diabetes

BACKGROUND/AIMS: Pre-existing diabetes mellitus (DM) has been identified as an adverse prognostic variable associated with increased mortality in various cancers. Although DM and hyperglycemia are considered risk factors for pancreatic cancer (PC), antidiabetic treatments for patients with advanced PC have been overlooked. This study aimed to evaluate the impact of hemoglobin A1c (HbA1c) levels on PC survival. METHODS: We retrospectively reviewed the medical records of first-diagnosed patients with advanced PC who were admitted to Konkuk University Medical Center from 2005 to 2011. RESULTS: A total of 127 patients were enrolled, and there were 111 deaths (87.4%) within the 7-year observational period. The most common etiology was disease progression (n=108). DM before PC diagnosis was observed in 65 patients (51.1%), including 28 patients with new-onset DM. The overall median survival times in patients with and without DM were 198 and 263 days, respectively (p=0.091). Survival time according to HbA1c was significantly different between the or =7.0% groups (362 and 144 days, respectively; p=0.038). In the HbA1c > or =7.0% group, the median overall survival time was 273 days for the metformin group and 145 days for the nonmetformin oral agent group; however, there was no significant difference between the two groups (p=0.058). CONCLUSIONS: A high HbA1c level may be associated with worse survival in patients with advanced PC with DM. Antidiabetic treatment, metformin in particular, was associated with an improved outcome.

Prevalence of renal dysfunction in patients with cirrhosis according to ADQI-IAC working party proposal

BACKGROUND/AIMS: A revised classification system for renal dysfunction in patients with cirrhosis was proposed by the Acute Dialysis Quality Initiative and the International Ascites Club Working Group in 2011. The aim of this study was to determine the prevalence of renal dysfunction according to the criteria in this proposal. METHODS: The medical records of cirrhotic patients who were admitted to Konkuk University Hospital between 2006 and 2010 were reviewed retrospectively. The data obtained at first admission were collected. Acute kidney injury (AKI) and chronic kidney disease (CKD) were defined using the proposed diagnostic criteria of kidney dysfunction in cirrhosis. RESULTS: Six hundred and forty-three patients were admitted, of whom 190 (29.5%), 273 (42.5%), and 180 (28.0%) were Child-Pugh class A, B, and C, respectively. Eighty-three patients (12.9%) were diagnosed with AKI, the most common cause for which was dehydration (30 patients). Three patients had hepatorenal syndrome type 1 and 26 patients had prerenal-type AKI caused by volume deficiency after variceal bleeding. In addition, 22 patients (3.4%) were diagnosed with CKD, 1 patient with hepatorenal syndrome type 2, and 3 patients (0.5%) with AKI on CKD. CONCLUSIONS: Both AKI and CKD are common among hospitalized cirrhotic patients, and often occur simultaneously (16.8%). The most common type of renal dysfunction was AKI (12.9%). Diagnosis of type 2 hepatorenal syndrome remains difficult. A prospective cohort study is warranted to evaluate the clinical course in cirrhotic patients with renal dysfunction.

Simultaneous Total Occlusion of Multiple Distal Coronary Arteries in Acute Myocardial Infarction

Simultaneous multiple coronary artery thrombosis is a rare finding in ST segment elevation myocardial infarction (STEMI). We report a case of myocardial infarction with multiple ST segment elevation on the electrocardiography and total occlusions of the distal left anterior descending artery (dLAD), as well as of the second and third obtuse marginal artery on emergency coronary angiography. Thrombus aspiration was performed at dLAD and systemic glycoprotein IIb/IIIa inhibitor was used successfully. In patients with STEMI, multiple coronary thromboses are unusual and associated with patient fatality. However, assertive thrombus aspiration and antiplatelet therapy could be effective in STEMI patients with multiple distal coronary artery occlusions.

Levofloxacin and Torsades de Pointes / 결핵및호흡기질환

Torsades de pointes associated with a prolonged QT interval is a life-threatening arrhythmia, which may be induced by any of the following: drugs, electrolyte imbalances, severe bradycardia and intracranial hemorrhage. Torsades de pointes is characterized by beat-to-beat variations in the QRS complexes in any ECG leads with rates of 200~250 per minute. Fluoroquinolones are widely used and well tolerated antibacterial agents. However, prolongation of the QT interval leads rarely to Torsades de pointes as a significant adverse effect. So, it should be used with caution in high-risk patients for developing Torsades de pointes. We report one case of 67-year old man with contact burns who experienced Torsades de pointes, which probably resulted from the use of levofloxacin, and no further episode occurred after its withdrawal.

Dantrolene and Post-operative Hyperthermia: A Case Report / 대한구급학회지

Malignant hyperthermia is a rare, fatal pharmacogenetic disorder that occurs during general anesthesia following exposure to a depolarizing muscle relaxant, such as succinylcholine, or volatile anesthetics. Clinical findings in malignant hyperthermia include muscle rigidity, sinus tachycardia, increased CO2 production, skin cyanosis with mottling, and marked hyperthermia. For treatment, cooling techniques must be accompanied by discontinuation of the provocative medication. Furthermore, dantrolene administration is the mainstay of treatment for malignant hyperthermia, and should be initiated as soon as the diagnosis is suspected. We recently experienced a case with post-operative fever of 41.0degrees C refractory to conventional anti-pyretic measures and finally resolved with dantrolene administration, in a patient with methicillin-sensitive Staphylococcus aureus monoarthritis of the knee and rapid progression of diffuse septic pneumonia requiring mechanical ventilation.

The Expression of NMDA Receptor 1 Correlates with Clinicopathological Parameters in Cutaneous Squamous Cell Carcinoma

BACKGROUND: Ionotropic glutamate receptors of the N-methyl-D-aspartate receptor (NMDAR) type are expressed on keratinocytes and play a role in the proliferation, differentiation, and cornification of keratinocytes. However, the expression profile of NMDAR and its role in cutaneous malignancy is unclear. OBJECTIVE: We analyzed the expression of NMDAR-1 in cutaneous squamous cell carcinoma (SCC) and investigated the relationship between NMDAR-1 expression and clinicopathological parameters. METHODS: Thirty-two patients with biopsy-proven cutaneous SCC were enrolled in this study. Each patient was analyzed for tumor diameter, location, local recurrence, and metastasis by conducting a chart review. The SCC specimens were histologically divided into differentiated and undifferentiated groups based on Broders' system. NMDAR-1 expression was examined by performing immunohistochemistry, and the relative staining intensity in the SCCs was graded into 5 levels. According to the staining intensity of NMDAR-1, the specimens were categorized into two groups: the higher group and the lower group. RESULTS: Fifteen (88%) of 17 tumors in the higher group were differentiated SCC, whereas 14 (93%) of 15 tumors in the lower group were undifferentiated SCC. In addition, NMDAR-1 expression was inversely correlated with metastasis (p=0.049). Local recurrence was associated with a lower staining intensity, but the results were not statistically significant. CONCLUSION: Our results demonstrate that NMDAR-1 expression in cutaneous SCC is significantly correlated with its differentiation and metastasis. Therefore, it may be a prognostic indicator for cutaneous SCC.

Expression of Toll-like Receptor 4 on Human Keratinocytes by Lipoteichoic Acid / 대한피부과학회지

BACKGROUND: We have recently shown that lipopolysaccharide (LPS), a major biologically active component of Gram-negative bacteria, mediate the activation of human keratinocytes by CD14 and Toll-like receptor (TLR 4). However, the mechanism of activation of keratinocytes by Gram-positive bacterial toxins remains unclear. OBJECTIVE: We investigated the mechanism of activation of human keratinocytes by lipoteichoic acid (LTA), a main stimulatory component of Gram-positive bacteria. METHODS: The effects of LTA on CD14, TLR2 and TLR4 mRNA expression were measured by quantitative RT-PCR in cultured human keratinocytes. To determine whether the effects of LTA on CD14, TLR2 and TLR4 expressions of the human keratinocytes were biologically functional, NF-kappaB nuclear translocation and IL-1alpha secretion were measured by immunofluorescence staining and ELISA, respectively. Furthermore, to determine whether these effects by LTA were specific for CD14, TLR2 and TLR4, some cells were pretreated with anti-CD14, anti-TLR2, or anti-TLR2 monoclonal antibodies prior to the addition of LTA. RESULTS: TLR4 mRNA expression on keratinocytes was augmented by exposure to LTA. LTA binding to keratinocytes resulted in NF-kappaB nuclear translocation and secretion of interleukin-1alpha. These responses by LTA were effectively abrogated by preincubating cells with anti-TLR4 monoclonal antibody, but not with anti-CD14 or anti- TLR2 monoclonal antibodies. CONCLUSION: These results indicate that, similar to LPS, LTA induces activation of human keratinocytes mainly through TLR4, however, in contrast to LPS signaling, LTA-induced keratinocyte activation is CD14-independent.