The effect of fibrin glue on the quantity of drainage after thyroidectomy: a randomized controlled pilot trial

Purpose@#A seroma is a collection of exudates after surgical trauma in wound healing. Fibrin glue is used to prevent seroma by reducing the generation of exudate. However, the impact of fibrin glue on the prevention of seroma remains debatable. Therefore, we conducted a randomized controlled pilot trial to investigate the effect of the amount of fibrin glue used on the generation of exudate after thyroidectomy and the sample size of future definitive trials. @*Methods@#Between February and December 2020, 41 patients were enrolled; 21 patients in the low fibrin group and 20 in the high fibrin group. Stratified randomization was performed based on sex, body mass index, and thyroiditis. All patients underwent total thyroidectomy and bilateral central compartment dissection. In the low and high fibrin groups, 2 mL and 6 mL of fibrin glue were applied to patients, respectively. @*Results@#Both the total drain volume and flow rate during the first 12 hours were lower in the high fibrin group than in the low fibrin group (65.0 mL vs. 47.6 mL, P = 0.008 and 2.7 mL/hr vs. 1.8 mL/hr, P = 0.002, respectively). The calculated sample size for future randomized controlled trial was 32 patients (α = 0.05, power = 0.8), and the power of this trial was 0.91 with μ 1 = 2.7, μ 2 = 1.8, σ = 0.9, and α = 0.05 (μ = mean, σ = standard deviation). @*Conclusion@#Six milliliters of fibrin glue could reduce total drain volume and flow rate of exudate after thyroidectomy. Therefore, applying an appropriate amount of fibrin glue after thyroidectomy may reduce postoperative seroma.

Assessment of thyroid-specific quality of life in patients with benign symptomatic thyroid nodules treated with radiofrequency or ethanol ablation: a prospective multicenter study

Purpose@#Radiofrequency ablation (RFA) and ethanol ablation (EA) are effective and safe for benign symptomatic thyroid nodules (BSTNs). However, relatively little is known about the effects of these procedures on patients’ quality of life (QoL). This prospective, multicenter study evaluated the effects of RFA and EA on changes in thyroid-specific QoL in patients with BSTNs and assessed the volume reduction and safety of these procedures. @*Methods@#Eighty-six consecutive patients with 86 BSTNs were prospectively included from two medical centers. RFA was performed for 55 BSTNs with solidity ≥50% and EA was performed for 31 BSTNs with solidity <50%. QoL was evaluated using an 11-scale, multiple-choice thyroid-specific QoL questionnaire. Nodule characteristics and QoL were evaluated at diagnosis and 1, 6, and 12 months after treatment. Overall QoL was rated from 0 (good) to 4 (poor). @*Results@#The mean longest size and volume of the index nodule were 4.2±1.5 cm and 21.6±22.1 mL, respectively. Patients received 1.1 treatments on average (range, 1 to 2). Significant post-treatment volume reductions were noted; however, the EA group showed a higher volume reduction than the RFA group at 1 (78.7%-16.1% vs. 49.1%-15.8%), 6 (86.3%-21.7% vs. 73.0%-14.5%), and 12 (90.9%-14.9% vs. 80.3%-12.4%) months. The score for each scale of the QoL questionnaire improved significantly during follow-up (all P<0.001). Overall QoL improved significantly, from 1.7±0.9 at diagnosis to 0.6±0.7 at the 12-month follow-up (P<0.001). There were no major complications. @*Conclusion@#Both RFA and EA are safe and effective in reducing nodule volume and improving thyroid-specific QoL in patients with BSTNs.

Thoracic Duct Embolization for Chyle Leakage after Thyroid Surgery

Chyle leakage (CL) due to lymphatic injuries is one of the rare complications that can develop after thyroidectomy. There are few studies on lymphatic embolization performed in case of CL after thyroid surgery. We report two cases of CL after thyroid surgery that were effectively treated by thoracic duct embolization. The patients had previously undergone total thyroidectomy with central compartment neck dissection with or without modified radical neck dissection. The amount of drainage from the operative site was ＞1000 mL per day in one patient and ＞500 mL per day in the other. In both cases, CL stopped after the thoracic duct embolization. Thoracic duct embolization seems to be an effective and important treatment option for CL after thyroid surgery.

The Cause of Cervical Lymph Node Recurrence after the Initial Surgery of Papillary Thyroid Carcinoma / 대한두경부종양학회지

BACKGROUND/OBJECTIVES: Papillary thyroid carcinoma (PTC) has generally an indolent character with a good prognosis. However, recurrence remains a major concern for the patients during their lifetime. Despite the slowly progressing character of PTC, recurrence can occur within a short period after initial surgery.This study aimed to determine the clinical findings and cause of recurrence in patients who underwent re-operative surgery due to neck node recurrence by reviewing the CT (computed tomographic) scan imaging of the recurrence of PTC retrospectively.MATERIALS #SPCHAR_X0026; METHODS: We reviewed the medical records of patients referred to Ajou University Hospital from January 2002 to January 2018. All patients had re-operative surgery due to neck node recurrence and CT scan results of preoperative evaluation and postoperative follow up. Over this period, 110 patients who underwent re-operation due to neck node recurrence with a CT scan were included in our cohort, resulting in a total of 220 re-operations.RESULTS: The time from initial operation to first re-operation was examined in 110 patients. The median time to re-operation was 28 months, with a range of 4 months to 186 months. Most re-operations (82.7%) occurred within the first five years, 43.6% were in the first two years from the initial surgery. The result of the retrospective CT review showed newly developed cases (21,19.1%), missed diagnosis cases (42,38.2%), real recur cases after surgery (33,30.0%), and remnant lymph nodes (LNs) cases (14,12.7%). We further sub-analyzed 14 cases with remnant LNs. Reasons for remnant LNs included insufficient operation (N=5) and beyond general surgical extent. (N=9).CONCLUSION: Re-operation due to cervical lymph node recurrence is mostly a persistent disease. They included a missed diagnosis and incomplete operation. These finding may reduce the reoperation of cervical lymph node recurrence by accurate preoperative evaluation and complete surgical resection at the initial surgery.

Cause-of-death statistics in 2016 in the Republic of Korea

This study aimed to analyze changes in the causes of death in the Korean population in 2016 and to provide some insights regarding how to cope with related issues of public health and welfare. The causes of death made available by Statistics Korea were classified according to the International Statistical Classification of Diseases and Related Health Problems, 10th revision as well as the KCD-7 (Korean Standard Classification of Diseases and Causes of Death), which has been modified to fit circumstances in Korea. The total number of deaths was 280,827, which was an increase of 4,932 (1.8%) from 2015. The crude death rate was 549.4 per 100,000 population, which was an increase of 7.9 (1.5%) from 2015. The 10 leading causes of death, in order, were malignant neoplasms, heart diseases, cerebrovascular diseases, pneumonia, intentional self-harm, diabetes mellitus, chronic lower respiratory diseases, liver diseases, hypertensive diseases, and transport accidents. The rank of hypertensive diseases rose from 10th in 2015 to 9th in 2016, while that of transfer accidents dropped from 9th in 2015 to 10th in 2016. The proportion of the number of deaths caused by cancer was 27.8%. The death rate due to cancer was 153.0 per 100,000 population, which was an increase of 1.4% from 2015; 16.5 deaths per 100,000 population were due to colon cancer, and 16.2 were due to stomach cancer. The above trends in causes of death reflect aspects of the population structure, disease patterns, lifestyle, and medical care in present-day Korean society.

Rapid and accurate diagnosis of Clostridium difficile infection by real-time polymerase chain reaction

BACKGROUND/AIMS: The incidence and severity of Clostridium difficile infection (CDI) have increased worldwide, resulting in a need for rapid and accurate diagnostic methods. METHODS: A retrospective study was conducted to compare CDI diagnosis methods between January 2014 and December 2014. The stool samples, which were obtained in presumptive CDI patients, were compared for their diagnostic accuracy and rapidity, including real-time polymerase chain reaction (PCR) of toxin genes, C. difficile toxin assay, and culture for C. difficile. RESULTS: A total of 207 cases from 116 patients were enrolled in this study and 117 cases (56.5%) were diagnosed as having CDI. Among the 117 cases, the sensitivities of real-time PCR, C. difficile toxin assay, and culture for C. difficile were 87.2% (102 cases; 95% CI, 80.7%–92.8%), 48.7% (57 cases; 95% CI, 41.0%–59.8%), and 65.0% (76 cases; 95% CI, 60.2%–78.5%), respectively (P < 0.005). Notably, 34 cases (29.0%) were diagnosed with CDI by real-time PCR only. The time required to obtain results was 2.27 hours (136.62±82.51 minutes) for real-time PCR, 83.67 hours (5,020.66±3,816.38 minutes) for toxin assay, and 105.79 hours (6,347.68±3,331.46 minutes) for culture (P < 0.005), respectively. CONCLUSIONS: We confirmed that real-time PCR of toxin genes is the most effective diagnostic method for accurate and early diagnosis of CDI. It also helps to diagnose hypervirulent CDI, such as ribotype 027 infection.

Evaluation of the VE1 Antibody in Thyroid Cytology Using Ex Vivo Papillary Thyroid Carcinoma Specimens

BACKGROUND: Recently, VE1, a monoclonal antibody against the BRAFV600E mutant protein, has been investigated in terms of its detection of the BRAFV600E mutation. Although VE1 immunostaining and molecular methods used to assess papillary thyroid carcinoma in surgical specimens are in good agreement, evaluation of VE1 in thyroid cytology samples is rarely performed, and its diagnostic value in cytology has not been well established. In present study, we explored VE1 immunoexpression in cytology samples from ex vivo papillary thyroid carcinoma specimens in order to minimize limitations of low cellularity and sampling/targeting errors originated from thyroid fineneedle aspiration and compared our results with those obtained using the corresponding papillary thyroid carcinoma tissues. METHODS: The VE1 antibody was evaluated in 21 cases of thyroid cytology obtained directly from ex vivo thyroid specimens. VE1 immunostaining was performed using liquid-based cytology, and the results were compared with those obtained using the corresponding tissues. RESULTS: Of 21 cases, 19 classic papillary thyroid carcinomas had BRAFV600E mutations, whereas two follicular variants expressed wild-type BRAF. VE1 immunoexpression varied according to specimen type. In detection of the BRAFV600E mutation, VE1 immunostaining of the surgical specimen exhibited 100% sensitivity and 100% specificity, whereas VE1 immunostaining of the cytology specimen exhibited only 94.7% sensitivity and 0% specificity. CONCLUSIONS: Our data suggest that VE1 immunostaining of a cytology specimen is less specific than that of a surgical specimen for detection of the BRAFV600E mutation, and that VE1 immunostaining of a cytology specimen should be further evaluated and optimized for clinical use.

An Unusual Case of Proctitis and Rectal Abscess due to Irritants by Artemisia asiatica Smoke (Ssukjwahun) / 대한소화기학회지

Proctitis is an inflammatory change of rectal mucosa induced by various agents or stimulus. Among many etiologies, it may be caused by medical treatments such as radiation or antibiotics. Proctitis usually presents with rectal ulcer but abscess formation is uncommon. Therapy using Ssukjwahun exerts its effect by directly applying the smoke around genital area and anus with various medicinal brewed herbs, especially worm-wood. Secondary metabolite of this plant, monoterpene, is known to facilitate circulation, exert anti-inflammatory effect, and help control pain. Herein, we report an unusual case of infectious proctitis presenting with rectal ulcer and abscess formation after perianal application of warm steam made by Artemisia asiatica smoke for treatment of dysmenorrhea.

Current Guidelines for Fine Needle Aspiration of Thyroid Nodules / 대한내분비외과학회지

Thyroid cancer is a hot issue in Korea because there is debate on screening and diagnosis of thyroid cancer. Therefore, we reviewed the guidelines for the management of thyroid nodules of other countries. Western countries accepted the criteria of fine needle aspiration including the tumor size of thyroid nodules, although ultrasonographic morphologic characteristics are more important to diagnose the thyroid cancer than tumor size. This recommendation is based on good prognosis of papillary thyroid microcarcinoma. However, small subset of papillary thyroid microcarcinoma has aggressive behavior, which we cannot discern from those with benign behavior before operation. Therefore, further researches are necessary to resolve these problems and improve the management of papillary thyroid cancer avoiding overtreatment and mismanagement.

Rectal perforation caused by a sharp pig backbone in a middle-aged patient with mild depression / 영남의대학술지

In Korea, cases of direct insertion of foreign bodies into the rectum are rare in the literature. Most cases of rectal insertion of foreign bodies are associated with sexual acts and psychiatric disorder such as schizophrenia. Objects inserted into the anus are usually blunt and shaped like the male genitalia. The removal method can be varied depending on the size and shape of the foreign object, its anatomical location, and the accompanying complications. In cases wherein attempts to remove the object fail or there are rectal perforation and peritonitis complications, immediate laparotomy may be required in order to prevent serious complications such as sepsis. Here, we report on a case of rectal perforation and peritonitis due to insertion of a foreign body in a middle-aged patient, with a literature review. He inserted a sharp pig backbone in his rectum and he only had depression. The patient underwent a Hartmann's operation as well as psychiatric counseling and treatment. Thus, after removal of foreign bodies, psychiatric counseling and treatment should be carried out in order to prevent similar accidents and to minimize the need for trauma medicine.

B-RafV600E inhibits sodium iodide symporter expression via regulation of DNA methyltransferase 1

B-RafV600E mutant is found in 40-70% of papillary thyroid carcinoma (PTC) and has an important role in the pathogenesis of PTC. The sodium iodide symporter (NIS) is an integral plasma membrane glycoprotein that mediates active iodide transport into the thyroid follicular cells, and B-RafV600E has been known to be associated with the loss of NIS expression. In this study, we found that B-RafV600E inhibited NIS expression by the upregulation of its promoter methylation, and that specific regions of CpG islands of NIS promoter in B-RafV600E harboring PTC were highly methylated compared with surrounding normal tissue. Although DNA methyltransferase 3a and 3b (DNMT3a,3b) were not increased by B-RafV600E, DNMT1 expression was markedly upregulated in PTC and B-RafV600E expressing thyrocytes. Furthermore, DNMT1 expression was upregulated by B-RafV600E induced NF-kappaB activation. These results led us to conclude that NIS promoter methylation, which was induced by B-RafV600E, is one of the possible mechanisms involved in NIS downregulation in PTC.

Central Lymph Node Metastasis Is an Important Prognostic Factor in Patients with Papillary Thyroid Microcarcinoma

Papillary thyroid microcarcinoma (PTMC) has been increasing, without a consensus for the management of this condition. In the present study, we analyzed the clinicopathological features of patients with PTMC to examine the impact of initial therapy and establish appropriate treatment. A total of 2,018 patients with PTMC were enrolled at a single university hospital. Of them, 1,245 patients (61.8%) underwent total thyroidectomy, and 1,838 patients (91.3%) underwent central lymph node (LN) dissection. Five-and 10-yr recurrence rates were 3.2% and 4.6%, respectively. In univariate analysis, the prognostic factors for recurrence were N stage, the number of LN metastases, and extrathyroidal extension. However, multivariate analysis revealed LN metastases and N stage as the only significant prognostic factors after adjusting for confounding factors (P < 0.001). Additionally, multivariate analysis of a subgroup consisting of PTMC patients without N1b revealed the number of central LN metastases as the only significant factor. Therefore, intraoperative examination for central LN metastasis may discriminate high or low risk group.

Acute Toxic Hepatitis Caused by an Aloe Vera Preparation in a Young Patient: A Case Report with a Literature Review / 대한소화기학회지

Aloe is one of the leading products used in phytomedicine. Several cases of aloe-induced toxic hepatitis have been reported in recent years. However, its toxicology has not yet been systematically described in the literature. A 21-year-old female patient was admitted to our hospital with acute hepatitis after taking an aloe vera preparation for four weeks. Her history, clinical manifestation, laboratory findings, and histological findings all led to the diagnosis of aloe vera-induced toxic hepatitis. We report herein on a case of acute toxic hepatitis induced by aloe vera.

Diabetic ketoacidosis with pulmonary thromboembolism / 영남의대학술지

Diabetic ketoacidosis (DKA), a fatal acute diabetic complication, is characterized by severe metabolic decompensation and intravascular volume depletion. These conditions may result in hypercoagulability and prothrombic state. Pulmonary thromboembolism (PTE) could be presented as an uncommon and life-threatening complication of DKA. Reported herein is a case involving a 54-year-old male patient who was admitted with DKA due to chronic alcohol consumption and stopping the intake of oral antidiabetic drugs. After low-molecular-weight heparin and warfarin treatment because of PTE during the DKA treatment, the patient's condition improved over the week that he was discharged on insulin and warfarin.

Thrombotic Thrombocytopenic Purpura and Rhabdomyolysis Associated With Acute Renal Failure in Hypothyroidism

Myopathy due to hypothyroidism can be detected in its early stage, but as the symptom is mild, complications such as rhabdomyolysis are rare. Thrombotic thrombocytopenic purpura in hypothyroidism is not yet clearly defined, and rare cases of it are reported. Reported herein is a case of thrombotic thrombocytopenic purpura and rhabdomyolysis associated with acute renal failure in hypothyroidism. A 70-year-old male was admitted to the hospital due to general weakness and muscle pain. Later, based on the laboratory findings, he was diagnosed with rhabdomyolysis associated with acute renal failure and thrombotic thrombocytopenic purpura combined with hypothyroidism. Initially, he was treated with fluid resuscitation due to rhabdomyolysis combined with acute renal failure but eventually, the levothyroxine supplement lowered the thyrotropin-stimulating hormone level. As a result, the patient recovered from rhabdomyolysis and thrombotic thrombocytopenic purpura without receiving plasmapheresis treatment.

A Case of Septo-Optic Dysplasia Resulting in Central Diabetes Insipidus and Nonobstructive Bilateral Hydronephrosis / 대한내과학회지

A 27-year-old male with nonobstructive hydronephrosis was referred from the urology department for polyuria evaluation and management. The patient was hospitalized for urinary tract infection and cystostomy was performed due to neurogenic bladder of unknown origin. The patient was of short stature and had visual impairment. From the interview, we discovered he had been suffering from polyuria and polydipsia for more than 20 years. Urine output was 13 L/day and urine osmolarity was 85 mOsm/kg. The results of a water deprivation test were consistent with central diabetes insipidus. Septo-optic dysplasia (SOD) was observed on brain magnetic resonance imaging (MRI). SOD is a very rare condition characterized by agenesis of the septum pellucidum or corpus callosum, which may cause optic nerve aplasia or hypoplasia, midbrain abnormalities and/or hypopituitarism. After desmopressin treatment, polyuria and hydronephrosis were improved. We report a case of a 27-year-old male diagnosed with SOD including diabetes insipidus, resulting in nonobstructive hydronephrosis.

The usefulness and accuracy of sentinel lymph node biopsy using single photon emission computed tomography/computed tomography with 99mTc phytate to detect locoregional lymph node metastases in patients with papillary thyroid carcinoma / 대한외과학회지

PURPOSE: Regional lymph node (LN) metastases are detected in 57-85% of patients with papillary thyroid carcinoma (PTC) and are associated with increased tumor recurrence. However, the management of lymphatic disease in patients with PTC has been ongoing source of debate. We have prospectively assessed the usefulness and accuracy of sentinel LN (SLN) biopsy for the detection of LN metastases in patients with PTC on preoperative imaging using single photon emission computed tomography/computed tomography (SPECT/CT) and 99mTc phytate. METHODS: We prospectively assessed 39 patients with PTC who had risk factors for recurrence or with the necessity of intraoperative LN sampling for suspicious LN metastases on preoperative imaging from August 2010 to March 2011. The patients underwent preoperative lymphoscintigraphy and SPETC/CT and intraoperative SLN biopsy (SLNB). RESULTS: 99mTc lymphoscintigraphy and SPECT/CT localized SLN in 38 patients (97.4%), with the gamma probe identifying 2.15 mean SLNs in the lateral neck of the 39 patients. Skip metastasis was found in one patient, and lateral compartment LN metastasis in 17 (43.5%). The sensitivity, specificity, and accuracy of SLNB for lateral compartment LN metastasis were 88.2%, 100%, and 94.8%, respectively. SLNB was more accurate and useful for lateral than for central compartment LN metastasis. CONCLUSION: SPECT/CT improved SLN detection and anatomical localization compared with lymphoscintigraphy. SLNB in patients with risk factors for recurrence or the necessity of intraoperative LN sampling for suspected LN metastases on preoperative imaging was accurate in detecting LN metastases and may help in deciding whether to perform lateral compartment dissection in patients with PTC.

Therapeutic Difficulties in Poorly Differentiated and Undifferentiated Thyroid Cancer / 대한갑상선학회지

Poorly differentiated thyroid cancer (PDTC) and anaplastic thyroid cancer (ATC) have poor prognosis and rare incidence compared to well differentiate thyroid cancer. Since the original description of PDTC in 1983, PDTC was introduced as a separate entity in the 2004 WHO Classification of Endocrine Tumors. PDTC was defined as a thyroid cancer with thyroglobulin-producing non-follicular non-papillary growth pattern and high-grade features, having an intermediate behavior between well differentiated thyroid cancer (WDTC) and ATC. But the criteria of PDTC are still controversial and heterogeneously applied in the diagnostic practice. Also the modalities of treatment, such as the extent of thyroid surgery, the use of radioiodine therapy and external radiation therapy are still controversial. ATC is rapidly progressing human carcinoma with a median survival of 4 to 12 months after diagnosis. Although the complete resection combined with external radiation therapy was reported to be effective recently and multimodality treatment has been recommended, current treatment of ATC has not been adequate for controlling the diseases. Therefore there are new attempts for treatment, such as chemotherapy with paclitaxel, clinical trials of combretastatin 4 phosphate and CS-7107 and multitargeted therapy of bevacizumab with doxorubicin, sorafenib, sunitinib etc. PDTC and ATC are an unexplored field like this, therefore, the studies for molecular pathology and therapeutic approach are necessary for improving survival and quality of life of patients.

Lateral Neck Lymph Node Metastasis in Papillary Thyroid Cancer / 대한내분비외과학회지

PURPOSE: Papillary thyroid carcinoma (PTC) is the most common thyroid cancer and lymph node (LN) metastasis is common in PTC. Lateral LN metastasis is associated with local recurrence of PTC. The aim of this study is to evaluate the patterns of lateral LN metastasis of PTC. METHODS: One-hundred seventy four patients who undergone total thyroidectomy, central LN and ipsilatereal or bilateral LN dissection due to PTC 'from 2007 to 2008 in Seoul National University Hospital were retrospectively reviewed. The average age of the patients was 50.4 years and the male to female ratio was 1:4.12. Sixty-seven patients (38.5%) had central LN metastasis and 47 patients (27.0%) had lateral node metastasis. RESULTS: The factors related with lateral LN metastasis of PTC are male gender, the tumor size, extrathyroidal extension, multifocality and central LN metastasis. The level III LN group was the most frequent site of lateral LN metastasis followed by the jugular, level IV, level II, and level V groups. The jugular LN metastasis is mainly related with the metastasis of the upper lateral neck area, including level II LNs, and the lymphatic pathway to the lower lateral neck area, including level IV, seems to be independent from the jugular LNs. Ten cases had lateral LN metastasis without central LN metastasis (skip metastasis). CONCLUSION: Lateral LN metastasis of PTC has a certain pattern. The operator must consider this pattern when managing patients with lateral LN metastasis of PTC.