Hemoptysis in Quadriplegia with Atrial Fibrillation Who Was Taking Edoxaban: a Case Report

The direct-acting oral anticoagulants (DOACs) would be the standard treatment for the prevention of stroke and thromboembolism in nonvalvular atrial fibrillation patients. The adverse effects of greatest concern are bleeding especially major bleeding. We present a case of a patient with a history of nonvalvular atrial fibrillation and pacemaker, who developed severe anemia after massive hemoptysis while taking DOAC; however, he has continued taking DOAC. Through this case, we have summarized the current management of major bleeding associated with anticoagulation and discuss the optimal regimen for restarting of anticoagulation therapy.

Rare Presentation of Richter's Transformation to Diffuse Large B Cell Lymphoma: a Case Report / 대한내과학회지

Richter's syndrome refers to the development of aggressive lymphoma in a patient with chronic lymphocytic leukemia (CLL). It occurs in about 2% to 10% of patients with CLL. The most frequent manifestation of Richter's syndrome is diffuse large B cell lymphoma (DLBCL). Extranodal involvement is rare but can occur. The prognosis of Richter's syndrome is very poor. We herein report a case of a rare presentation of Richter's syndrome. A 42-year-old man diagnosed with CLL 2 years previously developed nodules on the bilateral thighs and buttocks. A positron emission tomography (PET)-CT scan revealed high fluorodeoxyglucose uptake in multiple lymph nodes, skeletal muscles, and the myocardium. An ultrasonography-guided biopsy confirmed Richter's syndrome from CLL to DLBCL. The patient was treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy. After six cycles of chemotherapy, we performed a PET-CT scan that revealed a complete response. However, 3 months later, the syndrome recurred. The patient was undergoing salvage chemotherapy at the time of this writing.

Double Lumen Endobronchial Tube Malposition Due to Enlargement of Paratracheal Lymph Node / 계명의대학술지

Double lumen endobronchial tube (DLT) is used for lung separation in the surgical patients undergoing thoracic and mediastinal surgery. The use of DLT can lead to potential problems such as tube malposition and airway trauma. DLT can be placed in the inappropriate position due to abnormal and distorted anatomy of trachea or bronchus. We report a case of right main bronchial insertion of left-sided DLT by enlargement of paratracheal lymph node not detected in preoperative evaluations for 10 days.

Metastatic eyelid cancer from gastric adenocarcinoma / 영남의대학술지

Gastric cancer is the most common cancer in Korean males and can easily spread to distant organs such as the liver, lungs, brain, or bones. However, skin metastasis, particularly of the eye, is rare. Metastatic eyelid cancer is extremely rare; metastases from internal organs have not been reported so far. We recently experienced a patient with metastatic eyelid cancer from adenocarcinoma of the stomach. A 62-year-old female was admitted with a right upper eyelid mass and foreign body sensation. She had a history of stomach cancer of 3 years. She was treated by chemotherapy and radiotherapy for pathologic fracture. After receiving supportive care for 2 years, the mass appeared on her right pupil. Punch-biopsy of the mass was performed and histological examination revealed adenocarcinoma, the same as the initial histological result. We report this case with a review of related literature.

Complete atrioventricular block during tunneled cuffed hemodialysis catheter insertion in a patient with pre-existing left bundle branch block / 영남의대학술지

Arrhythmias are complications of tunneled cuffed hemodialysis catheter insertion. Most complications associated with arrhythmias occur during guide-wire access, where the guide wire can cause traumatic damage to the conduction system of the heart. Conducting system injury in tunneled cuffed hemodialysis catheter insertion often involves the right bundle, causing right bundle branch block (RBBB). Transient RBBB with sinus rhythm is not usually accompanied by abnormal vital signs. However if patients already have left bundle branch block (LBBB), new onset RBBB can cause complete atrioventricular block (AVB), which can lead to fatal complications requiring invasive treatment. We report on a patient with LBBB who developed complete AVB during hemodialysis catheter insertion.

Corrigendum: Laparoscopic Distal Gastrectomy for Gastric Cancer in Morbidly Obese Patients in South Korea

One of the authors' name was misspelled.

A Case of Type 1 Neurofibromatosis Associated with Multiple Metastatic Gastrointestinal Stromal Tumors / 영남의대학술지

Type 1 neurofibromatosis (von Recklinghausen's disease, NF-1) is an autosomal-dominant neurocutaneous-disorder characterized by systemic cafe'-au-lait spots, multiple cutaneous neurofibromas, axillary or inguinal freckling, and Lisch nodules (pigmented iris hamartomas). Approximately 10-25% of NF1 patients have gastrointestinal neoplasms. Gastrointestinal stromal tumor (GIST) in patients with neurofibromatosis is most commonly found in the small bowel and the stomach, and approximately 60% of such patients have multiple tumors or multiple tumor sites. Although, the increased incidence of GIST in patients with neurofibromatosis is well documented in pathology literature in English, but has rarely been documented in Korea. Here, we report a case of multiple GISTs in a 48-year-old woman accompanied by NF1. She was admitted to Yeungnam University Hospital with complaints of melena and dyspnea. A contrast-enhanced computed tomography (CT) scan revealed that multiple soft tissue masses were occupying the entire peritoneal cavity. An ultrasonogram- guided biopsy was performed and the tumors were found to have been composed of tumor cells that were positive for c-kit protein. The patient was put on Imatinib mesylate treatment, and further follow-up will be carried out.

Ankle-Brachial Index and Risk Factors for Peripheral Arterial Disease in Dialysis Patients / 대한신장학회지

PURPOSE: Peripheral arterial disease (PAD) is a predictable marker of coronary heart disease and cerebrovascular disease and its prevalence among chronic kidney disease (CKD) patients especially in end-stage renal disease (ESRD) patients undergoing dialysis is apparently increasing. Ankle-brachial index (ABI) is regarded as an easy, reliable, and noninvasive measure of the presence and severity of lower-extremity PAD (ABI or =0.9) and the prevalence of PAD was analyzed. We measured ABI with VP2000 PWV/ankle-brachial index. We also reviewed the clinical characteristics and evaluated the risk factors of PAD, retrospectively. RESULTS: One hundred seventeen patients on hemodialysis, and twenty one patients on peritoneal dialysis were included in this study. The mean age of total patients was 60.1 (24-84) years old. Thirty five patients out of one hundred thirty eight patients had an ABI index of less than 0.9 (PAD indicative). PAD was independently associated with age (p=0.013), duration of dialysis (p=0.013), history of coronary artery disease and cerebrovascular disease (p=0.001, p=0.001 respectively), diabetes (p=0.034), and increased LDL cholesterol (p=0.004) in univariate analysis. In multivariate logistic regression analysis, duration of dialysis, increased level of LDL-cholesterol and history of coronary artery disease were significantly related with PAD (p=0.008, p=0.019, p=0.018 respectively). CONCLUSION: Duration of dialysis, increased level of LDL-cholesterol and coronary artery disease were independent risk factors for PAD in patients with ESRD on dialysis.

A Case of Spontaneous Subdural Hematoma in a Patient with Autosomal Dominant Polycystic Kidney Disease / 대한신장학회지

Intracranial manifestations associated with autosomal dominant polycystic kidney disease (ADPKD) include arachnoid cysts, dolichoectasias, and subdural hematoma (SDH), although there are only a few reports of SDH in patients with ADPKD. We report a case of spontaneous SDH in a patient with ADPKD. A 33-year-old woman complained of severe nausea and vomiting for 10 days. She had suffered from a headache for several months. She was diagnosed with ADPKD and hypertension 6 years earlier, and the hypertension was well controlled. Her mental state was drowsy in the emergency room. Her blood pressure was 180/105 mmHg. There was no evidence of head trauma. Results of a peripheral blood CBC and blood chemistry analysis were within normal limits, as were the results of a blood coagulation test and urinalysis. She was pregnant and in the eighth week of gestation. Brain magnetic resonance imaging revealed SDH in the left lateral convexity and focally in the right lateral convexity, and brain herniation. Surgical drainage was performed through a burr hole, under general anesthesia. Intra-operatively, 62 mL of liquefied subdural hematoma were removed. She recovered completely without sequelae.

Prognostic Factors of Acute Renal Failure Patients Treated with Continuous Renal Replacement Therapy / 대한신장학회지

PURPOSE: Continuous renal replacement therapy (CRRT) has been used widely for treating critically ill patients with acute renal failure (ARF). We performed this study to identify predictors of mortality in critically ill ARF patients treated with CRRT. METHODS: We analyzed the data of 128 patients who were treated with continuous veno-venous hemofiltration (CVVH) or continuous veno-venous hemodiafiltration (CVVHDF) from May, 2002 to March, 2008. We compared the clinical data of survivors with non-survivors. RESULTS: On univariate analyses of prognostic factors of patients treated with CVVHDF, APACHE II scores (p=0.004), prothrombin time (INR) (p=0.033) and the number of inotropics used (p=0.005) were significantly lower in survivors than those of non-survivors. MAP (p=0.027), diastolic BP (p=0.015) and fibrinogen level (p=0.007) were significantly higher in survivors than those of non-survivors. Multivariate analysis revealed that APACHE II scores and fibrinogen level were the independent factors for the prediction of mortality. And on univariate analyses of prognostic factors of patients treated with CVVH, APACHE II scores (p=0.002) and the number of inotropics used (p=0.006) were significantly lower in survivors than in non-survivors. MAP (p=0.03), systolic BP (p=0.02) and diastolic BP (p=0.03) were significantly higher in survivors than in non-survivors. Multivariate analysis also revealed that APACHE II scores was the only independent factor for the prediction of mortality. CONCLUSION: This study showed that the independent prognostic factor for mortality in ARF patients treated with CRRT was the APACHE II score.

Successful Treatment of Sclerosing Encapsulating Peritonitis with Tamoxifen and Prednisolone / 대한신장학회지

Sclerosing encapsulating peritonitis (SEP) is an uncommon but serious complication of long-term peritoneal dialysis (PD). Entrapment of the intestine in fibrous tissue, causing complete intestinal obstruction, is referred to as SEP. The usual clinical presentation is with partial or complete small bowel obstruction, ascites, abdominal mass, or impaired peritoneal ultrafiltration. Conservative treatment carries a poor outcome and surgery has offered variable results. Even though there is no established medical treatment, immunosuppressive drugs, steroid and tamoxifen are often used. Tamoxifen is a nonsteroidal anti-estrogenic drug commonly used in the management of breast cancer. To our knowledge, this is the first case of sclerosing encapsulating peritonitis successfully treated with tamoxifen and prednisolone in Korea. Recently, we have treated three SEP patients with tamoxifen and prednisolone. All three patients showed clinical improvement within a few months.

Henoch-Schonlein Nephritis in Adults: Renal Outcomes and Prognostic Factors / 대한신장학회지

PURPOSE: Renal involvement of Henoch-Schonlein (HS) purpura is common, and the long-term prognosis depends on the degree of renal injury. The aim of our study was to search for prognostic factors of HS nephritis and its relationship with clinical, laboratory, and renal pathologic features. METHODS: Study population consisted of 81 patients (age > or =15 years) with HS nephritis who had been admitted to Chungnam National University Hospital from January, 1991 to February, 2008. We reviewed the clinical symptoms, laboratory data and pathologic findings of kidney of total 81 patients, and also analyzed the relationship between these and renal prognosis. RESULTS: The mean age of patients was 40.6 years and the median duration of follow-up was 16 months. Male to female ratio was 1.08. Kidney biopsies were carried out in 61 patients (75.4%). Regarding renal function, 14 (17.3%) of patients reached moderate to severe renal insufficiency, and 4 (4.9%) progressed to end-stage renal disease within 16 months (median, range 1.5-196 months) after diagnosis. Complete clinical remission was achieved in 26 patients (32.1%). The presence of gastrointestinal symptoms, relapse of purpura, hypertension, nephrotic syndrome, renal insufficiency, increased level of serum immunoglobulin A, and the magnitude of crescents and sclerotic glomeruli were significantly associated with poor renal prognosis (all p<0.05). In multivariate logistic regression analysis, initial elevated serum creatinine level and hypertension were independent prognostic factors (p=0.013, p=0.007). CONCLUSION: We concluded that the initial clinical findings including renal function and hypertension are important prognostic factors in adult HS nephritis.

Henoch-Schonlein Purpura and Peroneal Nerve Palsy after Hemorrhagic Fever with Renal Syndrome / 대한신장학회지

In the course of hemorrhagic fever with renal syndrome (HFRS), mild neurological symptoms such as headache, vertigo and nausea are common. Peripheral neuropathy in HFRS is very rare. Henoch- Sch?nlein purpura (HSP) is an immunologically medicated systemic vasculitis of small blood vessels affecting the skin, gastrointestinal tract, joints and kidneys, predominantly. Neurological complications in HSP include headache, focal cerebral deficit, coma, convulsion, subarachnoid hemorrhage and chorea. Peripheral neuropathy is also very rare. However there was no case report about HSP and peroneal nerve palsy after HFRS. With a brief review of the literature, we report a case of HSP and peroneal nerve palsy following HFRS.

A case of squamous cell cancer originated from ovarian mature teratoma presenting hydronephrosis with ureteral obstruction / 대한산부인과학회지

Mature cystic teratoma of the ovary is the most commom ovarian germ cell tumor and almost benign. Malignant transformation occurs in less than 2% of benign mature teratoma. Squamous cell carcinoma derived from ectoderm is the most frequent malignancy. Prognosis of squamous cell carcinoma in ovarian mature teratoma is generally poor but there is no consensus on optimal thrapy. We report one case of squamous cell carcinoma arising from mature cystic teratoma with a brief review of the literature.

The Protective Effect of Recombinant Human Erythropoietin and N-acetylcysteine in Radiocontrast-Induced Nephrotoxicity / 대한신장학회지

PURPOSE: We investigated the effects of recombinant human erythropoietin (EPO) and N-acetylcysteine (NAC) in the prevention of radiocontrast-induced nephrotoxicity in patients with underlying renal dysfunction, who are regarded as a high risk group. METHODS: This study included 77 individuals with renal insufficiency, defined by a serum creatinine concentration above 1.2 mg/dL or creatinine clearance of more than 15 mL/min/1.73m2 and less than 60 mL/min/1.73m2. These patients who needed radiologic interventions including the use of radiocontrast materials from August 2006 to May 2007 were randomly assigned to one of four groups, which were treated with EPO only, NAC only, EPO plus NAC and placebo respectively. The serum creatinine and cystatin-C were measured before, 24 hours and 48 hours after the intervention. The creatinine clearance was obtained using the Cockcroft-Gault equation. RESULTS: The serum level of creatinine in EPO plus NAC group was not significantly elevated 24 and 48 hours after radiocontrast exposure compared to control group (p=0.012). Also, the creatinine clearance of EPO plus NAC group was not significantly decreased after radiocontrast exposure compared to control group (p=0.046). The serum level of creatinine in EPO and NAC group increased less than control group, but there were no significant differences between the groups. Also, the creatinine clearance in EPO and NAC group decreased less than control group, but there were no significant differences between the groups. CONCLUSION: EPO plus NAC showed a renoprotective effect on radiocontrast study in patients with underlying renal dysfunction.

Prospective Comparison of the Traditional Method with a Extraoral Method for Temporomandibular Joint Reduction

PURPOSE: The usual technique of temporomandibular joint (TMJ) reduction, recommended by most emergency medicine textbooks, consists of downward forces applied to the mandible. However, it has been the authors' experience that conscious sedation and significant force is required to achieve reduction. For that reason, we designed a new method of TMJ reduction. The purpose of our study is to introduce the new method of TMJ reduction and to compare the traditional method with the new method. METHODS: We performed a prospective, randomized trial with 52 patients who were diagnosed as having a TMJ dislocation. The patients were divided into two groups: the group treated with the traditional method (25 cases) and treated with the new method (27cases). Patients with histories of trauma or inflammatory signs were excluded from this study. The new method is an extraoral approach in which the operator applies the coronoid process on the face in the posteroinferior direction. RESULTS: Age, sex, and history of TMJ dislocation showed no statistical differences between the two groups. Reduction of the TMJ dislocation was achieved in 15 (60.0%) of the traditional method group and in 25 (92.6%) of the new method group (p=0.005). The means of the reduction time were 11.8+/-6.2 sec in the traditional method group and 6.6 +/- 3.3 sec in the new method group (p=0.007). CONCLUSION: The new method was an effective treatment for TMJ dislocation without any sedations. I had a higher success rate and a shorter reduction time than traditional method.

Radiologic Intervention for Traumatic Epistaxis

We report a case in which traumatic epistaxis with a carotid cavernous fistula was successfully treated by using radiologic intervention. Since the inner facial bone is an anatomically weak structure and has numerous bleeding sites, traumatic epistaxis is profuse and can not be controlled well by using traditional treatments such as gauze, merocel(R), and foley balloon packing. Uncontrolled epistaxis may cause unstable vital signs and threaten the patient. In the case of failure through traditional treatments, angiographic embolization can be used as a treatment of choice because angiographic embolization can be done at a high success rate with few complications. Stroke, facial palsy, visual loss, and facial pain are the most common complications. In our case, we had tried traditional treatments first, but there was no marked improvement. After the angiographic embolization had been conducted, epistaxis was successfully controlled. The patient 's vital signs were stabilized, and he was admitted to the ICU.

The concentration of the amniotic fluid angiogenin and interleukin-6 in the pregnancy with elevated maternal serum human chorionic gonadotropin during the second trimester / 대한산부인과학회잡지

OBJECTIVE: This study is to measure the level of concentration of angiogenin, a cause of potent neovascularization and a marker of ischemia, and of interleukin-6 (IL-6), an indicator of acute inflammation, in the amniotic fluid of patients with elevated maternal serum free beta-hCG level during the second-trimester. MATERIALS AND METHODS: Twenty patients with elevated maternal serum free beta-hCG level (>2.5 MoM) at double screening test of Down syndrome were compared with the controlled group (<2.0 MoM). This study includes singleton gestation, gestational age of 14-18 weeks, and has no evidence of fetal structural and chromosomal anomalies. The levels of amniotic angiogenin and IL-6 were measured by enzyme-linked immunosorbent assay (ELISA) method. Data were analyzed by Mann-Whitney U test. p value <0.05 was considered significant. RESULTS: Amniotic angiogenin levels in the studied group were much lower than those in the controlled group (p<0.05), whereas the difference of IL-6 levels between the two groups was not significant. Nine studied patients delivered small for gestational age infants, but only one controlled patient (p<0.05) had the same infant. Other variables of perinatal outcome were not different between the two groups. CONCLUSION: That amniotic fluid angiogenin levels are significantly lower in patients with elevated maternal serum free beta-hCG suggests an inadequate angiogenesis. Elevated maternal serum free beta-hCG levels correlate with fetal growth restriction. IL-6 values in both groups have no significant difference.

Primary Clear Cell Carcinoma of the Ovary ; An Analysis of 9 Cases with Review of the Literature / 대한산부인과학회잡지

Clear cell carcinoma of the ovary is a clinicopathologic entity with distinct morphologic characteristics and known to be associated with poor prognosis irrespective of stage and prognostic benefits of chemotherapy have not been evidently demonstrated. This represents 2-3.6% of all ovarian malignancies. From October, 1991 to January, 1998, nine patients with primary clear cell carcinoma of the ovary treated in the deptartment of Gynecology and Obstetrics, University of Ulsan, Asan Medical Center were identified, and clinical and histologic review(including architectural pattern, mitotic activity, nuclear grading) was performed retrospectively. The age of the patients ranged from 30 to 67 year(mean+S.D.; 46.0+11.8) and the mean parity was 1.2 (+1.3). Five(55.6%) of nine patients had elevated level of CA 125. The size of the tumors varied from 3 cm to 20 cm with the mean maximal diameter of 12.1 (+6.3) cm. The FIGO stages of the patients were IC(6 cases, 66.7%), IIC (2 cases, 22.2%) and IV(1 case, 11.1%). All patients except one were treated by total abdominal hysterectomy and bilateral salpingoophorectomy with or without omentectomy and pelvic lymph node dissection. All except two were received postoperative chemotherapy with regimens such as CEC (cyclophosphamide + epirubicin + carboplatin), TC(taxol + carboplatin), CC(cyclophosphamide + carboplatin) or CAP (cyclophosphamide + adriamycin + cisplatin). The mean follow-up duration was 14.6 (+ 8.6) months and 8 patients were free of disease and one patient with stage IV disease died of disease during postoperative chemotherapy(4 months after surgery).