Analyzing Treatment Patterns for Neovascular Age-related Macular Degeneration with Expansion of the Korean Health Insurance Policy

Purpose@#We analyzed the incidence and prevalence of neovascular age-related macular degeneration (AMD) and the treatment patterns of AMD in response to changes in health insurance policies in South Korea. @*Methods@#We retrospectively analyzed the incidence and prevalence of neovascular AMD in patients diagnosed between 2010 and 2019. Data were extracted from the Korean National Health Insurance System database. The incidence and prevalence per 10,000 person-years and corresponding 95% confidence intervals were calculated. Furthermore, we recorded the usage of ranibizumab and aflibercept among newly diagnosed patients with neovascular AMD between 2010 and 2014. @*Results@#In total, 90,012 patients were diagnosed with neovascular AMD between 2010 and 2019. The incidence of neovascular AMD increased with age, except for individuals aged ≥ 90 years. The prevalence of neovascular AMD increased significantly from 30.29 per 10,000 person-years in 2010 to 50.8 per 10,000 person-years in 2019. The rate of intravitreal ranibizumab injections decreased following the introduction of aflibercept in 2014. Patients who switched from ranibizumab to aflibercept exhibited a higher drug switch rate than those who switched from aflibercept to ranibizumab (28.83% vs. 8.40%). Among newly diagnosed patients, approximately 65% received treatment covered by the health insurance system. On average, six injections were administered per year between 2010 and 2019; the number of injections increased in accordance with the maximum limit supported by the government. @*Conclusions@#The incidence and prevalence of neovascular AMD demonstrated an increasing trend. The treatment patterns are influenced by changes in government funding support policies. These findings provide valuable information for planning neovascular AMD treatment.

Comparison of the characteristics of macrolide-sensitive and macrolide-resistant Mycoplasma pneumoniae pneumonia requiring hospitalization in children

Purpose@#This study was performed to investigate differences in clinical, laboratory, and radiologic features of clinical course between macrolide-resistant Mycoplasma pneumoniae (MRMP) and macrolide-sensitive Mycoplasma pneumoniae (MSMP) pneumonia in children. @*Methods@#A total of 146 children hospitalized with Mycoplasma pneumoniae (MP) pneumonia in a tertiary hospital were enrolled in this study. Information on the characteristics was retrospectively obtained using electronic medical records. @*Results@#The duration of fever and hospitalization was significantly longer and respiratory virus coinfection was more common in the MRMP group than in the MSMP group (47.0% vs. 24.1%, P= 0.026). No significant intergroup difference in the laboratory findings, except monocytes (%), was observed. The proportion of patients with pneumonic lesions involving more than half of the whole lung was higher (28.2% vs. 10.3%), with a poorer response to the stepwise treatment for MP pneumonia, in the MRMP group than in the MSMP pneumonia group. MRMP pneumonia in children may be associated with a higher disease burden than MSMP pneumonia. @*Conclusion@#MRMP pneumonia in children might be associated with a more increased disease burden than MSMP pneumonia. This study suggested the need of distinguished therapeutic approaches to reduce the disease burden due to MRMP pneumonia in children.

Efficacy of Living Donor Liver Transplantation in Patients with Methylmalonic Acidemia / 대한소아소화기영양학회지

Purpose@#Despite aggressive medical and nutritional management, patients with methylmalonic acidemia (MMA) often suffer from multi-organ damage. Early deceased donor liver transplantation (DDLT) has emerged as an intervention to prevent disease progression. We investigated the efficacy of living donor LT (LDLT) with a potential carrier of MMA and a small volume of graft in patients with MMA as an alternative to DDLT. @*Methods@#Of five patients (three male, two female; median age 5.7 years; range, 1.3–13.7 years), four underwent carrier LDLT, while one underwent non-carrier auxiliary LDLT. All patients received pre- and post-LT continuous renal replacement therapy and were provided with minimal restriction diet according to serum MMA level after LT. MMA levels in the serum and urine, the incidence of metabolic crisis, and clinical findings before and after LT were compared. @*Results@#The survival rate was 100% during 2.2 years of follow up period after LT. In all five cases, MMA titer in the serum after transplantation decreased with less restrictive diet. Metabolic crisis was not observed during the follow-up period. In addition, no patient showed progression of severe renal impairment requiring hemodialysis. Progression of delayed cognitive development was not observed. Social functioning with improved neuropsychiatric development was observed. @*Conclusion@#This study showed that LDLT achieved improved quality of life with less restrictive diet, therefore it could be a feasible alternative option to DDLT for the treatment of patients with MMA, even with an auxiliary LT.

Efficacy of Living Donor Liver Transplantation in Patients with Methylmalonic Acidemia / 대한소아소화기영양학회지

Purpose@#Despite aggressive medical and nutritional management, patients with methylmalonic acidemia (MMA) often suffer from multi-organ damage. Early deceased donor liver transplantation (DDLT) has emerged as an intervention to prevent disease progression. We investigated the efficacy of living donor LT (LDLT) with a potential carrier of MMA and a small volume of graft in patients with MMA as an alternative to DDLT. @*Methods@#Of five patients (three male, two female; median age 5.7 years; range, 1.3–13.7 years), four underwent carrier LDLT, while one underwent non-carrier auxiliary LDLT. All patients received pre- and post-LT continuous renal replacement therapy and were provided with minimal restriction diet according to serum MMA level after LT. MMA levels in the serum and urine, the incidence of metabolic crisis, and clinical findings before and after LT were compared. @*Results@#The survival rate was 100% during 2.2 years of follow up period after LT. In all five cases, MMA titer in the serum after transplantation decreased with less restrictive diet. Metabolic crisis was not observed during the follow-up period. In addition, no patient showed progression of severe renal impairment requiring hemodialysis. Progression of delayed cognitive development was not observed. Social functioning with improved neuropsychiatric development was observed. @*Conclusion@#This study showed that LDLT achieved improved quality of life with less restrictive diet, therefore it could be a feasible alternative option to DDLT for the treatment of patients with MMA, even with an auxiliary LT.

Peripapillary Choroidal Thickness Change of Polypoidal Choroidal Vasculopathy after Anti-vascular Endothelial Growth Factor

PURPOSE: To investigate the peripapillary choroidal thickness (PCT) of polypoidal choroidal vasculopathy (PCV) and exudative age-related macular degeneration (AMD) and to evaluate their responses to anti-vascular endothelial growth factor (VEGF). METHODS: Thirty eyes with PCV and 25 eyes with exudative AMD who were treatment naïve were included in this study. PCT and subfoveal choroidal thickness were evaluated both before and after intravitreal anti-VEGF. RESULTS: The initial mean PCT of PCV (153.78 ± 56.23 µm) was thicker than that of exudative AMD (88.77 ± 23.11 µm, p < 0.001). Temporal, superior, nasal, and inferior PCTs of PCV were all thicker than those observedin exudative AMD (all p < 0.05). After anti-VEGF, the mean PCT of PCV was significantly reduced (134.17 ± 41.66 µm, p < 0.001), but the same was not true not in exudative AMD (86.87 ± 22.54 µm, p = 0.392). PCTshowed a similar tendency in all quadrants. CONCLUSIONS: PCV exhibits a thick choroid in the peripapillary region. PCT decreases after anti-VEGF in PCV but not in exudative AMD. In exudative AMD, subfoveal choroidal thickness decreased, but that in the peripapillary region did not.

Impact of Initial Vancomycin Trough Concentration on Clinical and Microbiological Outcomes of Methicillin-Resistant Staphylococcus aureus Bacteremia in Children

It is important to use vancomycin in a proper manner to ensure optimal drug exposure. Despite extensive use of vancomycin in children, studies on its optimal trough concentration (C(trough)) in the pediatric population remained rare. This retrospective study included children < 18 years old with culture-confirmed methicillin-resistant Staphylococcus aureus (MRSA) bacteremia who were hospitalized in our institute from January 2010 to April 2014. Clinical characteristics, initial vancomycin dose, Ctrough and clinical/microbiological outcomes were retrospectively collected from medical records. Forty-six MRSA bacteremia cases occurring to the patients with a mean age of 22.0 ± 46.9 months were included and all of them were healthcare-associated. Severe diseases requiring intensive care unit (ICU) stay, mechanical ventilation and/or resulting in death were observed in 57.8% (26/45); all-cause 30-day fatality was 11.1% (5/45). An initial C(trough) ≥ 15 μg/mL was achieved in only 4 (8.7%) cases with an average vancomycin dosage of 40.6 ± 7.9 mg/kg/day. Persistent bacteremia at 48 hours after initiation of vancomycin was observed more frequently in children with initial Ctrough < 10 μg/mL than in those with C(trough) < 10 μg/mL (P = 0.032). However, there was no statistically significant difference between the two groups in terms of 30-day mortality and recurrent bacteremia (P = 0.899, and P = 0.754, respectively). Although initial C(trough) may be a useful parameter for minimizing early microbiological failure, it does not predict 30-day fatality or recurrence in pediatric MRSA bacteremia. Further prospective data on vancomycin dosing are needed to find the optimal drug exposure and clarify its impact on clinical outcomes in pediatric populations.

Evaluation of Changes in Tear Film Lipid Layer Thickness Using Ocular Surface Interferometer after Artificial Tear Application

PURPOSE: The changes in tear film lipid layer thickness (LLT) after artificial tears application using LipiView®II interferometer were assessed. METHODS: We performed a prospective study of patients with dry eye disease. All subjects underwent measurement of tear film break-up time, Schirmer test, ocular surface staining, meibomian gland evaluation, and subjective score assessment using the Ocular Surface Disease Index. All subjects were randomly assigned to 1 of 3 groups using table of random numbers (group 1, sodium hyaluronate [HA] 0.1% eye drops without preservatives; group 2, HA 0.3% eye drops without preservatives and group 3, HA 0.1% with benzalkonium chloride 0.003%). LLT was measured before, immediately after and 1 hr, 3 hrs, and 6 hrs after artificial tears application. Additionally, the patients were divided into 2 subgroups depending on the presence of meibomian gland dysfunction (MGD) and further evaluated. RESULTS: Significant change in LLT was observed at 3 hrs after artificial tears instillation. LLT in groups 1 and 2 showed significant changes over time (p < 0.01 and p < 0.01, respectively). However, LLT in group 3 showed no change. LLT was unchanged in patients without MGD. Conversely, in MGD patients, a significant difference in LLT between groups 1 and 2 was observed immediately after and 1 hr and 3 hrs after instillation of artificial tears (p = 0.04, p < 0.01 and p = 0.02, respectively) but not at 6 hrs. However, no significant difference in LLT between groups 1 and 3 was observed in MGD patients. CONCLUSIONS: LLT after instillation of artificial tears measured using LipiView®II interferometer was affected by artificial tear concentration and presence of preservatives. Additionally, the presence of MGD can impact the pattern of LLT changes induced by artificial tear instillation. Therefore, LLT measurements using LipiView®II interferometer require at least a 6-hrs interval after use of eye drops, especially for patients with MGD or using artificial tears with preservatives.

Simplified suturing method using Hem-o-lock in two port laparoscopic myomectomy / 대한산부인과내시경학회지

The hem-o-lock is useful tools for the laparoscopic surgeon. We herein describe a simplified technique for suturing and knotting technique using hem-o-loc. After enucleation of the myoma, uterine parenchymal defect was closed laparoscopically using a 1-0 vicryl suture on a needle, also prepared with a hem-o-lock. Before suturing, the vicryl is tied up with hem-o-loc on the tail of continuous suture that is start point of suture site. Once the suture is passed, a hem-o-loc is used to cinch it down on the suture site and secure the knot tightly. All sutures can be completed with just one suture, continuously. We experienced no major surgical complication.

Metastatic Skin Lesions on Lower Extremities in a Patient with Recurrent Serous Papillary Ovarian Carcinoma: A Case Report and Literature Review / Journal of the Korean Cancer Association, 대한암학회지

Clinical observation of skin metastasis in ovarian cancer cases is relatively uncommon. And distant metastatic skin lesions including the extremities are much rarer still as most metastatic skin lesions are located in the skin in the abdominal wall adjacent to where the primary ovarian tumors exist. We report the case of a 60-year-old woman who presented skin lesions on both lower extremities as a consequence of the metastasis of serous papillary adenocarcinoma of the ovary. She presented with erythematous and painful cutaneous nodules on both upper legs and in the inguinal area 42 months after initial diagnosis of ovarian cancer. Skin biopsy revealed metastasis of adenocarcinoma in the dermis. She was treated with surgical excision and systemic chemotherapy. Literature review has suggested that a combined modality approach including surgical excision and chemotherapy may be useful in the management of skin metastases due to ovarian cancer.

Synchronous gynecologic malignancy and preliminary results of Lynch syndrome / 부인종양

OBJECTIVE: Lynch syndrome is a hereditary cancer syndrome that increases the risks of colorectal and gynecologic malignancies such as endometrial and ovarian cancer. Studies have shown that mutations in mismatch repair genes (MSH2, MSH6, and MLH1) are associated with Lynch syndrome. The aim of our study was to estimate the value of MSH2, MSH6, and MLH1 immunohistochemistry based on family history in a Korean sample. METHODS: Thirty six women with synchronous gynecologic tumors of endometrial and ovarian cancer were identified among patients being treated at our institution. Among them, 32 patients had tumor blocks (total 62 slides) available for analysis. According to a diagnostic algorithm, we performed immunohistochemistry analyses. Staining was scored based on intensity and proportion (negative or 0: intensity undetectable or minimal, proportion <5%; weak or 1+: intensity mild, proportion 5-30%; strong or 2+: intensity moderate to marked, proportion 30-99%). RESULTS: Among 32 eligible patients, 9 (28%) had a family history of cancer. Six patients (19%) were negative for MLH1; among them, four (4/6) were negative at both sites. Nine patients (28%) were negative for MSH2 or MSH6 at both sites or negative for both MSH2 and MSH6. Among these three patients showed negative staining for both sites. The three patients showing negative staining for MLH1, MSH2, and MSH6 at both sites with family history were considered to be the screening positive groups of Lynch syndrome. CONCLUSION: In this study, the frequency of Lynch syndrome associated immunohistochemical staining (MLH1, MSH2, and MSH6) group was estimated as 9% (3/32) among Korean women with synchronous gynecologic tumors.

Video-assisted thoracoscopic surgery for pulmonary metastasis of gestational trophoblastic neoplasia / 대한산부인과학회지

Gestational trophoblastic neoplasm (GTN) is prone to pulmonary metastasis. Although most pulmonary metastatic lesions response with chemotherapy, some lesions do not resolve and persist on radiologic investigations. A 25-year-old women was referred for persistent pulmonary metastatic lesion of GTN. Here, we present a case of chemo-resistant choriocarcinoma metastatic to lung managed by video-assisted thoracoscopic surgery.

Adnexal Clear Cell Carcinoma with Comedonecrosis: A Case Report

Adnexal clear cell carcinoma with comedonecrosis (ACCCC) is a very rare malignancy of the skin with an aggressive clinical course and a predilection for the scalp. This is the first reported case of ACCCC in Korea. A 79-year-old male presented with left abdominal masses that proved to be two subcutaneous nodules. The tumors histologically consisted of epithelial nests that showed a distinctive zonal arrangement. The centrally located clear cell areas with comedonecroses were merged with the peripheral squamoid cells, often exhibiting retraction artifacts and an infiltrating border. Nuclear pleomorphism and frequent mitoses were prominent. The clear cells were immunopositive for carcinoembryonic antigen and epithelial membrane antigen. We report here on a case of ACCCC involving the abdominal skin, and this tumor should be distinguished from the more indolent squamous cell and tricholemmal carcinomas.

Expression of p16, Rb and FHIT Proteins in Urothelial Carcinoma of the Urinary Bladder

BACKGROUND: The goal of this study was to investigate the expression of p16, retinoblastoma (Rb) and fragile histidine triad (FHIT) proteins in urothelial carcinomas of the urinary bladder, and to evaluate the relationship between clinicopathlogic parameters and each protein expression level. METHODS: The expression of p16, Rb, and FHIT proteins were studied in 176 patients with urothelial carcinoma of the urinary bladder by immunohistochemistry. RESULTS: The diffuse positive expression of the p16 protein was significantly associated with high grade and advanced tumor depth (p=0.007 and p=0.020). The loss of the Rb protein was significantly associated with old age and disease recurrence (p=0.020 and 0.037). The loss of the FHIT protein was significantly associated with advanced tumor depth (p=0.002). CONCLUSION: Our data suggest that p16 and FHIT proteins may be involved in the progression of urothelial carcinoma. In addition, p16 may be a useful prognostic marker for individual urothelial carcinoma patients.

The Usefulness of Color Doppler Ultrasonography In the Evaluation of Breast Mass

PURPOSE: To evaluate the usefulness of color Doppler ultrasonography in the differential diagnosis of breast masses. MATERIALS AND METHODS: We prospectively evaluated to pathologically proven breast lesions. Forty-three were benign (39 fibroadenomas, two papillomas and two lipoma) and 27 were malignant (25 infiltrating ductal cardinomas, one mucinous carinoma and one atypical medullary caricinoma). In 32 cases, we categorized color signal from 0 to III, according to the degree of vascularity, and analysed peak systolic velocity (PSV) and resistive index (RI). RESULTS: Color signals of malignant lesions tended to be high grade (II, III), whereas those of benign lesions tended to be low (0, I), and the difference was statistically significant (P<0.005). In the analysis of spectral waveform , correlation between RI, PSV and malignancy was statistically significant (P<0.02). RI above 0.7 and PSV above 10 were the highest recorded values for sensitivity and specificity. CONCLUSION: Color Doppler ultrasound is a useful modality to distinguish benign from malignant breast masses. Malignancy is suggested when the color signal is grade II or III, the resistive index is higher than 0.7, and peak systolic velocity is higher than 10cm/sec.

Ultrasonographic Analysis of Normal Thymus in Infants

PURPOSE: To analyse the ultrasonographic findings of normal thymus in infants and determine the pathologic findings. MATERIALS AND METHODS: Forty two infants without a history of chronic disease, tumor or steroid therapy were scanned in the axial planes with a 7.0 MHz sector transducer. Bilaterality, homogeneity, and the shape and intensity of thymic echogenicity were analysed; shapes were classified as one of three types, namely bilobate, quadrangular or triangular. The intensities of thymic echogenicity were compared with those of the liver and spleen under the same conditions (time-gain compensation, depth and gain). RESULTS: Bilaterality was seen in 36 cases, homogeneity in 35, homogeneity and bilaterality in 29, inhomogeneity and bilaterality in seven, and homogeneity and unilaterality in six. No case showed inhomogeneity and unilaterality. The shape was bilobate in 23 case, quadrangular in 13 and triangular in six, while the outer border was convex in 29 cases and straight in 13. In no case was echogenicity of the thymus greater than that of the liver or spleen. Transverse diameters were 21-47mm (mean, 37.0mm; SD, 9.4mm) and depths were 10-37.5mm (mean, 25.8mm; SD, 5.9mm). CONCLUSION: The usual findings of normal thymus in infants are bilaterality and homogeneity, convex or shaight outer border, and echointensity less than or equal to that of the liver and spleen. The possibility of thymic pathology is suggested when ultrasonography shows unilaterality, inhomogeneous echogenicity, and echogenicity greater than that of the liver and spleen.

Color Doppler Image of Thyroid Nodule: Differentiation Between Benign and Malignant Lesion

PURPOSE: To assess the utility of color Doppler sonography in the differential diagnosis of thyroid nodules. MATERIALS AND METHODS: Fifty patients with thyroid nodules(10 cases of follicular adenoma, 12 of adenomatous hyperplasia, 21 of papillary adenocarcinoma, and 7 of follicular adenocarcinoma) were analyzed. Colour signal analysis was performed by inspecting the signals in and around the nodules, and these were graded from 0 to III according to the degree of vascularity in internal and marginal blood flow. Peak systoic velocity (PSV) and resistive index (RI) in internal vascularity were used to analyse the flow signal. RESULTS: Internal colorsignals of malignant lesions tended to be high grade, whereas those of benign lesions tended to be low grade, with statistical significance(P<0.05). In spectral wave analysis, correlation between PSV and malignancy of thyroid nodules was statistically significant(P<0.05). The value of RI did not correlate with the malignancy of nodules, but tended to show a meaningful difference. CONCLUSIONS: Although further studies may be required, color Dopplersonography using color signal analysis and flow signals analysis is a useful imaging modality for the differentiation of benign and malignant lesions of thyroid nodules.