The clinical analysis of hyperglycemic controls with four times daily administration of insulin on diabetes in pregnancy / 대한산부인과학회지

OBJECTIVE: To determine whether administrating insulin four times daily, compared to 1-3 times daily, improves maternal and perinatal outcomes of diabetes. METHODS: From August 1998 to April 2004, the 14 pregnant diabetic women were treated with four times daily administration of NPH and insulin-lispro and 15 pregnant diabetic women were treated with 1-3 times daily administration of Mixtard (30% RI, 70% NPH) or NPH. We compared the maternal and fetal complications between two groups. The goals for therapy are to achieve and maintain normoglycemia (premeal whole blood capillary glucose levels of less than 90 mg/dL and 1-hour after-meal levels of less than 120 mg/dL). RESULTS: The pregnant diabetic women who were treated with four times daily administration of NPH and Insulin lispro, instead of 1-3 times daily administration of Mixtard or NPH, resulted in better maternal and fetal outcome. But there was no significant difference between two groups statistically. CONCLUSION: This study reveals that this four times daily administration of NPH and insulin-lispro protocol achieved the glucose target level without maternal hypoglycemic events and helped to reduce the perinatal complications in pregnant diabetic women.

A case of retroperitoneal teratoma / 대한산부인과학회잡지

Retroperitoneal teratomas, which were found occasionally in children but very rarely in adults, occur mainly at the upper pole of left kidney and diagnosed after they grow very enormously. Authors experienced one case of about 20 cm-size retroperitoneal teratoma, which occurred to a 30-year-old postpartum woman at the left upper pole of kidney.

5 Cases of Granulosa Cell Tumors of the Ovary / 대한산부인과학회잡지

Sex cord stromal tumors (GCT) of the ovary compose just 5% of ovarian tumors. Most of them are granulosa cell tumors (GCT). There are two types of tumors, juvenile (JGCT) and adult type (AGCT), which have different clinical and histopathological features. JGCT represents only 5% of GCT. GCT is characterized by secretion of estrogen. Patients may present with vaginal bleeding in adult type, and sexual pseudoprecocity in juvenile type, as results of prolonged exposure to tumor-derived estrogen. Surgery is a principle of treatment and required for definite tissue diagnosis, staging, and tumor debulking. Survival of patients with GCT is generally excellent because most patients present with early stage disease. Because of the propensity of GCT to recur years after initial diagnosis, prolonged surveillance such as physical examination and serum tumor markers such as estradiol and inhibin is reasonable. We present 5 cases GCT, 4 AGCT and 1 JGCT, with brief review of literature.

A Case of Successful Percutaneous Transarterial Embolization to Injured Pelvic Artery after Vaginal Delivery / 대한산부인과학회잡지

Even though arterial embolization was introduced as a treatment tool for postpartum hemorrhage, it is not performed frequently. As authors applied arterial embolization successfully to the patient who contracted retroperitoneal hematoma after delivery, we reported this case with a brief review of literature.

Clinical Significance of HPV DNA test for Management of Patients with Diagnosis of Atypical Squamous Cells of Undetermined Significance/Low-grade Squamous Intraepithelial Lesions / 대한산부인과학회잡지

OBJECTIVE: This study was performed to evaluate the clinical efficacy of high risk HPV DNA test using PCR for the detection of high-grade CIN or invasive cancer from patients with ASCUS or LSIL on Papanicolaou smear. METHODS: Sixty one patients with a Papanicolaou smear report of atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion underwent Cervical colposcopy and directed cervical biopsy and human papillomavirus test by PCR. We compared the detection rate of the high grade CIN and invasive cancer by Papanicolaou smear method only with that of both Papanicolaou smear and HPV PCR method. and we decided to be significant when P value was below 0.05 by SAS (v 6.02) program. RESULTS: The detection rate of high risk HPV DNA was 50.8% (31/61). The detection rate of high risk HPV DNA in high grade CIN and invasive cancer was 84.2% (16/19). Higher the grade of biopsy, more the detection rate of high risk HPV DNA. False negative rate which appeared high grade CIN or invasive cancer by biopsy was 31.2% (19/61) in Papanicolaou smear method only and 4.9% (3/61) in both Papanicolaou smear and HPV DNA method. CONCLUSION: We thought that additional HPV DNA test was useful to dectect behind high grade CIN or invasive cancer when the Papanicolaou smear result was ASCUS or LSIL.

The Report of the Results of HPV Oligonucleotide Microarray Tested on the First Voided Urine of Patients of CIN and Cervix Cancer / 대한산부인과학회잡지

OBJECTIVE: To know whether HPV Oligonucleotide Microarray (HPVDNAChip) can detect the HPV DNA in the urine and, if it can, to compare the results with Pap smear, biopsy, and cervix HPVDNAChip. METHODS: The authors had done Pap smear, cervix HPVDNAChip and colposcopy-guided punch biopsy as well as detailed information to those who visited Dept. of Ob. And Gyn. during 1st of April to 31st of May in 2003 for their uterine cervical problems related to the neoplasia. When they were determined to admit for treatment, urine had been collected to be tested by HPVDNAChip. RESULTS: Among 25 patients enrolled in this study, there were 10 whose urine HPVDNAChip test turned out positive (40%). Among 10 positive results, 9 patients had HPV 16 subtypes. Among 10 urine HPVDNAChip positive patients, there were 5 HSIL, 4 squamous cell cancer (SCC), and 1 ASCUS cell types on the Pap smears. Among 15 urine HPVDNAChip negative patients, there were 7 HSIL, 5 SCC, 1 ASCUS, 1 LSIL, and 1 AGUS. Among 10 urine HPVDNAChip there are 5 CIN3, and 4 invasive SCC, and 1 adenocarcinoma at the biopsy. Among 15 urine HPVDNAChip negative patients, there are 7 CIN3, 6 invasive SCC, 1 adenocarcinoma in situ, and 1 CIN1 patient. Whenever there were a urine HPVDNAChip 16 subtype positive, there were always cervix HPVDNAChip 16 subtype positive, but among the 12 urine HPVDNAChip negative patients, 5 had HPV 16 subtype positive and 4 had another subtypes and 3 had negative on cervix HPVDNAChip tests. CONCLUSION: Using HPVDNAChip, we verified that 40% of patients had the HPV DNA in their urine who had admitted for the treatment of their cervical neoplasm. And HPV 16 subtype was the most common type in the urine. If we can extend this data more widely, we might use it as an auxiliary tool for cervical HPV infection.

A Comparison Study of Fetal Acidemia in Relation to Anesthesia Method Following Elective Cesarean Delivery / 대한산부인과학회잡지

OBJECTIVE: The purpose of this study is to determine the effects of the methods of anesthesia on fetal acidemia following elective cesarean delivery among uncomplicated healthy parturients at term, with a single fetus and is to see the correlation of that results with maternal age, Apgar score. MATERIALS AND METHODS: The gestational age more than 37 weeks, singleton, estimated birth weight more than 2.5 kg with ultrasonographic profiles, 98 cases of uncomplicated parturients were included. Three methods of anesthesia - general, epidural, spinal - were chosen randomly. Umbilical artery blood samples just after delivery were obtained from a double clamped segment of cord using a 3 ml syringe that had been flushed with heparin, then transported in ice to the laboratory. RESULTS: There was no statistically significant difference between the three anesthesia groups in regarding to maternal age, birth weight, and Apgar score. The incidence of fetal acidemia was more prevalent in the epidural anesthesia group than the others, and less in the general anesthesia group. No clinically pathologic neonatal outcome was happened even one case of pathologic fetal acidemia among the spinal anesthesia group. The average PO2 of umbilical artery was 19.7 mmHg, and there was no statistically significant difference between the three anesthesia groups. The average PCO2 of umbilical artery was statistically high in the epidural anesthesia group. CONCLUSION: This study shows that the fetal acidemia can occur in three methods of anesthesia. Because there is no difference between the three methods of anesthesia with regarding to 1-minute, 5-minute Apgar scores and there is no specific finding for postpartum follow up of 1month. In conclusion, any method of anesthesia can be used safely in the view of neonatal outcome for elective cesarean delivery.

A Comparison Study of Fetal Acidemia in Relation to Anesthesia Method Following Elective Cesarean Delivery / 대한산부인과학회잡지

OBJECTIVE: The purpose of this study is to determine the effects of the methods of anesthesia on fetal acidemia following elective cesarean delivery among uncomplicated healthy parturients at term, with a single fetus and is to see the correlation of that results with maternal age, Apgar score. MATERIALS AND METHODS: The gestational age more than 37 weeks, singleton, estimated birth weight more than 2.5 kg with ultrasonographic profiles, 98 cases of uncomplicated parturients were included. Three methods of anesthesia - general, epidural, spinal - were chosen randomly. Umbilical artery blood samples just after delivery were obtained from a double clamped segment of cord using a 3 ml syringe that had been flushed with heparin, then transported in ice to the laboratory. RESULTS: There was no statistically significant difference between the three anesthesia groups in regarding to maternal age, birth weight, and Apgar score. The incidence of fetal acidemia was more prevalent in the epidural anesthesia group than the others, and less in the general anesthesia group. No clinically pathologic neonatal outcome was happened even one case of pathologic fetal acidemia among the spinal anesthesia group. The average PO2 of umbilical artery was 19.7 mmHg, and there was no statistically significant difference between the three anesthesia groups. The average PCO2 of umbilical artery was statistically high in the epidural anesthesia group. CONCLUSION: This study shows that the fetal acidemia can occur in three methods of anesthesia. Because there is no difference between the three methods of anesthesia with regarding to 1-minute, 5-minute Apgar scores and there is no specific finding for postpartum follow up of 1month. In conclusion, any method of anesthesia can be used safely in the view of neonatal outcome for elective cesarean delivery.

Clinical Significance of HPV DNA Chip Test in the Management of Atypical Squamous Cells of Undetermined Significance / 대한산부인과학회잡지

OBJECTIVE: Cervical intraepithelial neoplasia (CIN) and invasive cervix cancer were detected in some cases of atypical squamous cells of undetermined significance (ASCUS) PAP smear. So it is reasonable to evaluate and manage ASCUS PAP smear. In this study, we attempted to assess the clinical significance of a cytologic diagnosis of ASCUS and determine the usefulness of HPV DNA chip test (which is a new diagnostic method for HPV) in management and evaluation of ASCUS patients. METHODS: This study was performed from November 2001 to June 2002 and included 48 cases of ASCUS. They were evaluated by HPV DNA chip test and the pathology was evaluated by punch biopsy, cone biopsy or hysterectomy. The result of type 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68 and 69 in HPV DNA chip test were categorized as high risk. RESULTS: The rate of CIN II or above in ASCUS was 18.8% (9/48). The detection rate of high risk HPV DNA in ASCUS was 41.7% (20/48). The detection rate of high risk HPV DNA was 30.6% (11/36) in normal or reactive, 33.3% (1/3) in CIN I, 80% (4/5) in CIN II, 100% (2/2) in CIN III, 100% (2/2) in invasive cervix cancer. Higher the grade of pathology, more the detection rate of high risk HPV DNA chip test. The sensitivity for the prediction of CIN II or above by HPV DNA chip test was 88.9% and specificity was 69.2%, respectively. CONCLUSION: The use of HPV DNA chip test in patients with ASCUS may provide usefulness in detection of CIN II, CIN III and invasive cervix cancer.

A Case of Peripartum Cardiomyopathy Associated Preeclampsia / 대한산부인과학회잡지

Peripartum cardiomyopathy is an uncommon form of dilated cardiomyopathy that is often fatal to young women. Estimates of the incidence vary from 1 in 1,300 to 1 in 15,000 pregnancies. The diagnostic criteria of peripartum cardiomyopathy are onset of cardiac failure in the latter part of pregnancy or in the puerperium, absence of obvious cause for cardiac failure and absence of demonstrable heart disease before the last trimester of pregnancy. The delayed diagnosis of this disease may be common due to the rarity of this condition. The early diagnosis and medical treatment for this disease is critical because it may affect the patient's long term prognosis. The mortality rate has been reported to be ranged from 25% to 50%. Persistence of disease after 6 months indicates irreversible cardiomyopathy and portends worse survival. The recurrence of peripartum cardiomyopathy in subsequent pregnancy remains high. The clinical presentation and treatment of patients with peripartum cardiomyopathy are similar to those of patients with congestive heart failure. We experienced a case of this disease in 25 year-old woman who had preeclampsia and preterm labor at 33 weeks of gestation. And report this case with a brief review of the literatures.

The Comparison of Myometrial Cellular Proliferation and Apoptosis as a Cause of Leiomyoma and the Relationship with Menstrual Cycles and Expression of ER/PR / 대한산부인과학회잡지

OBJECTIVE: To know whether leiomyomas come from increased proliferation or from decreased apoptosis of uterine muscular cells, and compare the results with the menstrual cycles and expression of ER/PR. METHODS: Between Mar. 2003 to Jun. 2003, the authors got 15 leiomyomatous and normal myometrial tissues from the patients who had undergone hysterectomy transabdominally or laparoscopically. As soon as they were excised, these tissues had been sent to the pathologic department to be stained by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) to determine apoptotic index (A.I.), and immunohistochemistry of Ki-67 to do Ki-67 immunoreactivity index (K.I), and ER/PR. RESULTS: There was no statistically significant difference of A.I. between leiomyoma and normal myometrial tissues But there was a significantly higher Ki-67 immunoreactivity index in leiomyoma rather than normal myometrial tissue. The increase of K.I. in leiomyomas has the reverse correlation with age, but was not statistically correlated with the menstrual cycles. There was no significant different pattern of expressions of ER/PR between in leiomyoma and in normal uterus. CONCLUSION: The main reason the leiomyomas come from may be increased proliferation instead of decreased apoptosis of leiomyoma cells. Although leiomyomas were known to be influenced by sex hormone, there was no solid evidence of increase of K. I. correlated with menstrual cycle or expression status of ER/PR in leiomyomas. Maybe there are another factors such as age that control the pathogenesis of leiomyoma rather than hormones or their receptors.

Comparative Study on Treatment of Postmenopausal Symptoms with Black Cohosh Root Extract and Hormone Replacement Therapy / 대한산부인과학회잡지

OBJECTIVE: The fears and side effects of a prolonged hormone replacement therapy on the postmenopausal symptoms reinforce a growing interest about alternatives. The present study was performed to investigate whether black cohosh root extract (BCRE) can be used or not as an alternative to hormone replacement therapy (HRT) in order to relieve postmenopausal symptoms. MATERIAL & METHODS: Randomized, double-blind prospective clinical trial examined the effects of BCRE and HRT on Kupperman index, biochemical bone markers, lipid profiles, and side effects in 74 women with postmenopausal symptoms. Treatments included placebo (Festal(R)) (n=12), BCRE (Feramin(R)) (n=32) and HRT (Premarin(R)) (n=30) for 3 months. Kupperman index, biochemical bone markers (osteocalcin and deoxypyridinoline), and lipid profiles (total cholesterol, triglyceride and HDL-cholesterol) were measured at 0, 1 and 3 months. Side effects were checked at 3 months. RESULTS: BCRE was significantly effective in lowering of Kupperman index as much as HRT at two control times (1 month: p<0.05, 3 months: p<0.001). It also showed slightly favorable effects on biochemical bone markers and lipid profiles but not statistically significant. Fewer side effects were seen in BCRE than HRT. CONCLUSION: BCRE appears to be a safe and effective alternative to HRT for early postmenopausal symptoms and may be especially useful in women with intolerances or contraindications to traditional HRT.

Comparative Study on Treatment of Postmenopausal Symptoms with Black Cohosh Root Extract and Hormone Replacement Therapy / 대한산부인과학회잡지

OBJECTIVE: The fears and side effects of a prolonged hormone replacement therapy on the postmenopausal symptoms reinforce a growing interest about alternatives. The present study was performed to investigate whether black cohosh root extract (BCRE) can be used or not as an alternative to hormone replacement therapy (HRT) in order to relieve postmenopausal symptoms. MATERIAL & METHODS: Randomized, double-blind prospective clinical trial examined the effects of BCRE and HRT on Kupperman index, biochemical bone markers, lipid profiles, and side effects in 74 women with postmenopausal symptoms. Treatments included placebo (Festal(R)) (n=12), BCRE (Feramin(R)) (n=32) and HRT (Premarin(R)) (n=30) for 3 months. Kupperman index, biochemical bone markers (osteocalcin and deoxypyridinoline), and lipid profiles (total cholesterol, triglyceride and HDL-cholesterol) were measured at 0, 1 and 3 months. Side effects were checked at 3 months. RESULTS: BCRE was significantly effective in lowering of Kupperman index as much as HRT at two control times (1 month: p<0.05, 3 months: p<0.001). It also showed slightly favorable effects on biochemical bone markers and lipid profiles but not statistically significant. Fewer side effects were seen in BCRE than HRT. CONCLUSION: BCRE appears to be a safe and effective alternative to HRT for early postmenopausal symptoms and may be especially useful in women with intolerances or contraindications to traditional HRT.

Prolapse of the Fallopian Tube into the Vaginal Vault after Abdominal Hysterectomy / 대한산부인과학회잡지

Prolapse of the fallopian tube into the vaginal vault after hysterectomy is a rare phenomenon and it occurs more frequently after vaginal hysterectomy than abdominal hysterectomy. The exact incidence of tubal prolapse is unknown, because most of cases remain undiagnosed and may resolve before detection. The tubal prolapse may be suspected when granulation tissue or tender friable tissue are detected in vaginal cuff in women complaining lower abdominal pain, dysparenunia, vaginal discharge, or postcoital spotting. The definitive diagnosis of fallopian tube prolapse is made only by histologic confirmation. Reported methods of treatment have included transvaginal excision or transabdominal excision, cautery, and combined vaginal and laparoscopic salpingectomy. We experienced a case of fallopian tube prolapse after abdominal hysterectomy in a 40-year-old woman. We present this case with a brief review of the literature.

Clinical Significance of Group B Streptococcal Infection in Pregnant Women / 대한산부인과학회잡지

OBJECTIVE: This study was to evaluate the prevalence rate of group B streptococcal infection in pregnant women after 35th gestational week and the relationship between group B streptococcal infection and the prognosis of pregnant women and their neonates. METHODS: From January 1, 2000 to June 30, 2001, the medical records of 204 pregnant women who had visited department of Ob and Gyn, Inha Hospital for antenatal care were reviewed. The specimen were obtained from lower vaginal wall and perineum, and were inoculated on selective media to isolate group B streptococci. The relationship between group B streptococcal infection in those pregnant women and the prognosis of them and their neonates peripartum were evaluated. RESULTS: The prevalence of group B streptococci in pregnant women was 1.96% (4/204). No group B streptococcal infection was found in their neonates (0/4). There is no significant statistical differences in prognosis between the pregnant women with group B streptococci and those without group B streptococi. CONCLUSION: This study was revealed that the prevalence rate of group B streptococci in pregnant women was very low and the screening test for group B streptococcal infection in pregnant women might be regarded as meaningless. However, group B streptococcus has been known to cause many complications in pregnant women and their neonates. Further studies are needed for the significance of group B streptococcal infection in pregnant women and their neonates.

The Accuracy of Frozen Section Biopsy in the Diagnosis of Gynecologic Tumors / 대한산부인과학회잡지

OBJECTIVE: Frozen section evaluation of gynecologic tumors can be used to establish a histopathologic diagnosis and guide the surgeon to perform the appropriate surgical procedure. A retrospective study was conducted to determine the accuracy of frozen section diagnosis of gynecologic tumors. METHODS: We compared the result of 459 consecutive gynecologic frozen section diagnosis with their final diagnosis by paraffin sections from January 1996 to August 2001. RESULTS: 459 gynecologic tumors that underwent frozen section evaluation were studied. Frozen section was accurate in 94.9% of 390 ovarian tumors and inaccurate in 5.1%. The sensitivity, specificity, positive predictive value, and negative predictive value for frozen section in ovarian tumors were 86.7%, 97.8%, 84.4%, 97.7%. There was three false-positive and twelve false-negative cases. And frozen section was accurate in 68 of 69 uterine tumors. CONCLUSION: Frozen section diagnosis has important implications regarding the type and extent of surgery performed at the initial operation and this method can obtain the highest accuracy when there is cooperation between experienced surgeons and reliable, careful pathologists. Most incompatible frozen section diagnosis occurred especially in mucinous ovarian tumor. Performing multiple section is recommended in the frozen section diagnosis of mucinous ovarian tumors.

Clinical analysis of Pelviscopic surgery / 대한산부인과학회잡지

OBJECTIVE: Our purpose was to evaluate the safety and efficacy of pelviscopic surgery. METHODS: Between May 1996 and April 2000, we evaluated indication of operation, mean age, parity, previous operation history, type of operation, duration of hospitalization and complications. RESULTS: The results are summarized as follows ; 1) The mean age of patients was 34.8 years with ranges between 20 and 55 years old. 2) The majority of patients were between 36 years and 40 years old(23.6%). 3) The major clinical indications included 174 cases of adnexal mass(33.4%), 125 cases of ectopic pregnancy(24.0%), 59 cases of endometriosis(11.3%). 4) The types of operation composed of 168 cases diagnostic laparoscopy(30.7%), salpingectomy(17.2%), cystectomy(11.4%), LAVH(11.2%). 5) Previous laparotomy history was found in 146 cases(28.0%). 6) The mean duration of hospitalization was 4.4 days. CONCLUSIONS: The pelviscopy can be safely performed, resulting in reduced surgical morbidity, less blood loss, less postoperative discomfort and pain, shortened hospital stays and shorter recovery days. With the increased use of markers and ultrasonography to decrease the possibility of inappropriate surgery, combined with more defined exterpation techniques, the interest in laparoscopic ovarian surgery is burgeoning. And technologic advances afford us the opportunity to offer patients a number of alternatives to open surgery. The choice of anesthetic technique varies with requirements of the surgeon, the health status and preference of the patient, the type of facility and the availability of well trained professionals, support personnel and equipment. In conclusion, the pelviscopic surgery is alternative to laparotomy.

The significance of the TDx-FLM assay in the fetal lung maturity / 대한산부인과학회잡지

OBJECTIVE: The TDX analyzer, an automated fluorescence polarimeter, has been utilized to assess surfactant content in amniotic fluid. Amniostat-FLM is an immunologic semiquantitative agglutination test for determining the presence of phosphatidylglycerol in human amniotic fluid at concentration indicative of fetal lung maturity. We evaluated the usefulness of the recently introduced TDx-FLM assay in determining fetal lung maturity. METHODS: Seventy-three samples of amniotic fluid were analyzed. Among them, 18 samples were compared with Amniostat-FLM assay. RESULTS: Surfactant/albumin ratio using TDx-FLM assay increased with longer gestational age. And the concordance rate between Amniostat-FLM assay and TDx-FLM assay was 66.9%. CONCLUSION: The TDx-FLM assay appears to be a useful test in the field of fetal lung maturity testing.

The significance of the TDx-FLM assay in the fetal lung maturity / 대한산부인과학회잡지

OBJECTIVE: The TDX analyzer, an automated fluorescence polarimeter, has been utilized to assess surfactant content in amniotic fluid. Amniostat-FLM is an immunologic semiquantitative agglutination test for determining the presence of phosphatidylglycerol in human amniotic fluid at concentration indicative of fetal lung maturity. We evaluated the usefulness of the recently introduced TDx-FLM assay in determining fetal lung maturity. METHODS: Seventy-three samples of amniotic fluid were analyzed. Among them, 18 samples were compared with Amniostat-FLM assay. RESULTS: Surfactant/albumin ratio using TDx-FLM assay increased with longer gestational age. And the concordance rate between Amniostat-FLM assay and TDx-FLM assay was 66.9%. CONCLUSION: The TDx-FLM assay appears to be a useful test in the field of fetal lung maturity testing.

Three dimensional ultrasound volumetry of amniotic fluid in pregnant women / 대한산부인과학회잡지

OBJECTIVES: Our study was to measure how well semiquantitative three-dimensional ultrasonographic measures of amniotic fluid in the third trimester, to investigate the relationship between three-dimensional amniotic fluid volume and amniotic fluid index, two dimensional amniotic fluid volumes. METHODS: We compared amniotic fluid volume as measured by three-dimensional ultrasonographic techniques with amniotic fluid index including two dimensional amniotic fluid volume in 33 women during in the third trimester. RESULTS: There was highly significant linear correlations of three-dimensional amniotic fluid volumes with AFI (r=0.6898) and two dimensional amniotic fluid volume (r=0.7926). CONCLUSION: Three-dimensional ultrasonographic technology has clinical significance as a tool to measure amniotic fluid volume. There are highly significant correlations of three dimensional amniotic volumes with AFI and two dimensional volume.