Failed intubation of an unanticipated postintubation tracheal stenosis: a case report / 대한마취과학회지

Encountering a patient with unanticipated laryngotracheal stenosis (LTS) during anesthetic induction is challenging for an anesthesiologist. Because routine history taking and pre-anesthetic evaluation cannot rule out the possibility of LTS, other measures should be taken. Perioperative airway maintenance is considered crucial for avoiding complications such as airway edema, bleeding, obstruction, collapse, and ultimately respiratory failure and arrest. We report an unanticipated tracheal stenosis discovered during anesthetic induction that hindered endotracheal intubation. Because airway maintenance was difficult, we postponed surgery until determining the cause of the difficult entry, considered possible therapeutic approaches (both anesthetic and surgical), and provided successful surgery with a continuous epidural block.

Prevalence, Risk Factors and Clinical Characteristics in Patients with Genotype 6 Chronic Hepatitis C: A Single Institute Experience / 대한소화기학회지

BACKGROUND/AIMS: Hepatitis C genotypes 1 and 2 are widely distributed globally. In contrast, genotype 6 is found mainly in Southeast Asia, while genotype 6 is rare in Korea. This study aims to investigate the prevalence, risk factors and clinical characteristics of patients with genotype 6 chronic hepatitis C. METHODS: We retrospectively identified 133 HCV-infected patients who underwent HCV genotype analysis between January 2012 and December 2012, and analyzed the prevalence, risk factors and clinical characteristics of patients diagnosed with genotype 6 chronic hepatitis C. RESULTS: Among 133 patients, 53 patients (39.8%) were infected with genotype 1, 62 patients (46.6%) with genotype 2, 2 patients (1.5%) with genotype 3, 14 patients (10.5%) with genotype 6, and 2 patients (1.5%) with mixed genotypes (genotype 1 and 6). The risk factors associated with genotype 6 were acupuncture (n=4, 28.6%), intravenous drug use (n=3, 21.4%), tattoo (n=2, 14.3%), and transfusion (n=2, 14.3%). Of the 14 patients with genotype 6, 6 patients were treated with pegylated interferon and ribavirin. Five patients had reached the end of treatment. All patients reaching end of treatment for genotype 6 showed early virological response and sustained virological response. CONCLUSIONS: The prevalence of genotype 6 is 10.5% and mixed infections of genotype 1 and 6 are 1.5% in patients with chronic hepatitis C. A major potential risk factor is intravenous drug use and the treatment response rate to pegylated interferon plus ribavirin is high in patients with genotype 6 chronic hepatitis C. Large scale multicenter studies are needed.

Mycobacterium intracellulare Pulmonary Disease with Endobronchial Caseation in a Patient Treated with Methotrexate / 결핵및호흡기질환

Methotrexate (MTX) has been established as a standard disease-modifying anti-rheumatic drug. If adequate disease control is achieved for a reasonable period of time, tapering the MTX dosage is recommended because the chronic use of MTX can result in opportunistic infection. We present here a case of a woman with rheumatoid arthritis taking MTX, and the woman developed actively caseating endobronchial Mycobacterium intracellulare disease with pulmonary infiltrations. After discontinuing the MTX, the patient was able to tolerate 18 months of antimycobacterial treatment without flare ups of rheumatoid arthritis, and she completely recovered from nontuberculous mycobacterial respiratory disease.

A Case of Recurrent Exercise-Induced Acute Renal Failure and Renal Hypouricemia with R90H Mutation in a SCL22A12 Gene / 영남의대학술지

Acute renal failure with severe loin pain and patch renal ischemia after anaerobic exercise (ALPE) is a rare cause of exercise-induced acute kidney injury. Some ALPE patients also have renal hypouricemia. Mutations in the SCL22A12 gene are among the major factors of hypouricemia. Education for the prevention of relapse and genetic counseling should be recommended to ALPE patients with renal hypouricemia. This paper reports a 25-year-old man who showed recurrent exercise-induced ARF and renal hypouricemia with R90H mutation in his SCL22A12 gene.

Efficacy of Peginterferon and Ribavirin Combination Therapy of Chronic Hepatitis C: A Pooled Analysis / 대한소화기학회지

BACKGROUND/AIMS: A combination of peginterferon and ribavirin is the standard therapy for chronic hepatitis C (CHC). However, the respective study has not been carried out in a large scale in Korea. The purpose of this study was to collect the studies that have been reported in Korea in order to analyze the therapeutic effect of combination therapy and compare to find racial difference. METHODS: Twenty-eight papers related to the therapeutic effect of combination therapy in CHC patients were analyzed based on pooled analysis. RESULTS: Based on the analysis for genotype 1 in Korea, early virologic response (EVR), end of treatment response (ETR), and sustained virologic response (SVR) were 79.6% (125/157), 80.1% (166/207), and 62.7% (341/543). The EVR, ETR, and SVR for genotype 2 and 3 were 89.4% (119/133), 92.2% (203/220), and 84.1% (434/516). Data from other Asians showed that EVR and SVR for genotype 1 were 88.9% (290/326) and 64.4% (491/762) respectively and 88.8% (135/152), and 79.4% (151/190) for genotype 2 and 3 respectively. In Western, EVR and SVR for genotype 1 were 51.3% (1,981/3,860) and 42.4% (1,798/4,231) respectively, and for genotype 2 and 3 were 87.7% (350/399) and 77.8% (533/685) respectively. Based on the comparative analysis, no statistical difference in SVR between Koreans and other Asians (p=0.955) was observed; However, the SVR of Koreans was higher with significance than that of Westerns (p<0.001) On the other hand, there was no difference what so ever, in SVR for genotype 2 amongst the different races. CONCLUSIONS: The SVR of combination therapy for the Korean chronic hepatitis C patients was similar to other Asians but higher than Westerns.

A Case of Rectal Mucosa-associated Lymphoid Tissue Lymphoma Diagnosed by Endoscopic Unroofing Technique / 대한소화기학회지

Mucosa-associated lymphoid tissue (MALT) lymphoma is a typical primary gastrointestinal lymphoma, particularly in the stomach. Although primary rectal lymphoma is rare, it may present as a subepithelial tumor. Several techniques have been proposed for a tissue diagnosis in subepithelial tumor, including endoscopic ultrasonography (EUS)-guided fine needle aspiration (EUS-FNA), EUS-guided trucut biopsy (EUS-TCB), and tacked biopsy. However the diagnostic efficacy of these techniques appears to be limited. The unroofing technique involves removal of the overlying mucosa, thereby exposing the subepithelial lesion. It was originally reported as a method for endoscopic treatment of colorectal lymphangioma. In this case, a subepithelial tumor of the rectum was diagnosed using the endoscopic unroofing technique. This is a useful modality for the diagnosis of subepithelial tumor, because it provides histologic results in a safe and rapid manner.

Disseminated Cysticercosis

Disseminated cysticercosis is a rare form of cysticercosis in which the cysticerci spread out through the whole body. We report the first case of a 39-year-old Mongolian with disseminated cysticercosis. He visited our hospital with generalized tonic-clonic seizure. After extensive investigation from brain computed tomography (CT), spine magnetic resonance imaging (MRI), whole body MRI and pathologic biopsy, he was diagnosed as having cysticercosis involving the brain, subcutaneous tissue, and skeletal muscles through the whole body. We treated him with the albendazole in which case the followed MRI showed that numbers of cystic lesions were copiously decreased. We report an unsual case of disseminated cysticercosis treated with medical therapy.

The Combined Effects of Ginkgo Biloba Extracts and Aspirin on Viability of SK-N-MC, Neuroblastoma Cell Line in Hypoxia and Reperfusion Condition

OBJECTIVE: The purpose of this study is to investigate the combined effects of ginkgo biloba extract, ginkgolide A and B and aspirin on SK-N-MC, human neuroblastoma cell viability and mRNA expression of growth associated protein43 (GAP43), Microtubule-associated protein 2 (MAP2), B-cell lymphoma2 (Bcl2) and protein53 (p53) gene in hypoxia and reperfusion condition. METHODS: SK-N-MC cells were cultured with Dulbecco's Modified Eagle's Medium (DMEM) media in 37degrees C, 5% CO2 incubator. The cells were cultured for 8 hours in non-glucose media and hypoxic condition and for 12 hours in normal media and O2 concentration. Cell survival rate was measured with Cell Counting Kit-8 (CCK-8) reagent assay. Reverse transcriptase polymerase chain reaction (RT-PCR) was used to estimate mRNA levels of GAP43, MAP2, Bcl2, and p53 genes. RESULTS: The ginkgolide A and B increased viable cell number decreased in hypoxic and reperfused condition. The co-treatment of ginkgolide B with aspirin also increased the number of viable cells, however, there was no additive effect. Although there was no increase of mRNA expression of GAP43, MAP2, and Bcl2 in SK-N-MC cells with individual treatment of ginkgolide A, B or aspirin in hypoxic and reperfused condition, the co-treatment of ginkgolide A or B with aspirin significantly increased GAP43 and Bcl2 mRNA levels. In MAP2, only the co-treatment of ginkgolide A and aspirin showed increasing effect. The mRNA expression of p53 had no change in all treating conditions. CONCLUSION: This study suggests that the combined treatments of Ginkgo biloba extracts and aspirin increase the regeneration of neuroblastoma cells injured by hypoxia and reperfusion.

Role of 'Spot Sign' on CT Angiography to Predict Hematoma Expansion in Spontaneous Intracerebral Hemorrhage

OBJECTIVE: Patients with spontaneous intracerebral hemorrhage (ICH) presenting within 24 hours of symptom onset are known to be increased risk of hematoma expansion which is closely correlated with morbidity and mortality. We investigated whether tiny enhancing foci ('Spot sign') on axial view of 3-dimensional computed tomography angiography (3D-CTA) source images can predict subsequent hematoma expansion in spontaneous ICH. METHODS: During a 2-year period (March 2007-March 2009), we prospectively evaluated 3D-CTA of 110 patients with spontaneous ICH. Based on source images of 3D-CTA, patients were classified according to presence or absence of 'Spot sign'; 'Spot sign' (+) group, 'Spot sign' (-) group. Radiological factors and clinical outcomes were compared between two groups. RESULTS: Hematoma expansion occurred in 16 patients (15%). Mean Glasgow Coma Scale (GCS) score of patients with hematoma expansion was significantly different compared to score of patients without hematoma expansion (5 vs. 9, p < 0.001). Nineteen patients (16%) of 110 ICH patients demonstrated 'spot sign' on 3D-CTA. Among the 'spot sign' (+) group, 53% of patients developed hematoma expansion. Conversely 7% of patients without 'spot sign' demonstrated the hematoma expansion (p < 0.001). Initial volume and location of hematoma were significantly not associated with hematoma expansion except shape of hematoma. CONCLUSION: Our study showed that patients with hematoma expansion of spontaneous ICH had significant clinical deterioration. And the fact that 'spot sign' (+) group have higher risk of hematoma expansion suggests the presence of 'spot sign' on source images of 3D-CTA can give a clue to predict hematoma expansion in spontaneous ICH.

The Classification of Sentinel Lymph Node According to Radioactivity in Breast Cancer

PURPOSE: The sentinel lymph node (SLN) biopsy represents a new standard method for axillary staging in patients with breast cancer. Although the radioisotope technique has been used to identify SLN, no standard for radioisotope success has been defined. In this study, we intended to define the threshold level of radioactivity which could predict all cases of positive SLN. METHODS: SLN biopsy was performed in 86 patients with clinical stage T1-2, N0 breast cancer, using both isotope ((99m)Tc-ASC or (99m)Tc-HSA) and blue dye. All lymph nodes having higher isotope counts than the background were sampled. The nodes with the three highest radioactivities were identified as S1, S2 and S3 and the predictive value of metastatic SLN was analyzed according to the level of SLN-to-background ratio. RESULTS: SLN was successfully identified in 100% of the 86 patients, with 10.5% (9/86) of SLN identified by isotope alone and 1.2% (1/86) by blue dye alone. Metastasis of axillary lymph node was documented in 35 of 86 (40.7%) and the false negative rate of SLN metastasis was 8.6% (3/35). In 33 SLN metastatic cases, the node with the highest count (S1) contained metastasis in 29 (87.8%), but in 4 (12.2%) it was benign. The sensitivity of metastatic SLN was 91.4% (32/35) when only S1, S2 and S3 were biopsied. Although three patients had metastasis in S3, there were concurrent metastases in S1 or S2. Metastatic rates according to SLN-to-background ratios, of 1~4, 5~9, 10~20, 21~50, and >50 were 5/43 (11.6%), 8/43 (18.6%), 8/43 (18.6%), 7/43 (16.3%) and 15/43 (34.9%) respectively and there was no statistical significance (P=0.261). However, SLN with higher radioactivity had a higher metastatic rate (P=0.004). CONCLUSION: There was no optimal SLN-to-background ratio capable of identifying positive SLN in all cases but SLN with higher radioactivity had a higher metastatic rate. To reduce false negative rate, SLN biopsy requires the removal of all nodes higher than background regardless of the relative magnitude of counts and requires using both radioisotope and blue dye and the removal of all clinically suspicious non-SLN.

C-erbB-2 Expression Predicts Tamoxifen Efficacy in Breast Cancer Patients

PURPOSE: It has been reported that c-erbB-2 overexpression is associated with a resistance to tamoxifen therapy in many trials, but this is controversial. The aim of this study was to evaluate the c-erbB-2 status, and the response to tamoxifen, in breast cancer patients. METHODS: We enrolled 294 patients who had been treated with tamoxifen, 261 (88.8%) were ER and 33 PR positive respectively. The expressions of c-erbB-2 were analyzed using immunohistochemical methods. The median follow up was 36 months. We medical records retrospectively reviewed, and the recurrence rate analyzed and compared with other prognostic factors and survival rates, according to the c-erbB-2 status. RESULTS: The mean age of the patients was 45.23+/-10.47 (20~83). The incidence of invasive ductal carcinomas, invasive lobular carcinomas and DCIS were 91.2, 4.8 and 4.1%, respectively. The recurrence rate was 10.9% (32/294), and 22 of 225 (9.8%) in ER/PR (+/+), 7 of 36 (19.4%) in ER/PR (+/-) and 3 of 33 (9.1%) in ER/PR (-/+). The recurrence rates, according to the TNM stages 0, I, IIa, IIb, III were 0, 5.4, 6.5, 15.2 and 36.7%, respectively (P=0.000). The recurrence rates, according to the c-erbB-2 stati, were 16.5 and 8.4% in the positive and negative groups, respecively (P=0.039). The nuclear grade was higher in the c-erbB-2 positive group than in the negative group, but there was no relationship between the c-erbB-2 status and the other prognostic factors, such as axillary lymph node status, TNM stage or histological grade. The overall and disease free survivals were significantly shorter in the c-erbB-2 positive than the negative group (P<0.05). CONCLUSION: The patients with tumors positive for c-erbB-2 had shorter overall and disease free survivals, compared to patients with tumors negative for c-erbB-2, when treated with tamoxifen. Overexpression of c-erbB-2 may reduce the efficacy of tamoxifen therapy, although our number of patients was small and the follow up relatively short.

Decrease in Pulse Oximeter Readings Following Injection of Isosulfan Blue Dye / 한국유방암학회지

PURPOSE: A sentinel lymph node mapping with blue dye has been well accepted as a common procedure in breast cancer surgery. However, it is well known that blue dye absorbed into the circulation may interfere pulse oximetery reading. The aim of this study was to evaluate the change of pulse oximetery reading by isosulfan blue dye injection during sentinel lymph node mapping. METHODS: Thirteen breast cancer patients with normal preoperative cardiopulmonary functions were studied. Four ml of isosulfan blue dye was injected subdermally when the patient became stable after induction of general anesthesia. The pulse oximetery was monitored continuously. Multiple arterial blood gas analyses (ABGA) were performed before dye injection and 10, 30, 40 minutes after dye injection. The results of oxygen saturturation by oximetery (SpO2) and the results of arterial oxygen tension (SaO2) and arterial oxygen saturation (SaO2) by ABGA were compared. RESULTS: The value of both SaO2 and PaO2 measured by ABGA has not been altered by isosulfan dye injection. However SpO2 decreased by isosulfan dye injection. SpO2 decrease started 8.2+/-1.5 (2~0) minutes after dye injection and returned to preinjection level by 85.7+/-5.6 (60~126) minutes after injection. The lowest vaule of SpO2 was 95.6+/-1.2% (93~97). Mean duration of SpO2 decrease was 77.5+/-6.2 (40~117) minutes. The duration of SpO2 decrease was longer in the aged patients, but it was not statistically significant (p=0.3). There was no siginificant difference in duration of SpO2 decrease according to injection site, operation method, and body mass index (BMI). CONCLUSION: .Isosulfan dye injection using for sentinel lymph node mapping causes no change in true ABGA results but causes a mild reversible decrease in SpO2, It is important to look for other causes when SpO2 decrease is significant and persistent.