Clinical outcomes of three- or five-day treatment with clomiphene citrate combined with gonadotropins and a timed intercourse cycle in polycystic ovary syndrome patients / 대한생식의학회지

OBJECTIVE: This study aimed to investigate the effect of a new clomiphene citrate (CC) regimen on preventing thin endometrial lining in polycystic ovary syndrome (PCOS) patients receiving CC plus gonadotropin treatment with a timed intercourse cycle. METHODS: A total of 114 women with PCOS were included in this trial. Patients were divided into two groups and treated in accordance with the controlled ovarian stimulation (COS) protocol. In group A, 104 COS cycles in 67 patients were included, and in each cycle 150 mg CC was given for three days, starting from day 3. In group B, 69 COS cycles in 47 patients were included, in which 100 mg CC was given for five days, starting from day 3. The thickness of the endometrium was measured on the day of human chorionic gonadotropin (hCG) injection. Timed intercourse was recommended at 24 and 48 hours after the hCG injection. RESULTS: Additional doses of human menopausal gonadotropin and the number of days of hCG administration were not significantly different between the two groups. Endometrial thickness on the day of hCG administration was significantly larger in group A than group B (9.4+/-2.1 mm vs. 8.5+/-1.7 mm, p=0.004). The pregnancy rate was significantly higher in group A than in group B (38.4% vs. 21.7%, p=0.030). CONCLUSION: Three-day CC treatment resulted in a significantly higher pregnancy rate than the standard five-day CC treatment in a timed intercourse cycle in PCOS patients. Facilitating adequate endometrial growth via the early discontinuation of CC might be a crucial factor in achieving a higher pregnancy rate.

Ovarian Cavernous Hemangioma Presenting as a Large Growing Mass in a Postmenopausal Woman: A Case Report and Review of the Literature

Ovarian hemangiomas are usually of the cavernous type, and are rarely encountered. A 73-year-old woman presented with lower abdominal discomfort. Subsequent physical examination depicted a palpable mass in the lower abdomen. Abdominopelvic computed tomography (CT) revealed a well-circumscribed mass with thin septa measuring 12.1 x 9.0 cm in the right ovary. Levels of the tumor markers cancer antigen (CA)-125 and CA 19-9 were within the normal range. At laparoscopy, the tumor was found to be confined to the right ovary and to have a smooth surface. The final histopathological result was ovarian cavernous hemangioma. Microscopically, the mass consisted of multiple, dilated, blood-filled vascular channels separated by loose connective tissue, and all were lined by a single layer of flattened endothelium. The authors present a case of ovarian cavernous hemangioma presenting as a large growing mass in a postmenopausal woman and review previously published literature.

Clinicopathological significance of atypical glandular cells on Pap smear

OBJECTIVE: To investigate the clinical significance of atypical glandular cells (AGC) by analyzing the prevalence and histologic outcomes of patients with AGC according to Pap smear. METHODS: The medical records of 83 patients who were diagnosed AGC on Pap tests at the Pusan National University Hospital outpatient department and health care center from January 1998 to March 2006 were reviewed. RESULTS: The prevalence of AGC was 55 of 54,160 (0.10%) and 28 of 54,160 (0.05%) for AGC-not otherwise specified (NOS) and neoplastic associated AGC, respectively. The histopathologic results of the AGC-NOS group (n=55) were as follows: low-grade squamous intraepithelial lesion, 7 (12.7%); high-grade squamous intraepithelial lesion, 4 (7.2%); adenocarcinoma of cervix, 3 (5.4%); endometrial carcinoma, 2 (3.6%); and other malignancies including 2 ovarian cancer cases and 1 breast cancer case, 3 (5.4%). The histopathologic results for the AGC-associated neoplastic group (n=28) were as follows: low-grade squamous intraepithelial lesion, 1 (3.5%); high-grade squamous intraepithelial lesion, 3 (10.7%); adenocarcinoma of cervix, 5 (17.8%); endometrial carcinoma, 4 (4.8%); and additional malignancies including 3 stomach cancer cases, 2 ovarian cancer cases, and 2 breast cancer cases; 7 (25%). CONCLUSION: AGCs may represent a variety of benign and malignant lesions. AGC-associated neoplastic findings may be related to gynecological or extrauterine malignancies. Thus, when AGCs, especially neoplastic AGCs, are encountered, it is best to evaluate the cervix not only for typical maladies, but also for gynecological and non-gynecological malignancies.

A Case of Reversible Cerebral Vasoconstriction Syndrome in a Patient Complicated with Preeclampsia / 대한주산의학회잡지

The reversible cerebral vasoconstriction syndromes (RCVS) is a group of conditions, which is characterized by a reversible segmental constriction, typically associated with recurrent thunderclap headaches, and is often complicated by ischemia or hemorrhagic stroke. Clinical situations, associated with the development of RCVS, include pregnancy or the postpartum period, as well as various medications and illicit drugs. However, vasoconstriction syndromes remain poorly characterized, under-recognized, and difficult to diagnose, because of the lack of specific diagnostic tests or diagnostic criteria. Therefore, we present a first case of reversible cerebral vasoconstriction syndrome of pregnancy complicated with preeclampsia, diagnosed by a magnetic resonance image and angiography, which results in chronic cerebral infarction, with a brief review of the relevant literature.

A case of acute pancreatitis induced by hypertriglyceridemia in gestational diabetes / 대한산부인과학회지

Hypertriglyceridemia is a rare cause of pancreatitis in pregnancy. Pregnancy is related with hypertriglyceridemia especially in the 3rd trimester due to increase of estrogen. Diabetes is known as a common cause of secondary lipid metabolism disorder and is often associated with hypertriglyceridemia. Shock and sepsis related to pancreatitis in pregnancy result in a relatively high morbidity and mortality rate for both the mother and the fetus. Hypertriglyceridemic pancreatitis complicated in gestational diabetes has not previously been reported. We report a case of 26(+4) weeks gestational aged primigravida with acute pancreatitis induced by hypertriglyceridemia in gestational diabetes. We reviewed the clinical courses and treatments of acute pancreatitis in pregnancy with the literatures.

A case of acute pulmonary edema with peripartum cardiomyopathy in severe preeclampsia / 대한산부인과학회지

Women with severe preeclampsia or eclampsia who develop pulmonary edema most often do so postpartum and some of these women have cardiac failure. Peripartum cardiomyopathy is defined as a cardiac failure occurring in the latter part of pregnancy or in the peripartum, without obvious cause and prior evidence of heart disease. It is very rare but the mortality rate is as high as 10~50%. Here, we describe a case of a woman who has undergone emergency Cesarean section due to complicated severe preeclampsia with acute pulmonary edema and peripartum cardiomyopathy at 33+1 weeks of gestation.

Thalidomide for Treating Metastatic Hepatocellular Carcinoma: A Pilot Study

BACKGROUND: Thalidomide has been reported to have antitumor activity for treating metastatic hepatocellular carcinoma (HCC). We evaluated the safety and efficacy of using thalidomide for treating selected patients with unresectable or metastatic HCC, and their disease was refractory to systemic chemotherapy. METHODS: Eight patients with measurable and metastatic HCC that had progressed with prior systemic chemotherapy and who desired further active therapy were enrolled in this study. Thalidomide was given orally at bedtime and it was started at 200 mg/day with no further dose escalation. The response was measured at 2-month intervals. RESULTS: The median age was 44 years (range: 34-52 years) and all the patients had received doxorubicin-based systemic chemotherapy prior to their enrollment. Each patient received thalidomide for a median of 152 days (range: 5-422 days). One partial response was observed (12.5%, 95% CI; 0-42%) along with 4 cases of stable diseases. The most commonly encountered toxicity was somnolence; grade 3 somnolence was noted for one patient, which led to treatment discontinuation. Skin rash was observed in one responding patient. CONCLUSIONS: The results indicate that thalidomide may feasibly offer disease stabilization to metastatic HCC patients. Further dose escalation of thalidomide, or its combination with other chemotherapeutic agents, may be of interest and this should be investigated for treating patients with metastatic HCC.

Endoscopic Treatment with Band Ligation and Electrocoagulation for Non-Variceal, Non-Ulcer Upper Gastrointestinal Bleeding / 대한소화기내시경학회지

BACKGROUND/AIMS: This study compared the therapeutic efficacy of endoscopic band ligation (EBL) with that of electrocoagulation for treating non-variceal, non-ulcer (NVNU) upper gastrointestinal (UGI) bleeding. METHODS: This study included 89 patients who underwent EBL and 56 patients in whom monopolar electrocoagulation was performed for NVNU UGI bleeding. The lesions treated were Mallory-Weiss tear in 91 patients, Dieulafoy's lesion in 42 patients and angiodysplasia in 12 patients. RESULTS: The initial hemostatic rate was 97% in the EBL group and 91% in the electrocoagulation group, but this was not statistically different. Rebleeding occurred in 5 of 89 patients (5.6%) in the EBL group and in 8 of 56 patients (14.3%) in the electrocoagulation group (p=0.07). Thrombocytopenia or prothrombin time prolongation was confirmed to be a significant risk factor for rebleeding. The rebleeding rate in the high risk group was significantly lower than in the EBL group (9% vs. 30%, respectively, p=0.03). The median procedure time was significantly shorter in the EBL group compared with that in the electrocoagulation group (median 5.6 minutes vs. 8.3 minutes, respectively, p=0.04). CONCLUSIONS: EBL and electrocoagulation are both effective for treating NVNU UGI bleeding, and EBL is especially safe and effective for the cases with a high risk for rebleeding.

A Case of Colon Obstruction Developed during the Recovery Period of Acute Pancreatitis / 대한소화기학회지

Complications of acute pancreatitis usually occur in pancreas and its contiguous organs. The prevalence of colonic invasion is rare, however, the consequence is fatal, with mortality above 50%. The initial symptoms and onset times are variable and major affected sites are transverse colon and splenic flexure. The spread of inflammatory exudates into the colon is the main mechanism of colonic invasion. If the colonic stenosis develops, it is necessary to manage it surgically. We report a case who arrived at the hospital with watery diarrhea and abdominal distension in the recovery period of acute alcoholic pancreatitis and was diagnosed as a colonic obstruction in the splenic flexure. The patient underwent loop ileostomy instead of the resection of the lesion because of severe adhesion around the splenic flexure. The patient died due to sepsis 5 days after the operation.

A Case of Pneumatosis Cystoides Intestinalis / 대한소화기내시경학회지

Pneumatosis cystoides intestinalis (PCI) is characterized by the presence of multiple gas-filled cysts within the bowel wall. PCI may be idiopathic or secondary to a variety of disorders. Theories to explain cyst development include injury to the intestinal wall, a break in the mucosal barrier and rupture of a pulmonary bleb. PCI has been associated with chronic obstructive pulmonary disease, use of non-steroidal anti-inflammatory drugs, collagen vascular disease, organ transplantation, necrotizing enterocolitis, pseudomembranous colitis, and mechanical obstruction. PCI is usually found incidentally on an imaging study. Oxygen therapy has become the treatment of choice for patients with symptoms caused by pneumatosis. We experienced a case who found to have PCI by simple abdomen, computed tomography and colonoscopy in a diabetic patient who visited hospital due to abdominal pain accompanying with congestive heart failure. So, we report a case of PCI in a 53-year old woman with the review of recent literatures.

Experience with Clinical Performance Examination using Standardized Patients at Gachon Medical School / 한국의학교육

PURPOSE: This study aims to abstract the differences of scores between the clinical instructors and standardized patients (SPs) in a clinical performance examination (CPX) using SPs and to correlate the concordance between the evaluation scores and the school records. METHODS: The CPX was administered in 2003 to a total of thirty-six fifth year medical students at Gachon Medical School. The examination consisted of four cases, and four stations were duplicated, each requiring a total of 7.5 minutes per station. Evaluation of the student' s performances was conducted by both clinical instructors and SPs using a formatted checklist. Results were analysed by t-test, agreement rates, and Pearson correlation. RESULT: The mean scores given out by the clinical instructors and the SPs for the newly developed case were significantly different, while those scores for pre-existing cases were not in the old cases. The correlation coefficients between these two evaluation groups were relatively high. And agreements between the two evaluation groups were 0.37~0.72. The mean scores among clinical instructors were not significantly different, but the correlation coefficients and agreement rates were relatively high. The correlation between the evaluation scores and school records did not correlate significantly. CONCLUSION: It is concluded that the CPX is a useful tool to measure the students' essential competences in areas of knowledge, skills and attitude during the subinternship stage. In conducting a successful CPX, it is crucial to reconsider the recycling of cases and the selection and training of SPs aside from the development of an objective checklist.

Acute Exacerbation of Chronic Hepatitis B During Thalidomide Therapy for Multiple Myeloma: A Case Report

We report a case of acute fatal exacerbation of chronic hepatitis B in a 50-year-old man with multiple myeloma being treated with thalidomide. The patient had a medical history of chronic hepatitis B and was diagnosed with stage IIIA multiple myeloma. He suffered two episodes of transient transaminitis of unknown origin after successive autologous stem cell transplantations. Spontaneous resolutions of the transaminitis were observed without special management. At that time, PCR of hepatitis B virus (HBV) were all-negative. After 5-months' administration of thalidomide for the second relapse of the multiple myeloma, he suddenly experienced dizziness and jaundice. The level of HBV DNA was 1, 641 pg/mL and the serologic tests for other viruses were negative. Despite conventional supportive care, he expired due to septic shock caused by Klebsiella pneumonia. Based on the stable disease status of the multiple myeloma and exclusion of other hepatotoxic agents, it was assumed that the exacerbation of the hepatitis B virus during the thalidomide therapy preceded the bacterial sepsis. With the increased use of thalidomide in cancer treatment, cautious monitoring of the viral burden should be performed in patients with chronic hepatitis B.

Polymorphism in Codons 10 and 25 of the Transforming Growth Factor-beta1 Gene in Korean Population and in Patients with Liver Cirrhosis and Hepatocellular Carcinoma / 대한소화기학회지

BACKGROUND/AIMS: The genetic polymorphism of transforming growth factor-beta1 (TGF-beta1) at codons 10 and 25 which influences the production of TGF-beta1 is related to fibrogenesis in the lung and liver. We evaluated the genetic polymorphism at codons 10 and 25 in controls and in patients with liver cirrhosis (LC) and hepatocellular carcinoma (HCC). METHODS: Blood samples were collected from controls (n=35), patients with LC (n=64), and HCC (n=49). Genomic DNA was isolated and polymerase chain reaction (PCR) was done for a segment including codons 10 and 25. The results of direct sequencing for PCR products were compared between the controls and the patients. RESULTS: There was no genetic polymorphism at codon 25 and three types of genetic polymorphism at codon 10. The leucine homozygous genotype (CTG/CTG) at codon 10 was more common in patients with LC than the controls (p=0.01) and especially in patients with LC caused by HBV (p=0.004). The polymorphism at codons 10 in patients with HCC was similar to the controls. However, leucine homozygous genotype was more common in patients with HCC of uninodular morphology than those of massive morphology (p=0.007). CONCLUSIONS: The genetic polymorphism of TGF-beta1 at codon 10 might be associated with LC and morphology of HCC. The potential usefulness of TGF-beta1 genotyping needs further studies in large scale.

Clinical Usefulness of Plasma Activities of Gelatinase (Matrix Metalloproteinase-2 and 9) in Chronic Liver Disease / 대한간학회지

BACKGROUND/AIMS: Gelatinase (matrix metalloproteinase (MMP) -2 and 9) has an important role in the pathogenesis of liver cirrhosis (LC) and hepatocellular carcinoma (HCC). In this study, we evaluated the relationship of gelatinase to chronic liver disease. METHODS: Four groups of subjects were examined; healthy control (10 cases), chronic hepatitis (18 cases), LC (15 cases), and HCC (28 cases). The plasma of each subject was obtained, and the equal quantification of plasma protein was done. The plasma activities of MMP-2 and 9 were measured by zymography. RESULTS: The activities of plasma MMP-2 in patients with LC were significantly higher than those in controls (p=0.009) and in patients with chronic hepatitis (p=0.011), but not different from those in patients with HCC. The activities of plasma MMP-9 in patients with LC were significantly higher than those in controls, but not different from those in patients with chronic hepatitis or HCC. In patients with LC (regardless of having HCC), the activities of MMP-2 correlated with total bilirubin (r=0.323, p=0.048) and Child-Pugh score (r=0.414, p=0.012). The activities of MMP-2 and 9 were higher in patients with LC (regardless of having HCC) caused by alcohol than caused by HBV (p=0.009 and 0.002 for each one). CONCLUSIONS: The plasma activity of MMP-2 may be a useful marker for the diagnosis and determination of the severity of LC. The plasma activity of MMP-9 was not useful for HCC, but may be a marker for alcoholic LC. Further study is needed to determine why the plasma activity of gelatinase was higher in patients with LC caused by alcohol than by HBV.

A Case of Common Bile Duct Web Presenting with Obstructive Jaundice without Choledocholithiasis / 대한소화기내시경학회지

Biliary web is an extremely rare disease. It has been reported about 40 cases worldwide and 7 cases in Korea. Most cases have been incidentally found at operation or autopsy because of its rare incidence and absence of specific clinical manifestations. On cholangiography, billiary web typically appears as slit like or shelf like radiolucent narrowing. We experienced a case of biliary web of the common bile duct with obstructive jaundice that was diagnosed by endoscopic retrograde cholangiopancreatography and treated by surgery in a 65 year-old male who complained of right upper quadrant pain for 4 days. We report a case of biliary web of the common bile duct with obstructive jaundice with a review of the literature.

Viral Breakthrough in HBeAg-Negative Chronic Hepatitis B Patients Receiving Lamivudine Therapy / 대한간학회지

BACKGROUND/AIMS: Long-term efficacy and the rate of viral breakthrough in patients with HBeAg- negative chronic hepatitis B receiving lamivudine therapy is uncertain. This study was conducted to determine the rate of viral breakthrough according to the HBeAg status and the relation of viral breakthrough with YMDD mutants. METHODS: Two hundred and five patients with HBeAg-positive and 49 patients with HBeAg-negative chronic hepatitis B, who had received lamivudine for at least 9 months, were included. The mean durations of the lamivudine treatment were 176 months and 155 months in HBeAg-positive and negative patients, respectively. Analysis of HBV genome for YMDD mutations was performed by restriction-fragment-length polymorphism assay and direct sequencing. RESULTS: While the cumulative rates of viral breakthrough at 12th and 24th months of the lamivudine therapy were 0% and 7% in the HBeAg-negative group, they were 12% and 39% in the HBeAg-positive group. The cumulative rate of viral breakthrough in the HBeAg-negative group was significantly lower than in the HBeAg-positive group (p<0.01). In multivariate analysis, the only significant factor related to viral breakthrough was the HBeAg status (p<0.05). The YMDD mutants were detected in all patients with viral breakthrough irrespective of HBeAg status. However, in patients without viral breakthrough, the rate of YMDD mutants was significantly higher in the HBeAg-negative group than in the HBeAg-positive group (13.3% vs 5.1%; p<0.01). CONCLUSIONS: Lamivudine is expected to be more persistently effective in HBeAg-negative chronic hepatitis B because of a lower viral breakthrough rate than in HBeAg-positive chronic hepatitis B in spite of the emergence of YMDD mutants.

Clinical and Virologic Characteristics of Lamivudine Resistance in HBV-associated Chronic Liver Disease / 대한간학회지

BACKGROUND/AIMS: Lamivudine therapy in chronic hepatitis B has been shown to be effective in inhibiting HBV replication. However, lamivudine resistance has been developed with prolonged use. We studied to determine the prevalence, predictive factors, and clinical outcomes of lamivudine resistance. Mutations in YMDD motif of HBV polymerase, which have been associated with lamivudine resistance, were also assessed. METHODS: 170 patients with HBV-associated chronic liver disease who have received lamivudine for at least one year, were studied. The clinical, biochemical, and virologic characteristics were analyzed and compared according to presence (resistance group) or absence (non-resistance group) of DNA breakthrough. Their clinical outcomes were regularly followed. Stored sera before treatment and after DNA breakthrough were examined for detection of HBV polymerase mutation by direct sequencing and/or RFLP. RESULTS: Cumulative rates of lamivudine resistance after one and two years of treatment were 11% and 34%, respectively. In the resistance group, as compared to the non-resistance group, age, the presence of HBeAg before treatment, and disappearance of HBeAg during treatment, were significantly different. The predictive factors associated with lamivudine resistance were not found. ALT and HBV-DNA level after lamivudine resistance was variable, but jaundice or hepatic failure was absent. Mutation in YMDD motif was detected in 73% and other variable mutations were detected before treatment and after DNA breakthrough. CONCLUSIONS: Lamivudine resistance increases the longer the duration of treatment and clinical outcomes are variable. The mutation in YMDD motif was found in about 2/3 of cases. Other causes for lamivudine resistance may be considered.

Clinical Study of Gastrointestinal Carcinoid Tumors / 대한소화기내시경학회지

BACKGROUND/AIMS: Carcinoid tumors are often indolent asymptomatic tumors, however significant proportions are malignant. The patients with these tumors have usually been treated by radical excision. Recently, small gastrointestinal carcinoid tumors can be easily be detected with increasing use of endoscopy and surgical treatment has been questioned. We evaluate clinical characteristics of gastrointestinal carcinoid tumors and clinical usefulness of endoscopic resection in treatment of gastrointestinal carcinoid tumors. METHODS: We reviewed the medical records of 37 cases of gastrointestinal carcinoid tumors over the past three years in our instituide. RESULTS: The peak incidence was in the 5th decade and slight male predominance. The most comgastrointestinal carcinoid tumors were diagnosed by endoscopy with biopsy. Twenty-six cases of carcinoid tumors of size less than 15 mm have been safely treated with endoscopic resection. All of the patients are alive and clinically free of disease during 23 months after endoscopic resection. CONCLUSIONS: Recently, the detection of small carcinoid tumors in gastrointestinal tract, especially in rectum, is increasing with frequent use of endoscopy. Endoscopic resection was found to be useful and safe for treatment of small gastrointestinal carcinoid tumors.

Fatty Liver

No abstract available.

Three Case of Acute Pancreatitis Complicating Endoscopic Insertion of the Biliary Stent / 대한소화기내시경학회지

Acute pancreatitis is one of the major complications of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST). Various etiology such as mechanical, chemical, hydrostatic, and thermal factor are thought to be involved for this procedure-related pancreatitis. However, acute pancreatitis can occur as a direct complication of endoscopic biliary drainage (EBD). Although the exact mechanism remains unclear, it is postulated that the stent compresses pancreatic ductal orifice and resultant pancreatic outflow obstruction actually provokes pancreatitis. Using the larger stent diameter over 10 Fr and a straight stent rather than curved one, proximal rather than distal bile duct obstruction are risk factors for stent-induced pancreatitis. We report on three cases of acute pancreatitis complicating the EBD with a plastic stent, nasobiliary catheter, and covered-metallic stent respectively.