Acute Type B Aortic Dissection in a Patient with Previous Endovascular Abdominal Aortic Aneurysm Repair

Endovascular aortic repair (EVAR) was relatively safe, and became a widely performed procedure. If aortic dissection (AD) occurred in patient with previous EVAR, it could cause fatal complications like endograft collapse. Surgical treatment was limited in this situation for comorbidities and complex anatomies. Here we report a rare case of acute type B AD developed following trans-radial coronary intervention in a patient with previous EVAR of abdominal aortic aneurysm, which was treated with thoracic EVAR.

Impact of Diltiazem Alone versus Diltiazem with Nitrate on Five-Year Clinical Outcomes in Patients with Significant Coronary Artery Spasm

PURPOSE: Calcium channel blockers diltiazem and nitrate have been used as selective coronary vasodilators for patients with significant coronary artery spasm (CAS). However, no study has compared the efficacy of diltiazem alone versus diltiazem with nitrate for long-term clinical outcomes in patients with CAS. MATERIALS AND METHODS: A total of 2741 consecutive patients without significant coronary artery disease with positive CAS by acetylcholine (Ach) provocation test between November 2004 and May 2014 were enrolled. Significant CAS was defined as a narrowing of >70% by incremental intracoronary injection of 20, 50, and 100 µg of Ach into the left coronary artery. Patients were assigned to either the diltiazem group (n=842) or the dual group (diltiazem with nitrate, n=1899) at physician discretion. To adjust for potential confounders, a propensity score matching (PSM) analysis was performed using the logistic regression model. After PSM analysis, two well-balanced groups (811 pairs, n=1622, C-statistic=0.708) were generated. RESULTS: At 5 years, there were similar incidences in primary endpoints, including mortality, myocardial infarction, revascularization, and recurrent angina requiring repeat coronary angiography between the two groups. Diltiazem alone was not an independent predictor for major adverse cardiovascular events or recurrent angina requiring repeat coronary angiography. CONCLUSION: Despite the expected improvement of endothelial function and the relief of CAS, the combination of diltiazem and nitrate treatment was not superior to diltiazem alone in reducing mortality and cardiovascular events up to 5 years in patients with significant CAS.

Routine Angiographic Follow-Up versus Clinical Follow-Up after Percutaneous Coronary Intervention in Acute Myocardial Infarction

PURPOSE: Differences in the utility of routine angiographic follow-up (RAF) and clinical follow-up (CF) after percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) are not well understood. The present study aimed to compare the 3-year clinical outcomes of RAF and CF in AMI patients who underwent PCI with drug-eluting stents (DES). MATERIALS AND METHODS: A total of 774 consecutive AMI patients who underwent PCI with DES were enrolled. RAF was performed at 6 to 9 months after index PCI (n=425). The remaining patients were medically managed and clinically followed (n=349); symptom-driven events were captured. To adjust for any potential confounders, a propensity score matched analysis was performed using a logistic regression model, and two propensity-matched groups (248 pairs, n=496, C-statistic=0.739) were generated. Cumulative clinical outcomes up to 3 years were compared between RAF and CF groups. RESULTS: During the 3-year follow-up period, the cumulative incidences of revascularization [target lesion revascularization: hazard ratio (HR), 2.40; 95% confidence interval (CI), 1.18–4.85; p=0.015, target vessel revascularization (TVR): HR, 3.33; 95% CI, 1.69–6.58; p=0.001, non-TVR: HR, 5.64; 95% CI, 1.90–16.6; p=0.002] and major adverse cardiac events (MACE; HR, 3.32; 95% CI, 1.92–5.73; p<0.001) were significantly higher in the RAF group than the CF group. However, the 3-year incidences of death and myocardial infarction were not different between the two groups. CONCLUSION: RAF following index PCI with DES in AMI patients was associated with increased incidences of revascularization and MACE. Therefore, CF seems warranted for asymptomatic patients after PCI for AMI.

A Typical Case of L-Transposition of the Great Arteries Initially Presented as Complete Atrioventricular Block in Middle-Aged Man

L-transposition of the great arteries (L-TGA) is a rare congenital anomaly and could cause complete atrioventricular (AV) block at relatively younger age. We present a case of 43-year-old male who complained of dizziness due to complete AV block. We confirmed L-TGA using transthoracic echocardiography and cardiac computed tomography. Permanent pacemaker was inserted without complications. No invasive treatment including corrective surgery was performed because patient's cardiac function was almost normal and the symptom was completely resolved after pacemaker insertion.

Prevalence of Gastrointestinal Diseases and Treatment Status in Noncardiac Chest Pain Patients

BACKGROUND AND OBJECTIVES: We evaluated the prevalence of gastroesophageal reflux diseases (GERD) in noncardiac chest pain (NCCP) patients, risk factors for GERD, and status of prescriptions for GERD in Korean population. SUBJECTS AND METHODS: This was a retrospective non-interventional observational nation-wide 45-center study. Patients with a normal coronary angiogram (CAG) and upper gastroendoscopy within 2 years after CAG were enrolled. The prevalence of GERD was examined. Other gastrointestinal diseases including peptic ulcer diseases or gastritis were also examined. Risk factors for GERD were compared between the GERD group and non-GERD group. The ratio of patients medicated for gastrointestinal diseases (antacids or proton-pump inhibitor) was also examined. RESULTS: Nine hundred four patients were enrolled. Among the NCCP patients, GERD was present in 436 (48.2%), peptic ulcer disease in 154 patients (17.0%), and gastritis in 659 (72.9%). There was no difference in risk factors for GERD between the GERD and non-GERD patients. Medications for GERD and other gastrointestinal diseases were prescribed in 742 (82.1%) patients. CONCLUSION: GERD was common (42.8%) in Korean NCCP patients and most (82.1%) received the prescription of gastrointestinal medications. No differences were evident in risk factors between GERD and non-GERD patients.

Surgical Removal of a Left Ventricular Thrombus Which Showed Morphologic Changes Over Time in a Patient with Stress-Induced Cardiomyopathy

Although stress-induced cardiomyopathy (SCMP) is a reversible disease and the prognosis is usually excellent, several complications can occur and can result in fatal adverse events. The formation of left ventricular (LV) thrombus is one of these critical complications of SCMP. This report describes a case of SCMP complicated by formation of a LV thrombus that became increasingly mobile as LV contractility recovered, and for which surgical removal was performed. Here, we report a case of SCMP complicated by LV thrombus and review the literature regarding this topic.

Ethanol Infusion in the Vein of Marshall in a Patient with Persistent Atrial Fibrillation

We report the case of a 64-year-old male with persistent atrial fibrillation (AF) terminated by ethanol infusion into vein of Marshall as add-on therapy. Three-dimensional automated complex fractionated atrial electrogram (CFAE) during AF revealed clustering of CFAE at perimitral isthmus (PMI) and its unipolar mapping showed rotor-like activation, which was suggested to be critical in the perpetuation of AF. AF was organized to atrial tachycardia (AT) by 100% ethanol infusion in the vein of Marshall. Adjunctive radiofrequency ablation at PMI successfully terminated AT and led to bidirectional block of PMI.

An Imported Case of Severe Falciparum Malaria with Prolonged Hemolytic Anemia Clinically Mimicking a Coinfection with Babesiosis

While imported falciparum malaria has been increasingly reported in recent years in Korea, clinicians have difficulties in making a clinical diagnosis as well as in having accessibility to effective anti-malarial agents. Here we describe an unusual case of imported falciparum malaria with severe hemolytic anemia lasting over 2 weeks, clinically mimicking a coinfection with babesiosis. A 48-year old Korean man was diagnosed with severe falciparum malaria in France after traveling to the Republic of Benin, West Africa. He received a 1-day course of intravenous artesunate and a 7-day course of Malarone (atovaquone/proguanil) with supportive hemodialysis. Coming back to Korea 5 days after discharge, he was readmitted due to recurrent fever, and further treated with Malarone for 3 days. Both the peripheral blood smears and PCR test were positive for Plasmodium falciparum. However, he had prolonged severe hemolytic anemia (Hb 5.6 g/dl). Therefore, 10 days after the hospitalization, Babesia was considered to be potentially coinfected. A 7-day course of Malarone and azithromycin was empirically started. He became afebrile within 3 days of this babesiosis treatment, and hemolytic anemia profiles began to improve at the completion of the treatment. He has remained stable since his discharge. Unexpectedly, the PCR assays failed to detect DNA of Babesia spp. from blood. In addition, during the retrospective review of the case, the artesunate-induced delayed hemolytic anemia was considered as an alternative cause of the unexplained hemolytic anemia.

Morinda citrifolia Inhibits Both Cytosolic Ca2+-dependent Phospholipase A2 and Secretory Ca2+-dependent Phospholipase A2

This study investigated the effects of the methanol extracts of Morinda citrifolia containing numerous anthraquinone and iridoid on phospholipase A2 (PLA2) isozyme. PLA2 activity was measured using various PLA2 substrates, including 10-pyrene phosphatidylcholine, 1-palmitoyl-2-[14C]arachidonyl phosphatidylcholine ([14C]AA-PC), and [3H]arachidonic acid (AA). The methanol extracts suppressed melittin-induced [3H]AA release in a concentration-dependent manner in RAW 264.7 cells, and inhibited cPLA2/sPLA2-induced hydrolysis of [14C]AA-PC in a concentration- and time-dependent manner. A Dixon plot showed that the inhibition by methanol extracts on cPLA2 and sPLA2 appeared to be competitive with inhibition constants (Ki ) of 3.7microgram/ml and 12.6microgram/ml, respectively. These data suggest that methanol extracts of Morinda citrifolia inhibits both Ca2+-dependent PLA2 such as, cPLA2 and sPLA2. Therefore, Morinda citrifolia may possess anti-inflammatory activity secondary to Ca2+-dependent PLA2 inhibition.

The Prognostic Value of the Preoperative Lymphocyte Count in Patients with Gastric Cancer

PURPOSE: The aim of this study was to evaluate the prognostic value of the peripheral blood lymphocyte count before surgery in those patients with gastric cancer. MATERIALS AND METHODS: The study group was comprised of a series of 1,054 patients who underwent curative gastrectomy. The appropriate lymphocyte count cutoff value was determined. The prognostic factors were evaluated by univariate and multivariate analyses. RESULTS: The lymphocyte count cutoff value was 1,500/ul. The patients were classified into two groups: Group A had a lymphocyte count > or =1,500/ul (n=765) and Group B had a lymphocyte count <1,500/ul (n=289). There were statistically significant differences between the groups according to their age (P<0.001), the tumor stage (P=0.038) and the tumor size (P<0.001). The 5- and 10-year survival rates of Group A were 80.1% and 76.6%, respectively and those of Group B were 72.4% and 63.5%, respectively (P=0.002). When multivariate analysis was performed by the Cox proportional hazards model, the lymphocyte count was not an independent prognostic factor. CONCLUSION: Although the prognosis of patients with a high lymphocyte count was better than that of the patients with a low lymphocyte count, our results did not support using the preoperative peripheral blood lymphocyte count as an independent prognostic factor for patients with gastric cancer.

MR Imaging of Intradural Extramedullary Tuberculoma of the Spinal Cord: Report of Two Cases

Intradural extramedullary tuberculoma of the spinal cord is a rare manifestation of the spinal tuberculosis, with a few cases described so far. Recently, we have experienced two cases of extensive intradural extramedullary tuberculoma at the thoracic spine. So, we report these cases with review of the literatures.

Prostaglandin E1 Increases cGMP Levels in Beating Rabbit Atria: Lack of Effects of PGE1-induced Cyclic Nucleotides on Secretory and Contractile Functions

Members of prostaglandin (PG) E-series elicit cellular effects mainly through adenylyl cyclase-cAMP signaling. The role of PGE2-induced increase in cAMP has been shown to be compartmentalized in the cardiac myocytes: PGE2-induced increase of cAMP is not involved in the control of cardiomyocytic contraction. The purpose of the present study was to define the effect of PGE1 on the cGMP levels and the role of PGE1 in the atrial secretory function. Experiments were performed in perfused beating rabbit atria and atrial contractile responses, cGMP and cAMP efflux, and atrial natriuretic peptide (ANP) secretion were measured. PGE1 increased cGMP as well as cAMP efflux concentration in a concentration-dependent manner, however, no significant changes in atrial secretory responses were observed (with 1.0microM PGE1; for cGMP, 144.76+/-37.5%, n=11 versus -16.81+/-4.76%, n=6, control, p<0.01; for cAMP, 187.60+/-41.52%, n=11 versus 7.38+/-19.44%, n=6, control, p<0.01). PGE1 decreased atrial dynamics slightly but transiently, whereas PGE2 showed similar effects but with lower potency. Isoproterenol increased atrial cAMP efflux (with 2.0 nM; 145.71+/-41.89, n=5 versus 7.38+/-19.44%, n=6, control, p<0.05) and mechanical dynamics and decreased ANP secretion. The PGE1-induced increase in cGMP efflux showed a bell-shaped concentration-response curve. PGE1-induced increase of cGMP efflux was not observed in the presence of L-NAME, an inhibitor of nitric oxide (NO) synthase, or ODQ, an inhibitor of NO-sensitive guanylyl cyclase. L-NAME and ODQ showed no significant effect on the PGE1-induced transient decrease of atrial dynamics. These data indicate that PGE1 increases cGMP levels via NO-soluble GC signaling in the cardiac atrium and also show that PGE1-induced increases in cGMP and cAMP levels are not involved in the regulation of atrial secretory and contractile functions.

Ca2+-induced Ca2+ Release from Sarcoplasmic Reticulum Negatively Regulates Myocytic ANP Release in Beating Rabbit Atria

It is not clear whether Ca2+-induced Ca2+ release from the sarcoplasmic reticulum (SR) is involved in the regulation of atrial natriuretic peptide (ANP) release. Previously, we have shown that nifedipine increased ANP release, indicating that Ca2+ entry via voltage-gated L-type Ca2+ channel activation decreases ANP release. The purpose of the present study was two-fold: to define the role of SR Ca2+ release in the regulation of ANP release and whether Ca2+ entry via L-type Ca2+ channel is prerequisite for the SR-related effect on ANP release. Experiments were performed in perfused beating rabbit atria. Ryanodine, an inhibitor of SR Ca2+ release, increased atrial myocytic ANP release (8.69+/-3.05, 19.55+/-1.09, 27.31+/-3.51, and 18.91+/-4.76% for 1, 2, 3, and 6microM ryanodine, respectively; all P< 1) with concomitant decrease in atrial stroke volume and pulse pressure in a dose-dependent manner. In the presence of thapsigargin, an inhibitor of SR Ca2+ pump, ryanodine-induced increase in ANP release was not observed. Thapsigargin attenuated ryanodine-induced decrease in atrial dynamic changes. Blockade of L-type Ca2+ channel with nifedipine abolished ryanodine-induced increase in ANP release (0.69+/-5.58% vs. 27.31+/-3.51%; P< 0.001). In the presence of thapsigargin and ryanodine, nifedipine increased ANP release and decreased atrial dynamics. These data suggest that Ca2+-induced Ca2+ release from the SR is inversely involved in the regulation of atrial myocytic ANP release.

Significance of Thrombocytosis as a Prognostic Factor after Radical Nephrectomy in Patients with Renal Cell Carcinoma / 대한비뇨기과학회지

PURPOSE: It has previously been reported that patients with renal cell carcinomas(RCC) with normal platelet count have an increased survival rate compared with those with thrombocytosis. Whether thrombocytosis was associated with poor prognosis in patients with a renal cell carcinomas was determined. MATERIALS AND METHODS: The record of 161 patients with renal cell carcinomas, who underwent radical nephrectomies, between January 1993 and December 2001, were retrospectively reviewed. The inclusion criteria were at least one perioperative platelet count and a histologic diagnosis of RCC. The survival, pathological tumor stage and grade, histological cell subtype, age, gender, hematuria and history of flank pain were recorded from the charts. Platelet counts were checked, and any patient with at least 1 platelet count greater than 400,000/mm3 was classified with thrombocytosis. RESULTS: Mean patient age and follow-up duration were 56.6, ranging from 30 to 80 years, and 49.8+/-28.8 months, respectively. There were 30 and 131 patients with thrombocytosis and persistently normal platelet counts, respectively. 11 of the 30 patients with thrombocytosis and 7 of the remaining 131 patients died of disease progression. Patients with thrombocytosis had a mean survival of 63.6 months, compared with 115.9 months in those without. The pathological tumor stage, nuclear grade and flank pain were associated with thrombocytosis(p<0.005). However, no statistically significant associations were found between other prognostic factors(cell subtype, gender, age and hematuria) and the presence of thrombocytosis. CONCLUSIONS: Perioperative thrombocytosis was found more frequently in patients with advanced RCC, and those patients showed poorer survival compared with those with a normal platelet count. These results suggest that the perioperative platelet count could be a new prognostic factor in patients with RCC having undergone a radical nephrectomy.

Spontaneous Aortic Dissection in a Patient with Neurofibromatosis

Neurofibromatosis type 1 (NF-1), or von Recklinhausen's disease, is an autosomal dominant disorder that primarily affects the skin, the central and peripheral nervous systems, and the skeleton. Vasculopathy, such as, aneurysm or stenosis of large vessels is a less common manifestation of NF-1, but spontaneous aortic dissection in NF-1 is very rare. We report a case of acute aortic dissection with incidental aneurysm of the right femoral artery in NF-1.

Deletion of Y-Chromosome Specific Genes in Testicular Germ Cell Tumor / 대한비뇨기과학회지

PURPOSE: We hypothesized that the deletion of Y-chromosome specific genes is associated with testicular tumors. To test this hypothesis, we analyzed the expressions of five Y-chromosome specific genes in testicular tumor samples. MATERIALS AND METHODS: Thirty-five human testicular tumor specimens were processed for the micro-dissection of pure epithelial cells. The DNA was extracted, and polymerase chain reactions performed using five different specific primers (ZFY, DYS203, SMCYM45, GDB187507 and RH38676). These primers were designed based on sequences available in the public genome data bank. RESULTS: Deletion was observed in 88.6% of the testicular tumor specimens with at least one Y-chromosome specific gene. The losses of DYS203, ZFY, SMCYM45, RH38676 and GDB187507 were shown in 51.4, 42.9, 40, 28.6 and 20% of cases, respectively. There was a different pattern of loss of the Y-chromosome specific genes according to the histologic types of germ cell tumor. The losses of the DYS203 and GDB187507 genes were seen more frequently in the advanced stages. CONCLUSIONS: There was a significant loss of the Y-chromosome specific genes in testicular germ cell tumors. The loss of the DYS203 gene was observed in about half the cases, and was more frequent in the higher stages of testicular tumor. The loss of Y-chromosome specific genes is associated with testicular tumors, suggesting their role in the pathogenesis of this disease.

Effects of Temperature Change on Heat Shock Protein 70 Expression in Rat Testes / 대한비뇨기과학회지

PURPOSE: It has been reported that exposure of the testes to elevated temperatures results in decreased spermatogenesis. The aim of this study was to investigate the effects of temperature change on the expression of heat shock protein 70 (HSP 70) during spermatogenesis in rat testes. MATERIALS AND METHODS: Twenty-seven Sprague-Dawley rats (200-230g) were randomly divided into control, hot bath and hot bath followed by cold bath, groups. The hot bath consisted of immersion in a 41-43 degrees C water bath for 10 minutes, and the cold bath consisted of immersion in a 18-20 degrees C water bath for 3 minutes. Each bathing was performed twice a day, three times a week, for a total of four weeks. Hematoxylin & Eosin staining was performed to evaluate the degree of spermatogenesis, and Western blot & immunohistochemistry were performed to investigate the expression of HSP 70 in the rat testes. RESULTS: From the histological tests, the spermatogenesis was severely impaired in hot bath group, but preserved in hot bath followed by cold bath group. The expression of HSP 70 in the hot bath group increased 1.5 times compared to that in the control group (p=0.075). However, the hot followed by cold bath group showed similar findings to those in the controls (p=0.934). Immunohistochemical analysis for the expression of HSP 70 demonstrated significant elevations in the hot bath group, and HSP 70 immunoreactivity was found in the Leydig cells and fibroblasts in all three groups, but the levels of expression of the HSP 70 in the control, and the hot followed by cold bath, groups were similar. CONCLUSIONS: The results of this study demonstrate an elevation in the expression of the HSP 70 only occurred in the hot bath group, which suggests the induction of a coping mechanism for exposure to high temperature. As the levels of expression of the HSP 70 in the control, and hot followed by cold bath, groups were comparable, is suggestive of the levels of HSP 70 being consistent with those seen with normal spermatogenesis.

Comparative Study of Angiography and Magnetic Resonance Image in Verifying Obliteration of Arteriovenous Malformation after Gamma Knife Radiosurgery

OBJECTIVE: The purpose of this study is that magnetic resonance(MR) imaging can substitute for conventional angiography in verifying obliteration of arteriovenous malformation(AVM) after Gamma Knife radiosurgery. METHODS: Among the patients of AVM treated with Gamma Knife between 1992 and 1997, all of 40 patients who had been followed up more than 2 years(range 24-101 months) had no AVM on follow-up MR images. Follow-up imaging was performed every 6 months or when clinically warranted. Conventional angiography was performed when the AVM was no longer seen on MR images. RESULTS: Among 40 patients who had shown total obliteration on MR images, thirty one patients(77.5%) showed complete obliteration of the lesion on angiography. However, subtotal obliteration was shown in five patients(12.5%) and partial obliteration in four patients(10.0%). CONCLUSION: The conventional angiography is absolutely needed for verifying obliteration of AVMs and to eliminate the misunderstanding of follow-up MR images.

A Case of Pulmonary Alveolar Proteinosis Associated with Pulmonary Tuberculosis / 결핵

Pulmonary alveolar proteinosis(PAP) is a disorder in which an insoluble, proteinaceous material, rich in phospholipids, is deposited in the alveoli and bronchioles. The deficiency in the clearance and degradation of the i ntra-alveolar phospholipoproteinaceous material in PAP most likely represents a dysfunction of the type II pneumocytes. Although the pathogenesis and causative treatment of PAP is unclear a whole lung bronchopulmonary lavage is a relatively safe and effective treatment. Here we experienced a case of pulmonary alveolar proteinosis in a 62 year old female patient who had pulmonary tuberculosis approximately 20 years ago. She complained of aggravated dyspnea and chronic cough, and presented fine inspiratory crackles at both lung fields. diffuse ground glass opacity with some area of consolidation and smooth interlobular septal thickenings in both upper, right middle lobes, and a portion of right lower lobe. Optical microscopy of the lung tissue obtained by an open lung biopsy many granulomas containing acid-fast smear positive bacilli and diffuse homogeneous PAS-positive fluid in the alveolar space. Immunohistochemical stain showed surfactant A in the alveolar space. Antituberculosis drugs with bronchoalveolar lavage were used to treat the disease. There after she showed improvement in her symptoms and a partial improvement in the chest X-ray and HRCT findings. We present a case of PAT associated with pulmonary tuberculosis.

A Case of Pulmonary Alveolar Proteinosis Associated with Pulmonary Tuberculosis / 결핵

Pulmonary alveolar proteinosis(PAP) is a disorder in which an insoluble, proteinaceous material, rich in phospholipids, is deposited in the alveoli and bronchioles. The deficiency in the clearance and degradation of the i ntra-alveolar phospholipoproteinaceous material in PAP most likely represents a dysfunction of the type II pneumocytes. Although the pathogenesis and causative treatment of PAP is unclear a whole lung bronchopulmonary lavage is a relatively safe and effective treatment. Here we experienced a case of pulmonary alveolar proteinosis in a 62 year old female patient who had pulmonary tuberculosis approximately 20 years ago. She complained of aggravated dyspnea and chronic cough, and presented fine inspiratory crackles at both lung fields. diffuse ground glass opacity with some area of consolidation and smooth interlobular septal thickenings in both upper, right middle lobes, and a portion of right lower lobe. Optical microscopy of the lung tissue obtained by an open lung biopsy many granulomas containing acid-fast smear positive bacilli and diffuse homogeneous PAS-positive fluid in the alveolar space. Immunohistochemical stain showed surfactant A in the alveolar space. Antituberculosis drugs with bronchoalveolar lavage were used to treat the disease. There after she showed improvement in her symptoms and a partial improvement in the chest X-ray and HRCT findings. We present a case of PAT associated with pulmonary tuberculosis.