Adult Patients with Congenital Muscular Torticollis Treated with Bipolar Release: Report of 31 Cases

OBJECTIVE: We assessed the surgical results of bipolar release in 31 adult patients with uncorrected congenital muscular torticollis (CMT) and more than 12 months of follow-up. METHODS: Thirty-one patients underwent a bipolar release of the sternocleidomastoid muscle (SCM) and were retrospectively analyzed. The mean follow-up period was 14.9 months (range, 12–30). The mean age at time of surgery was 30.3 years (range, 20–54). Patients were evaluated with a modified Lee’s scoring system, cervicomandibular angle (CMA) measurement, and a global satisfaction rating scale using patient self-reporting. RESULTS: The modified Lee’s scoring system indicated excellent results in 4 (12.9%) patients, good in 18 (58.1%), and fair in 9 (29.0%) at the last follow-up after surgery. The improvements in neck movement and head tilt were statistically significant (p<0.05). The preoperative mean CMA was 15.4° (range, 5.4–29.0), which was reduced to a mean of CMA of 6.3° (range, 0–25) after surgery (p<0.05). The global satisfaction rating scale was 93.7% (range, 90–100). A transient sensory deficit on the ipsilateral lower ear lobe was noted in three cases. No significant permanent complications occurred. CONCLUSION: Bipolar release of the SCM is a safe and reliable technique for the treatment of CMT in adults.

Pneumocephalus and Pneumorrhachis due to a Subarachnoid Pleural Fistula That Developed after Thoracic Spine Surgery

Development of a communication between the spinal subarachnoid space and the pleural space after thoracic spine surgery is uncommon. Subarachnoid pleural fistula (SAPF), a distressing condition, involves cerebrospinal fluid leakage. Here we report an unusual case of SAPF, occurring after thoracic spine surgery, that was further complicated by pneumocephalus and pneumorrhachis postthoracentesis, which was performed for unilateral pleural effusion.

A Case of Ciliated Foregut Cyst of the Gallbladder / 대한소화기학회지

Congenital cysts of the gallbladder are extremely rare, hence only a few ciliated foregut cysts of gallbladder have been reported. We report a case of a 20-year-old woman presenting with mild right upper quadrant abdominal discomfort, with normal levels of serum bilirubin and liver function tests. Abdominal ultrasonography revealed a well-defined cystic mass measured about 2 cm attached to the neck of gallbladder, with internal echogenic debris suggesting a complicated cyst, such as a hemorrhagic cyst. Abdominal computed tomography and magnetic resonance cholangiopancreatography revealed similar findings. Laparoscopic cholecystectomy showed a slightly distended gallbladder. The size of cyst on the neck was 1.6x1.2 cm, and it contained mucosa lined by ciliated pseudostratified columnar epithelium and underlying smooth muscle layers. Histopathology identified a ciliated foregut cyst of gallbladder.

Eosinophilic Gastritis Presenting as Tissue Necrosis

Eosinophilic gastroenteritis is very rare disorder that is characterized by eosinophilic infiltration of the gastrointestinal tract in the absence of any definite causes of eosinophilia. It is associated with various clinical gastrointestinal manifestations, and depends on the involved layer and site. We report a case of eosinophilic gastritis presenting with severe necrosis. The symptoms disappeared immediately after beginning steroid treatment, and the eosinophil count decreased to the reference range. The patient showed eosinophilic gastritis characterized by necrotic change such as necrotizing gastritis. It is a unique presentation of eosinophilic gastritis. To the best of our knowledge, no case of eosinophilic gastritis characterized by necrotic change such as necrotizing gastritis has been previously reported in Korea.

A Case of IgG4-Related Pancreas and Kidney Disease Mimicking a Renal Pelvic Malignancy / 대한내과학회지

IgG4-related sclerosing disease is a disease entity that has recently attracted attention, manifesting as a multiorgan disease characterized by high serum IgG4 levels, extensive IgG4-positive plasma cells and lymphocyte infiltration of the affected organs, with the pancreas (autoimmune pancreatitis) and kidney as representative targets. In cases of renal involvement, parenchymal lesions are predominant, such as renal cortical lesions or diffuse renal enlargement. However, mass-like lesions involving the renal pelvis are very rare, and mass forming or pelvic involvement types should be distinguished from lymphomas, metastatic cancers and other genitourinary malignancies to avoid unnecessary surgery. Herein, we report a case of IgG4-related sclerosing disease involving the kidney as an unusual involvement pattern presenting as a mass-like lesion with pelvic and perirenal involvement.

Clinical and Radiologic Analysis of Posterior Apophyseal Ring Separation Associated with Lumbar Disc Herniation

OBJECTIVE: We analyzed the clinical and radiologic features of posterior apophyseal ring separation (PARS) with lumbar disc herniation and suggest the proper management options according to the PARS characteristics. METHODS: We reviewed case series of patients with PARS who underwent surgery of lumbar disc herniation. Preoperative symptoms, neurologic status, Body Mass Index, preoperative and postoperative Visual Analogue Scale (VAS) and Korean-Oswestry Disability Index (K-ODI) scores, operation types were obtained. PARS size, locations, the degree of resection were assessed. RESULTS: PARS was diagnosed in 109 (7.5%) patients among 1448 patients given surgical treatment for single level lumbar disc herniation. There were 55 (50.5%) small PARS and 54 (49.5%) large PARS. Among the large PARS group, 15 (27.8%) had lower endplate PARS of upper vertebra at the level of disc herniation. Thirty-nine (72.2%) were upper endplate PARS of lower vertebra. Among the group with upper endplate PARS of lower vertebra, unresected PARS was diagnosed in 12 (30.8%) cases and resected PARS was diagnosed in 27 (69.2%) cases. VAS and K-ODI scores changes were 3.6+/-2.9 and 5.4+/-6.4 in the unresected PARS group, 5.8+/-2.1 and 11.3+/-7.1 in the resected PARS group. The group with upper endplate PARS of lower vertebra showed significant difference of VAS (p=0.01) and K-ODI (p=0.013) score changes between unresected and resected PARS groups. CONCLUSION: The large PARS of upper endplate in lower vertebra should be removed during the surgery of lumbar disc herniation. High level or bilateral side of PARS should be widely decompressed and arthrodesis procedures are necessary if there is a possibility of secondary instability.

Recurrence Rate after Herniotomy only versus Discectomy in Lumbar Disc Herniation

OBJECTIVE: Lumbar disc herniation (LDH) recurrence necessitating reoperation can pose problems following spinal surgery, with an overall reported incidence of approximately (3-13%). The purpose of this study is to identify the rate of recurrent disc herniation, to discuss the radiologic indications for herniotomy and to analyze clinical outcomes compared with conventional discectomy. METHODS: This study is a retrospective case control study. The authors retrospectively reviewed 114 patients who underwent herniotomy & conventional discectomy by a single surgeon for single-level LDH between June 2009 and May 2012. Herniotomy group was 57 patients and conventional discectomy group was 57 patients that were selected from 631 patients using stratified randomization. Evaluation for LDH recurrence included detailed medical chart and radiologic review and telephone interview. Postoperative VAS and the Korean version of ODI were examined one week after surgery. Clinical outcome was investigated according to Odom's criteria from three months to three years. RESULTS: Of the 114 patients for whom the authors were able to definitively assess symptomatic recurrence status, four patients (7%) experienced LDH recurrence following single-level herniotomy and three patients (5.2%) conventional discectomy. There were no differences in the VAS and Korean version of ODI between herniotomy group and conventional discectomy group. The herniotomy group had better results than the conventional discectomy group in clinical outcome from three months to three years, but the difference was not significant. CONCLUSION: There were no significant differences in clinical outcome between herniotomy and conventional discectomy. Recurrence rates following herniotomy for LDH compare favorably with those in patients who have undergone conventional discectomy, lending further support for its effectiveness in treating herniotomy.

Effect of Sunlight Exposure on Serum 25-Hydroxyvitamin D Concentration in Women with Vitamin D Deficiency: Using Ambulatory Lux Meter and Sunlight Exposure Questionnaire / 가정의학회지

BACKGROUND: Vitamin D is an important factor in human health. Yet, vitamin D deficiency is very common. We aimed to confirm serum 25-hydroxyvitamin D (25OHD) concentration change after sunlight exposure and to elucidate the relationship between the amount of sunlight exposure and serum 25OHD level change by ambulatory lux meter and sunlight exposure questionnaire. METHODS: Twenty healthy young women were enrolled. They were educated to obtain 20 minutes of sunlight exposure during weekdays from October to November, 2010, during which they were to wear an ambulatory lux meter on an arm. All subjects completed a one-week recall sunlight exposure questionnaire at the end of the study. Before and after sunlight exposure, serum 25OHD level was measured. RESULTS: Mean pre-exposure serum 25OHD concentration was 11.01 ng/mL. The mean change of pre- and post-exposure 25OHD level was -0.62 ng/mL, but it was not statistically significant. The mean personal sunlight exposure recorded by ambulatory lux meter, 292.6 lux/s, showed no significant relationship with average change of 25OHD and average weekly sunlight exposure score, 11.9, calculated by the sunlight exposure questionnaire. However, the mean change of serum 25OHD level and weekly sunlight exposure score showed significant negative correlation (r = -0.469, P = 0.037). CONCLUSION: Change of serum 25OHD concentration after four weeks of sunlight exposure was not statistically significant in women with vitamin D deficiency. However, serum 25OHD concentration change was significantly negatively correlated with the sunlight exposure score by the questionnaire.

Warfarin-Induced Eosinophilic Pleural Effusion

A 29-year-old man suffering from dyspnea and eosinophilic pleural effusion after being on warfarin for pulmonary thromboembolism for a period of one month, was readmitted to our hospital. Etiology of pleural effusion other than warfarin was excluded. To the best of our knowledge, this is the first case of warfarin-induced pleural effusion reported in Korea.

Warfarin-Induced Eosinophilic Pleural Effusion

A 29-year-old man suffering from dyspnea and eosinophilic pleural effusion after being on warfarin for pulmonary thromboembolism for a period of one month, was readmitted to our hospital. Etiology of pleural effusion other than warfarin was excluded. To the best of our knowledge, this is the first case of warfarin-induced pleural effusion reported in Korea.

Determination of Diastolic Dysfunction Cut-Off Value by Tissue Doppler Imaging in Adults 70 Years of Age or Older: A Comparative Analysis of Pulsed-Wave and Color-Coded Tissue Doppler Imaging

BACKGROUND AND OBJECTIVES: The cut-off value of diastolic dysfunction by tissue Doppler imaging (TDI) is affected by aging and modalities used (pulsed-wave vs. color-coded). The purpose of this study was to investigate the diastolic function of healthy elderly people and to determine the appropriate cut-off value of diastolic dysfunction in elderly individuals. SUBJECTS AND METHODS: Healthy volunteers (n=76) and patients with hypertension (n=51) aged > or =70 years underwent 2-dimensional and Doppler echocardiography. Mitral annulus velocities of TDI were measured at septal and lateral sites using the pulsed-wave and color-coded modalities. The appropriate cut-off value of diastolic dysfunction for healthy elderly individuals was defined as the lower limit of the 95% confidence interval for early diastolic mitral annulus velocity (Ea). RESULTS: The mean septal and lateral Ea were 6.5+/-1.5 and 8.3+/-1.7 cm/s, respectively, by pulsed-wave TDI, and 6.1+/-1.4 and 7.9+/-1.7 cm/s, respectively, by color-coded TDI. The cut-off values for diastolic dysfunction were as follows: septal and lateral Ea were 6.1 and 7.9 cm/s by pulsed-wave TDI, and 5.7 and 7.5 cm/s by color-coded TDI, respectively. When the group was stratified by gender, Ea was significantly lower in women than men. CONCLUSION: When interpreting diastolic function as measured by TDI in elderly subjects, different cut-off values should be considered based on the TDI modality, annulus site, and gender.

A Case of Right Ventricular Dysfunction Caused by Pectus Excavatum

Pectus excavatum compresses the underlying right side of the heart, which might lead to right ventricular dysfunction as illustrated in this case report.

A Case of Cardiac Amyloidosis With Diuretic-Refractory Pleural Effusions Treated With Bevacizumab

Cardiac amyloidosis describes a clinical disorder caused by infiltration of abnormal insoluble fibrils in the heart, characterized by progressive heart failure and a grave prognosis. Pleural effusion in cardiac amyloidosis may represent a sign of heart failure, but it can also result from pleural infiltration of amyloid, manifested by recurrent large fluid accumulations. Recently, the role of vascular endothelial growth factor (VEGF) has been implicated in the pathogenesis of refractory pleural effusion. We report a case of a 53 year-old female patient with cardiac amyloidosis who presented with recurrent accumulation of large pleural effusions. She was initially treated with high dose loop diuretics, but the pleural effusion persisted, with the daily amount of drainage averaging 1 L/day. Accumulation of pleural fluid did not subside after 3 cycles of melphalan/prednisolone therapy. After the introduction of bevacizumab, an anti-VEGF antibody, the amount of pleural effusion decreased significantly. Efficacy of anti-VEGF therapy for refractory pleural effusions needs to be defined through further studies.

A case of successful posaconazole salvage therapy for rhinocerebral mucormycosis after failure of amphotericin B / 대한내과학회지

A 58-year-old man with uncontrolled type 2 diabetes mellitus developed rhinocerebral mucormycosis. The infection progressed to intracranial extension despite more than 5 weeks of treatment with amphotericin B. The patient then received oral posaconazole, 800 mg/d, in divided doses for 6 months. Salvage treatment with the new azole antifungal posaconazole resulted in dramatic clinical improvement as early as 1 week after the initiation of therapy. Oral posaconazole continued through 24 weeks of treatment, with marked clinical, mycological, and radiological improvements and no adverse events. Here we review the medical literature on rhinocerebral mucormycosis, which is a rapidly progressive and often fatal infection. The treatment of choice is amphotericin B, which failed in our patient. Our case report suggests that posaconazole appears to be a well tolerated and effective salvage treatment option for rhinocerebral mucormycosis, including disseminated disease.

Nationwide Survey of the Use of Absorbable Mesh in Breast Surgery in Korea / 한국유방암학회지

The aim of this study is to investigate the use of absorbable mesh in breast surgery in Korea. We conducted a survey from members of Korea Breast Cancer Society by phone, E-mail, and notice on the website from 6th to 20th April 2009. A total of 54 breast surgeons had responded to the survey. Of these, 40 surgeons (74.1%) had used absorbable mesh during breast surgery, with Vicryl mesh(R) being the choice of every surgeon and Interceed(R) having been used by 36 (90%) of the surgeons. In responding to the indications for mesh use, 26 surgeons (65%) indicated that mesh use was effective when a deformity was expected regardless of T stage. Contraindications for mesh use principally included existing patients' comorbidity such as a wound healing problem, diabetes mellitus and immunocompromised condition. Thirty one surgeons (77.5%) had experienced an infection in the mesh insertion site. However, on a case basis, only 39 of 843 cases (4.6%) had resulted in an infection. In the follow up after mesh use, 33 of the 37 responding surgeons (89.2%) used breast ultrasonography. Nineteen of the 38 respondents (50%) replied that the mesh was absorbed in 6 months and it did not confuse diagnostic imaging. The cited merits of mesh included maintenance of breast shape following surgery (n=38/49, 77.6%) and ease of surgical use (n=35/49, 71.4%). However, the high price of mesh was cited as a disadvantage by 33 of the 48 respondents (68.8%). In summary, survey results mentioned above show that surgical mesh use in breast surgery is increasing by times and the procedures greatly varies by surgeons. Thereby, we suggest that a guideline for mesh use should be made in the near future.

A Data Warehouse Based Retrospective Post-marketing Surveillance Method: A Feasibility Test with Fluoxetine / 대한의료정보학회지

OBJECTIVE: Post-marketing surveillance (PMS) is an adverse events monitoring practice of pharmaceutical drugs on the market. Traditional PMS methods are labor intensive and expensive to perform, because they are largely based on manual work including phone-calling, mailing, or direct visits to relevant subjects. The objective of this study was to develop and validate a PMS methodology based on the clinical data warehouse (CDW). METHODS: We constructed a archival DB using a hospital information system and a refined CDW from three different hospitals. Fluoxetine hydrochloride, an antidepressant, was selected as the target monitoring drug. Corrected QT prolongation on ECG was selected as the target adverse outcome. The Wilcoxon signed rank test was performed to analyze the difference in the corrected QT interval before and after the target drug administration. RESULTS: A refined CDW was successfully constructed from three different hospitals. Table specifications and an entity-relation diagram were developed and are presented. A total of 13 subjects were selected for monitoring. There was no statistically significant difference in the QT interval before and after target drug administration (p=0.727). CONCLUSION: The PMS method based on CDW was successfully performed on the target drug. This IT-based alternative surveillance method might be beneficial in the PMS environment of the future.

The Clinical Significance of Serum-Hydroxyproline in Acute Coronary Syndrome

BACKGROUND AND OBJECTIVES: The serum hydroxyproline level (SHL) has been regarded as evidence of collagen breakdown or extra-cellular matrix reorganization. The role of SHL as a diagnostic parameter in acute coronary syndrome, and the SHL changes depending on the left ventricular remodeling after acute myocardial infarction, was evaluated. SUBJECTS AND METHODS: Venous blood samples were obtained from 122 patients with AMI at the time of admission, and on days 7, 21 and 90, and once from 15 patients with stable angina, 15 with unstable angina and 12 healthy subjects. The SHL was measured using the amino acid analysis system (HPLC). The regional wall motion index (RWMI), LVEF and LV dimensions were determined in the early (0.05). However, there was a significant elevation in the SHL 14 day after AMI in the patients of the non-reperfusion group (4.36+/-1.46, 7.63+/-2.69 microgram/L, p=0.032). After 2 week, there was no significant difference in the SHL. There was a significant relationship between the late left ventricular ejection fraction and the SHL (r=-0.414, p=0.037), but no significant relationship between the other factors and the SHL (p>0.05). CONCLUSION: The serum hydroxyproline levels were significantly increased in patients with acute coronary syndrome, which reflect the early change in left ventricular remodeling in acute myocardial infarction.

A Case of Torsades de Pointes Induced by Complete Atrioventricular Block and Hypokalemia

Torsades de pointes (TdP) is a rare complication of a complete atrioventricular block with QT prolongation. Additional risk factors, such as hypokalemia, may increase the risk of TdP during atrioventricular (AV) block. We experienced a case of TdP, caused by a complete heart block and hypokalemia, which was successfully treated by implanting a permanent pacemaker and correction of the electrolyte imbalance.

The Clinical Experiences of B-type Natriuretic Peptide Blood Concentrations for Diagnosis in Congestive Heart Failure : The Single Hospital Experience Based on the Large Clinical Database

BACKGROUND: B-type natriuretic peptide (BNP) has been used as a standard diagnostic tool to define heart failure. The aim of this study was to evaluate the clinical experiences of BNP levels based on a large clinical database. METHODS: From Oct. 2002 to July 2003, 3830 patients were analyzed. The patients were divided into the 3 groups: control, systolic (SHF) and diastolic heart failure (DHF) patient groups, via an echocardiography and the Framingham clinical criteria. The BNP was measured with a Triage(R) kit. Both the clinical and echocardiography profiles were analyzed. RESULTS: The mean age of the patients was 62.8 years, with 49.0% males. The control group included 661, the SHF group 475 and the DHF group 287 patients. In the control group, the mean BNP level was 31.5+/-24.0 pg/mL, with the BNP level in the women higher than in the men (28.0+/-23.8 vs. 34.9+/-23.7 pg/mL, p=0.041). The SHF patients group had significantly higher BNP levels than the other groups (p=0.008). In the patients with SHF, the BNP levels, according to the NYHA grade, showed significant differences (I: 169.3+/-138.7, II: 391.1+/-231.4, III: 780.1+/-698.3 and IV: 1078.9+/-946.2 pg/mL, p=0.009). In the patients with diastolic dysfunction (n=787) according to the diastolic dysfunction, the BNP levels, showed significant differences (relaxation abnormality: 108.2+/-78.2, pseudo-normal: 419.0+/-109.8 and restrictive physiology: 510.4+/-231.6 pg/mL, p=0.009). The accuracy in the BNP level when separating the SHF from the control patients was 0.98 (AUC=0.98), with 92.5% sensifivity and 86.1% specificity at a cut-off of 108 pg/mL. CONCLUSIONS: The levels of blood BNP were present in various ranges according to the clinical situation and extent of heart failure.

The Experience of Transradial Coronary Intervention for Chronic Total Occlusion

BACKGROUND AND OBJECTIVE: We try to evaluate the feasibility of transradial approach in patients with a chronic total occlusion. SUBJECTS AND METHODS: Between Mar., 2000 and Oct., 2002, 52 consecutive patients, with 54 lesions, underwent transradial coronary intervention for a chronic total occlusion, which was defined as duration of an occlusion of more than 1 month. The patients were divided into the success or failure group, with the clinical, angiographic and procedural factors compared between the two groups. RESULTS: The overall success rate of the transradial approach was 57.7% (31/54). The most common cause of failure of the transradial coronary intervention was an inability to pass the lesions using a guidewire (17 of 23 failures, 74%). Five cases were crossed over to the femoral artery due to an approach failure of the guiding catheter into the coronary ostium; severe subclavian tortuosity and stenosis in 2 cases, radial artery looping in 1 and poor guiding support in the other 2. A procedural success was more common in lesions with no side branch, no bridging collateral, short duration of occlusion and lesions less than 15mm in length. Non-Q wave myocardial infarction occurred in 1 case. There were no major entry site complications. CONCLUSION: The radial artery might be a feasible vascular route in the percutaneous coronary intervention of chronic total occlusions with comparable procedural success rates and no major access site complications.