Emphysematous Gastritis with Concomitant Portal Venous Air and Acute Necrotizing Esophagitis in Type 1 Diabetes with Diabetic Ketoacidosis: A Case Report and Literature Review of a Rare Complication in Diabetes / 임상당뇨병

Emphysematous gastritis is a rare disorder characterized by emphysematous change of the gastric wall due to infection with a gas-forming organism. Acute necrotizing esophagitis is a rare disorder with an unknown pathogenesis. Above two disorders rarely occur together, only three global cases have been reported to date. Such a case has never been reported in Korea, we report a novel case of severe emphysematous gastritis with concomitant portal venous air and acute necrotizing esophagitis in type 1 diabetes presenting with diabetic ketoacidosis. A 24-year-old man known to have type 1 diabetes and pulmonary tuberculosis was brought to the emergency room for epigastric pain with vomiting. His body mass index was 14.7, and the laboratory findings demonstrated leukocytosis and acidosis, as well as elevated serum glucose, ketone, and C-reactive protein levels. Enhanced computed tomography showed portal vein gas and edematous wall thickening without enhancement in the stomach wall, with air density along the stomach and esophageal wall. The patient required surgical intervention of total gastrectomy and cervical esophagostomy followed by esophagocolostomy and esophageal reconstruction. Early radiologic diagnosis and clinical suspicion of this disease and prompt intervention including antibiotics, decompression, and surgery are important for a good prognosis.

Partial Androgen Insensitivity Syndrome Presenting with Gynecomastia

Gynecomastia is a benign enlargement of the male breast caused by the proliferation of glandular breast tissue. Determining the various causes of gynecomastia such as physiological causes, drugs, systemic diseases, and endocrine disorders is important. Androgen insensitivity syndrome (AIS) is a rare endocrine disorder presenting with gynecomastia and is a disorder of male sexual differentiation caused by mutations within the androgen receptor gene. All individuals with AIS have the 46 XY karyotype, although AIS phenotypes can be classified as mild, partial or complete and can differ among both males and females including ambiguous genitalia or infertility in males. We experienced a case of partial AIS presenting with gynecomastia and identified the androgen receptor gene mutation.

A Case of Acute Suppurative Thyroiditis with Thyrotoxicosis in an Elderly Patient

Acute suppurative thyroiditis (AST) is a rare condition, as the thyroid gland is relatively resistant to infection. Thyroid function tests are usually normal in AST. A few cases of AST associated with thyrotoxicosis have been reported in adults. We report a case of AST that was associated with thyrotoxicosis in a 70-year-old woman. We diagnosed AST with thyroid ultrasonography and fine needle aspiration of pus. The patient improved after surgical intervention and had no anatomical abnormality. Fine needle aspiration is the best method for the difficult task of differentiating malignancy and subacute thyroiditis from AST with thyrotoxicosis. Earlier diagnosis and proper treatment for AST might improve the outcome.

Safety and Efficacy of Modern Insulin Analogues

BACKGROUND: A1chieve(R) was a noninterventional study evaluating the clinical safety and efficacy of biphasic insulin aspart 30, insulin detemir, and insulin aspart. METHODS: Korean type 2 diabetes patients who have not been treated with the study insulin or have started it within 4 weeks before enrollment were eligible for the study. The patient selection and the choice of regimen were at the discretion of the physician. The safety and efficacy information was collected from the subjects at baseline, week 12, and week 24. The number of serious adverse drug reactions (SADRs) was the primary endpoint. The changes of clinical diabetic markers at week 12 and/or at week 24 compared to baseline were the secondary endpoints. RESULTS: Out of 4,058 exposed patients, 3,003 completed the study. During the study period, three SADRs were reported in three patients (0.1%). No major hypoglycemic episodes were observed and the rate of minor hypoglycemic episodes marginally decreased during 24 weeks (from 2.77 to 2.42 events per patient-year). The overall quality of life score improved (from 66.7+/-15.9 to 72.5+/-13.5) while the mean body weight was slightly increased (0.6+/-3.0 kg). The 24-week reductions in glycated hemoglobin, fasting plasma glucose and postprandial plasma glucose were 1.6%+/-2.2%, 2.5+/-4.7 mmol/L, and 4.0+/-6.4 mmol/L, respectively. CONCLUSION: The studied regimens showed improvements in glycemic control with low incidence of SADRs, including no incidence of major hypoglycemic episodes in Korean patients with type 2 diabetes.

A Case of Metformin-Induced Acute Kidney Injury without Lactic Acidosis: A Case Report / 대한구급학회지

Metformin is an oral antidiabetic drug in the biguanide class, which is used for type 2 diabetes. The side effects of metformin are mostly limited to digestive tract symptoms, such as diarrhea, flatulence and abdominal discomfort. The most serious potential adverse effect of metformin is lactic acidosis. A 51-year-old man was admitted due to hypoglycemia as a result of an overdose of antidiabetic drugs. He took massive dose of metformin. Conservative treatment failed for metabolic acidosis without lactic acidosis accompanied by acute kidney injury. Hemodialysis was executed to correct the high anion gap metabolic acidosis and acute kidney injury, and the patient recovered fully from metabolic acidosis. This case illustrates that the presence of clinical conditions, such as metformin-induced acute kidney injury and metabolic acidosis, can be developed without lactic acidosis. Prompt recognition of metabolic acidosis and early intervention with hemodialysis can result in a successful clinical outcome.

XRCC1 Polymorphisms and Risk of Papillary Thyroid Carcinoma in a Korean Sample

Polymorphisms of DNA repair genes, X-ray repair cross-complementing group 1 (XRCC1) might contribute to individual susceptibility to different types of cancers. We analyzed the relationship between XRCC1 polymorphisms and the risk of papillary thyroid carcinoma in a Korean sample. A hospital-based case-control study was performed in 111 papillary thyroid carcinoma patients and 100 normal control subjects. XRCC1 Arg194Trp and Arg399Gln single nucleotide polymorphisms (SNPs) were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The XRCC1 Arg194Trp Arg/Trp genotype was significantly associated with a decreased risk of papillary thyroid carcinoma compared to that of Arg/Arg genotype (odds ratio [95% confidence intervals]; 0.550 [0.308-0.983]). There was no significant association between XRCC1 Arg399Gln genotypes and risk of papillary thyroid carcinoma. Based on these results, the XRCC1 Arg194Trp Arg/Trp genotype could be used as a useful molecular biomarker to predict genetic susceptibility for papillary thyroid carcinoma in Koreans.

A Case of Demyelinating Peripheral Neuropathy Associated with Hashimoto's Thyroiditis

Peripheral neuropathy is somewhat common in hypothyroidism. But, demyelinating peripheral neuropathy in Hashimoto's thyroiditis is extremely rare. The pathophysiology of demyelinating peripheral neuropathy associated with Hashimoto's thyroiditis is unclear and complex and various mechanisms including the cell mediated and antibody mediated responses may be operative. We report a 68-year-old woman who presented with paresthesia and gait disturbance. She was diagnosed with hypothyroidism 7 years prior and has been on thyroid hormone. Serum antithyroglobulin antibody was significantly elevated. Nerve conduction studies revealed sensory-motor demyelinating polyneuropathy with prolonged distal latencies and reduced conduction velocities. She was under the suspicion of the lymphoma of thyroid. Surgery was performed which turned up to be Hashimoto's thyroiditis. With the impression of rare demyelinating peripheral neuropathy associated with Hashimoto's thyroiditis after other causes were excluded, she was treated with steroid which ameliorated rapidly her neurological symptoms.

The Relationship between Diabetic Retinopathy and Macrovascular Complication in Patients with Type 2 Diabetes / 대한내과학회지

BACKGROUND/AIMS: Type 2 diabetes with microvascular complications is often accompanied by macrovascular complications. However, the relationship between the two complications is unclear. In this study, we determined the relationship between diabetic retinopathy and morphological changes of the carotid artery. METHODS: We analyzed the presence of plaque and mean carotid intima-media thickness (CIMT) in patients with type 2 diabetes (n = 133) using high-resolution ultrasound. The presence and severity of retinopathy were graded according to fundus photographs. RESULTS: The mean CIMT of the diabetic retinopathy (DR) group (0.111 +/- 0.048 cm) was significantly greater than that of the nondiabetic retinopathy (No DR) group (0.074 +/- 0.039 cm, p = 0.007). An abnormal mean CIMT (> 0.08 cm) was more frequently observed in the DR group (76%) than that in the No DR group (23.1%; odds ratio, 10.609; 95% confidence interval, 3.072-36.639; adjusted by age, body mass index, hypertension, and diabetes duration). Although the mean CIMT in patients with plaque was significantly greater than that of patients without plaque, no significant difference was observed between the DR (36%, 17 patients) and NoDR (18.5%, 20 patients) groups in the presence of plaque. CONCLUSIONS: Diabetic retinopathy was associated with an increased CIMT but not with atherosclerotic plaques. However, the increases in IMT were associated with the presence of plaques, which predispose patients to cardiovascular disease. These results imply that the microvascular complications of diabetes have indirect relationships with the cardiovascular complications of diabetes.

Appropriate Surgical Extent in the Surgery for Graves' Disease / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Thyroidectomy for Graves' disease is a rapid, safe, highly successful treatment modality. Also thyroidectomy allows pathological examination for diagnosis of suspected cancer. However, the extent of thyroidectomy in Graves' disease is still controversial. The aim of this study is to evaluate the appropriate surgical extent by comparing the postoperative outcomes of two groups of patients with Graves' disease who underwent total or less than total thyroidectomy. SUBJECTS AND METHOD: We carried out a retrospective review of 33 patients who underwent thyroidectomy for Graves' disease from January 2001 to December 2010. We investigated the postoperative thyroid hormone function and complication rate according to the extent of thyroidectomy. RESULTS: Among the 33 patients with Graves' disease, 19 patients underwent total thyroidectomy, six patients bilateral subtotal thyroidectomy (BST) and eight patients lobectomy and contralateral subtotal lobectomy (LCSL). Postoperative hypothyroidism, euthyroidism, and hyperthyroidism occurred in 27 (81.7%), 2 (6.1%) and 4 (12.2%) patients, respectively. Postoperative recurrent hyperthyroidism was observed in 2 (33.3%) patients of BST and in 2 (25.0%) of LCSL. One patient was found with permanent hypoparathyroidism, and two with transient vocal cord paralysis. According to histopathologic report, nine patients were accompanied with thyroid cancer. CONCLUSION: Thyroidectomy for Graves' disease has high success rate, low recurrence rate and low complication rate. In terms of surgical extent, total thyroidectomy is a more appropriate procedure because of its low recurrence of hyperthyroidism.

Changes of Central Obesity is the Major Determinant of Influences of Weight Reduction on Bone Mineral Density / 대한골다공증학회지

OBJECTIVES: Obesity and osteoporosis have been increasing for decades but their relationship to bone mineral density (BMD) and fat mass has not been defined. The aim of this study was to investigate how changes in body composition affect BMD after a weight reduction. MATERIALS AND METHODS: We reviewed 48 middle-aged obese women who had participated in our diet program and succeeded in reducing their weight. Body composition was measured by the dual-energy X-ray absorptiometry method, and metabolic syndrome was defined as described in the ATP-III guidelines. All differences between baseline and 12 weeks later were expressed as [{12th week data-baseline data}/baseline datax100]. RESULTS: The mean age of the participants was 38.29+/-10.89 years, and the mean follow-up time was 85 days. The mean body mass index was 31.50+/-5.19 kg/m2. Basal BMD decreased with age and increased with weight and appendicular lean mass. In a regression analysis, appendicular lean mass was positively correlated with leg BMD (R2=0.235, B=0.015, P<0.001) and age (B=-0.002, P=0.046), and appendicular lean mass (B=0.019, P=0.049) was the main determinant of total BMD (R2=0.272). After weight reduction, the total body BMD change ratio (R2=0.281) was negatively related to the change of fat mass, trunk fat mass (B=-0.042, P=0.087) and waist circumference (B=-0.108, P=0.014). CONCLUSIONS: Our findings suggest that BMD is determined by muscle mass, and that changes in central obesity may also affect BMD.

A Case of Pseudohypoparathyroidism with Graves' Disease

Pseudohypoparathyroidism is a rare disease that is characterized by target cell resistance to the effects of parathyroid hormone and this disease is classified into various types depending on the phenotypic and biochemical findings. The patients with pseudohypoparathyroidism present with the clinical and biochemical features of hypoparathyroidism, but they have an increased serum level of parathyroid hormone. We experienced a case of pseudohypoparathyroidism in a 24 years old woman who had Graves' disease at that time. She had hypocalcemia, hyperphosphatemia, an elevated serum parathyroid hormone level and a normal urinary basal cyclic AMP(adenosine monophosphate) level. She also had a normal phenotypic appearance. Therefore, she was classified as suffering with pseudohypoparathyroidism type II. The clinical and laboratory abnormalities were improved by calcium supplementation in addition to vitamin D. To the best of our knowledge, this is the first case of pseudohypoparathyroidism combined with Graves' disease in Korea.

Differences in Clinical Characteristics between Patients with Non-Erosive Reflux Disease and Erosive Esophagitis in Korea

Gastroesophageal reflux disease (GERD) is caused by abnormal reflux of gastric contents into the esophagus. GERD can be divided into two groups, erosive esophagitis and non-erosive reflux disease (NERD). The aim of this study was to compare the clinical characteristics of patients with erosive esophagitis to those with NERD. All participating patients underwent an upper endoscopy during a voluntary health check-up. The NERD group consisted of 500 subjects with classic GERD symptoms in the absence of esophageal mucosal injury during upper endoscopy. The erosive esophagitis group consisted of 292 subjects with superficial esophageal erosions with or without typical symptoms of GERD. Among GERD patients, male gender, high body mass index, high obesity degree, high waist-to-hip ratio, high triglycerides, alcohol intake, smoking and the presence of a hiatal hernia were positively related to the development of erosive esophagitis compared to NERD. In multivariated analysis, male gender, waist-to-hip ratio and the presence of a hiatal hernia were the significant risk factors of erosive esophagitis. We suggest that erosive esophagitis was more closely related to abdominal obesity.

Young Aged Colorectal Cancer Patients: Do They Have a Bad Prognosis? / 대한소화기내시경학회지

BACKGROUND/AIMS: Many previously published articles have reported poor outcomes for young patients with colorectal cancer as compared to that of older patients with colorectal cancer. However, these studies have tended to be small and have various biases. This study was retrospectively designed to determine the clinical course and survival rate of young patient with colorectal cancer. METHODS: All the patients who underwent surgery for colorectal cancer at Hanyang University Hospital between 1995 and 2001 were identified. These patients were assigned to two age groups: the 45 years old and below 45 years old group (123 patients) and the group over the age of 45 (421 patients). RESULTS: The size of the tumor mass was significantly larger in the young group. There were no significant differences between the two groups for the stage at the time of diagnosis, the differentiation, the degree of lymph node involvement, the cancer location and the gross finding. The median cancer specific survival time was worse for the old group as compared with that of the young group. Age, differentiation, lymph node involvement and the Duke stage were the significant prognostic factors on univariate analysis. Age and the Duke stage were the independent prognostic factors that were significantly correlated with survival on the multivariate analysis using the Cox proportional hazard model. CONCLUSIONS: Contrary to prior reports, younger patients with colorectal cancer appear to have a better survival rate than that of older patients with colorectal cancer.

A case of diabetes mellitus associated with Klinefelter's syndrome / 대한내과학회지

An increased frequency of diabetes or impaired glucose tolerance in Klinefelter's syndrome has been previously reported. Insulin resistance is considered to be the cause of this phenomenon in Klinefelter's syndrome, which is associated with low serum SHBG and sex hormone deficiency. Sex hormone deficiencies also result in dyslipidemia and metabolic syndrome. The interrelationship between diabetes, metabolic syndrome, and androgen deficiency is complex. Here we report a case of an 18-year-old man first diagnosed with diabetes mellitus 3 years ago. Upon physical examination the patient showed characteristic phenotypes compatible with primary hypogonadism. Subsequently, tests aimed at determining the cause of hypogonadism, including a chromosomal analysis, suggested Klinefelter's syndrome. The patient's HOMA-IR score was compatible with insulin resistance. Therefore, when diabetes mellitus develops at a young age with characteristic phenotypes, a careful history and physical examination may be needed to determine whether the patient might have primary hypogonadism caused by Klinefelter's syndrome.

Effectiveness of Suppressive Therapy with Levothyroxine in Benign Thyroid Nodules / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The effectiveness of suppressive therapy with Levothyroxine in benign thyroid nodule is controversial. The favorable response varies between 9-68%. The aim of this study was to evaluate the effect of Levothyroxine suppressive therapy on benign thyroid nodules in comparison with untreated patients. SUBJECTS AND METHOD: A total 98 patients diagnosed with benign thyroid nodules by high resolution ultrasonography and fine needle aspiration cytology from January 2001 to June 2007 was evaluated retrospectively. The case group included 55 patients who received Levothyroxine suppressive therapy for longer than 6 months with documentation of thyroid stimulating hormone (TSH) suppression level. The control group included 43 patients who were followed up without any treatment. We measured TSH, free T4, and thyroid nodule volume by ultrasound every 6 months. RESULTS: In 13 patients (23.6%) of the case group, nodule volume decreased more than 50% after the Levothyroxine suppressive therapy. In 10 (23.2%) of the control group, nodule volume decreased more than 50 % after the follow-up of 6 months. There was no significant difference between the two groups. The change of nodule volume was not related to the TSH suppression level, the number of nodule or the type of nodule. CONCLUSION: We concluded that Levothyroxine suppressive therapy was not effective in volume reduction of benign thyroid nodules.

International Aeromedical Evacuation / 항공우주의학회지

No abstract available.

Clinical Manifestation and Differential Diagnosis of Thyroid Follicular Neoplasm / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: A preoperative differential diagnosis between follicular adenoma and follicular carcinoma of thyroid is very difficult, and the standard basis for distinction is the presence of capsular and/or vascular invasion. In this study, we analyzed the findings of preoperative tests and clinical features to facilitate the differential diagnosis and treatment of the follicular neoplasm. SUBJECTS AND METHOD: A retrospective review of medical records was carried out on 104 patients who had undergone thyroid surgery and had been diagnosed with thyroid follicular adenoma or carcinoma from 1995 through 2004. The final pathologic diagnosis was compared to the various clinical data including the result of fine needle aspiration cytology (FNAC) and ultrasonographic findings. RESULTS: Of total 104 cases, 82 were follicular adenoma and 22 were follicular carcinoma. The incidence of carcinoma was significantly higher in male than in female. The result of FNAC were divided into 6 cytodiagnostic groups, namely, inadequate, colloid nodule without atypia, colloid nodule with atypia, follicular neoplasm without atypia, follicular neoplasm with atypia, or highly suspicious malignancy. The incidence of carcinoma was significantly higher in the groups with atypia such as colloid nodule with atypia, follicular neoplasm with atypia, and highly suspicious malignancy than in the groups without atypia. The incidence of follicular carcinoma was significantly higher in ill-defined marginal cases. Calcification on ultrasonography also indicated the possibility of malignancy. CONCLUSION: The incidence of follicular carcinoma was significantly high in male patients, atypia in FNAC, and ill-defined margin and calcification on ultrasonography.

Association between Insulin, Insulin Resistance, and Gallstone Disease in Korean General Population / 대한소화기학회지

BACKGROUND/AIMS: Diabetes is one of the risk factors of gallstone diseases. Many studies found a positive association between insulin and gallstones in individuals with diabetes. However, this association is unclear in non-diabetes. So we conducted a case-control study for the evaluation of the association between gallstone diseases and fasting serum insulin level, insulin resistance in non-diabetic Korean general population. METHODS: This study was a prospective case-control study on 118 Korean subjects which included clinical examination, abdominal ultrasound, and blood chemistries. Serum fasting insulin level were determined by radioimmunoassay and concentrations of cholesterol, glucose, and triglycerides by standard enzymatic colorimetric methods. Insulin resistance was determined by the homeostasis model assessment (HOMA-IR). Body mass index (BMI), percentage of body fat, and waist hip ratio were also measured. RESULTS: We studied 118 subjects with no clinical evidence of diabetes mellitus and serum glucose<126 mg/dL. Compared with controls (n=89), cases (n=29) had higher levels of serum insulin, glucose, triglyceride levels, and BMI. In t-test and chi-square test for variables, the association between gallstone disease and serum insulin, HOMA-IR index, and BMI were statistically significant (p<0.05). In multiple logistic regression analysis, gallstone disease risk increased with the level of serum insulin (p=0.024, odds ratio=1.376) and HOMA-IR index (p=0.013, odds ratio=2.006). CONCLUSIONS: We suggest that hyperinsulinemia and insulin resistance could be associated with gallstone formation in individuals without clinical diagnosis of diabetes mellitus and with normal serum glucose level.

The relation of the testosterone level with metabolic syndrome and coronary artery disease in Korean middle-aged and elderly men / 대한내과학회지

BACKGROUND: Abdominal obesity is an essential component of metabolic syndrome and it causes insulin resistance. In contrast to women, the serum testosterone level has an inverse relationship with the visceral fat mass in men. Therefore, we investigated the relation of the serum testosterone concentration with metabolic syndrome and coronary artery disease in Korean middle-aged and elderly men. METHODS: 211 male subjects who were admitted to the cardiology department due to chest pain at Hanyang University Hospital from January to December, 2005 (mean age: 59.1+/-10.7 yrs) were enrolled in this study. All the blood samplings for laboratory tests, including the testosterone and estradiol tests, were done between 6 AM to 8 AM. Coronary artery disease was defined when there was more than 50% narrowing of the vascular lumen on the coronary angiography. Metabolic syndrome was defined according to the NCEP-ATP III guidelines. RESULTS: Among the other cardiovascular risk factors, metabolic syndrome was the most important contributor to coronary artery disease (adjusted OR=4.32, 95% CI: 1.96-9.52). Even after adjustment for age, BMI, smoking, alcohol consumption and hypertension, lower testosterone was associated with a higher fasting glucose level (p<0.01) and higher insulin resistance (p<0.05). Each SD (1.88 ng/mL) increase in the total testosterone was associated with a 51% reduced risk of having metabolic syndrome (OR=0.49; 95% CI, 0.36-0.68). Although men with coronary artery disease tended to have lower testosterone levels, there was no statistical significance. CONCLUSIONS: Lower testosterone levels might have a causative role in the development of metabolic syndrome and possibly coronary artery disease through the induction of insulin resistance.

Radiologic Diagnosis and Surgical Treatment of Primary Hyperparathyroidism / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: With the advance in serum chemical analyses, the diagnosis of primary hyperparathyroidism has become more common, and patients without signs or symptoms attributable to the disease have increased. We performed this study to obtain further understanding and more supporting ideas for the diagnosis and treatment of primary hyperparathyroidism. SUBJECTS AND METHOD: A retrospective study of 19 patients with primary hyperparathyroidism who were treated by surgery from march 1999 to June 2005 was performed. RESULTS: Preoperative localization was performed with computerized tomography, ultrasonography and 99m Tc-sestamibi scan. A 99m Tc-sestamibi scan has an accuracy of 84% and ultrasonography has an accuracy of 67% for parathyroid tumors. Combination of ultrasonography and 99m Tc-sestamibi scan had the accuracy of 93%. All patients were treated by surgery. After surgery, serum calcium and intact parathyroid hormone levels returned rapidly to normal. Parathyroid carcinomas were firm in consistency and adhered to the surrounding tissue and thyroid gland. CONCLUSION: Ultrasonogram and 99m Tc-sestamibi scan was effective for preoperative localization of tumor. If parathyroid carcinoma is suspected, the mass with potential local invasion or regional metastasis should be removed with en bloc resection.