Reconstruction of the Three-Dimensional Mandibulofacial Defects Using a Single Cutaneous Perforator-Based Fibula Osteocutaneous Flap

The reconstruction of the mandibulofacial defects is a difficult task when there are full-thickness cheek defects involving mandible, inner mucosa and outer skin. There are several reconstructive options for the coverage of large defects, but most of the methods are complicated, and time- and effort-consuming. We hereby present a case of fibula osteocutaneous flap based on a single peroneal artery perforator in the reconstruction of a three-dimensional mandibulofacial defects.

Double-Fold Operation with a Partial Incision and Continuous Buried Suture

BACKGROUND: The double fold operation is one of the most common aesthetic surgeries in Korea. There are many methods to make double fold using non-incision, incision and partial incision. Patients seeking double folds prefer natural appearance, less downtime, minimal scarring technique. The most favorable method is the minimal invasive but long-lasting fold formation technique. METHODS: From October 2003 to September 2016, this procedure was applied in 7,963 patients who worried about surgical scar or preferred non-incision method with puffy eyelids. Five stab incisions including two small incisions were taken in the upper eyelid. Through the small incision lines, the pretarsal muscle and the orbital fat were removed to facilitate tissue adhesion. The double fold line was made with the continuous buried suture. The suture was tied in the fifth stab incision site and the knot was placed deeply to prevent granuloma formation. RESULTS: This method was performed in all patients. The complications were asymmetry (52 cases), fold loosening (43 cases), granuloma (12 cases), conjunctival hemorrhage (5 cases), and scar (4 cases). Especially 74% of fold loosening cases were developed in mild ptotic patients. CONCLUSIONS: This method achieves good cosmetic result, shorter operation time, less morbidity, faster recovery in puffy eyelids than the other method.

Maximal pericoronary adipose tissue thickness is associated with hypertension in nonobese patients with acute or chronic illness

BACKGROUND/AIMS: Recent studies have shown an association of epicardial fat thickness with diabetes and hypertension (HTN) in asymptomatic populations. However, there is lack of information as to whether there is similar association between pericoronary adipose tissue (PAT) and HTN in the patients who have acute or chronic illness. METHODS: This study included 214 nonobese patients hospitalized with acute or chronic noncardiogenic illness. PAT thicknesses were measured from fat tissues surrounding left and right coronary arteries in enhanced, chest computed tomography scans, yielding the maximal PAT value from left and right coronary arteries was used for analysis. Baseline data from hypertensive (n = 81) and normotensive (n = 133) patients were collected and compared. RESULTS: PAT is positively correlated with age (r = 0.377, p <0.001), body mass index (BMI; r = 0.305, p < 0.001), systolic blood pressure (r = 0.216, p = 0.001), and total cholesterol (r = 0.200, p = 0.006). The hypertensive group was older (69.58 ± 11.69 years vs. 60.29 ± 14.98 years), and had higher PAT content (16.30 ± 5.37 mm vs. 13.06 ± 5.58 mm) and BMI (23.14 ± 3.32 kg/m² vs. 20.96 ± 3.28 kg/m²) than the normotensive group (all p < 0.001). Multivariate analysis showed that age (odds ratio [OR], 2.193; p = 0.016), PAT thickness (OR, 1.065; p = 0.041), and BMI (25 ≤ BMI < 30 kg/m² ; OR, 6.077; p = 0.001) were independent risk factors for HTN. CONCLUSIONS: In nonobese patients with noncardiogenic acute or chronic illness, PAT thickness is independently correlated with HTN, age, and BMI.

Life Threatening Complication of Self-made Remedy for Controlling High Blood Pressure-Coronary Artery Vasospasm Associated with Iatrogenic Thyrotoxicosis

We report the case of a middle aged woman who was previously diagnosed with hypertension. She had been drinking a kelp concentrate solution daily for her hypertension instead of taking the prescribed medicine due to her personal beliefs about the kelp solution. As a consequence, she experienced vasospastic angina complicated by myocardial infarction and cardiogenic syncope resulting from iatrogenic thyrotoxicosis. Complementary medicine is widely used by the general population. However, there is still a lack of evidence regarding their efficacy and safety. This case shows that inadequate use of complementary medicine could have no effect and may even be harmful. In patients with chronic diseases such as hypertension, self-care in the form of life style modification, home blood pressure monitoring and medial adherence are important for disease management.

Septal Reposition and Correction of a Deviated Nose Using a Nasal Wedge Bone Graft after Osteotomy in Corrective Rhinoplasty

BACKGROUND: Patients with deviated nose frequently present concomitant nasal bone as well as septal deviation. Many surgical methods have been developed to address such septal deviation, along with various osteotomy techniques to correct bone deviation. The authors performed medial and paramedian osteotomies to treat deviated nose with mild hump, and utilized the acquired wedge shaped bone graft to achieve septal reposition and bony vault correction. METHODS: From October 2014 through June 2015, 10 patients with nasal bone deviation that showed sufficient lateral nasal wall angle but deviated dorsum and septum on their preoperative facial computed tomography were included in this study. The authors performed open rhinoplasty to expose the planned osteotomy site, and conducted medial and paramedian osteotomy that resulted in the separation of a wedge-shaped bone fragment. Bony septum deviation was then treated with the swing door maneuver, and the resected 2 to 3 mm portion of the nasal bone was stabilized by inserting the wedge-shaped bone graft acquired from the previous osteotomy procedures. Consecutive clinical examinations were followed on postoperative 1, 3, and 6 months to observe any recurrences. RESULTS: All patients were satisfied with their surgical results, and no recurrent deviations were noted. CONCLUSIONS: Precise bone resection and transposition is essential for a successful corrective rhinoplasty. However, medial and lateral osteotomy are not mandatory procedures in all cases, and the nasal wedge bone graft that was utilized to support the treated septal bone may have aided in sustaining the surgical correction.

Therapeutic Hypothermia for Cardioprotection in Acute Myocardial Infarction

Mild therapeutic hypothermia of 32-35degrees C improved neurologic outcomes in outside hospital cardiac arrest survivor. Furthermore, in experimental studies on infarcted model and pilot studies on conscious patients with acute myocardial infarction, therapeutic hypothermia successfully reduced infarct size and microvascular resistance. Therefore, mild therapeutic hypothermia has received an attention as a promising solution for reduction of infarction size after acute myocardial infarction which are not completely solved despite of optimal reperfusion therapy. Nevertheless, the results from randomized clinical trials failed to prove the cardioprotective effects of therapeutic hypothermia or showed beneficial effects only in limited subgroups. In this article, we reviewed rationale for therapeutic hypothermia and possible mechanisms from previous studies, effective methods for clinical application to the patients with acute myocardial infarction, lessons from current clinical trials and future directions.

Higher Blood Pressure Variability in White Coat Hypertension; from the Korean Ambulatory Blood Pressure Monitoring Registry

BACKGROUND AND OBJECTIVES: Blood pressure variability (BPV) was recently shown to be a risk factor of stroke. White coat hypertension (WCH) used to be regarded as innocuous, but one long-term follow-up study reported that WCH increased stroke rate compared to normotension (NT). In this study, we aimed to evaluate the relationship between WCH and BPV. SUBJECTS AND METHODS: We analyzed 1398 subjects from the Korean Ambulatory Blood Pressure Registry, who were divided into NT (n=364), masked hypertension (n=122), white coat hypertension (n=254), and sustained hypertension (n=658) groups. RESULTS: Baseline characteristics were similar among groups. The average real variability (ARV), a highly sensitive BPV parameter, was highest in the WCH group, followed by the sustained hypertension, masked hypertension, and NT groups. The results persisted after being adjusted for covariates. The WCH vs. sustained hypertension results (adjusted mean±standard error) were as follows: 24-h systolic ARV, 22.9±0.8 vs. 19.4±0.6; 24-h diastolic ARV, 16.8±0.6 vs. 14.3±0.5; daytime systolic ARV, 21.8±0.8 vs. 16.8±0.6; and daytime diastolic ARV, 16.2±0.6 vs. 13.4±0.5 (p<0.001 for all comparisons). CONCLUSION: From the registry data, we found that subjects with WCH or masked hypertension had higher BPV than NT. However, long-term follow-up data assessing the clinical influences of WCH on stroke are needed.

Predictive value of CHADS2 score for cardiovascular events in patients with acute coronary syndrome and documented coronary artery disease

BACKGROUND/AIMS: The CHADS2 score, used to predict the risk of ischemic stroke in atrial fibrillation (AF) patients, has been reported recently to predict ischemic stroke in patients with coronary heart disease, regardless of the presence of AF. However, little data are available regarding the relationship between the CHADS2 score and cardiovascular outcomes. METHODS: This was a retrospective study on 104 patients admitted for acute coronary syndrome (ACS) who underwent coronary angiography, carotid ultrasound, and transthoracic echocardiography. RESULTS: The mean age of the subjects was 60.1 +/- 12.6 years. The CHADS2 score was as follows: 0 in 46 patients (44.2%), 1 in 31 (29.8%), 2 in 18 (17.3%), and > or = 3 in 9 patients (8.7%). The left atrial volume index (LAVi) showed a positive correlation with the CHADS2 score (20.8 +/- 5.9 for 0; 23.2 +/- 6.7 for 1; 26.6 +/- 10.8 for 2; and 30.3 +/- 8.3 mL/m2 for > or =3; p = 0.001). The average carotid total plaque area was significantly increased with CHADS2 scores > or = 2 (4.97 +/- 7.17 mm2 vs. 15.52 +/- 14.61 mm2; p = 0.002). Eight patients experienced cardiovascular or cerebrovascular (CCV) events during a mean evaluation period of 662 days. A CHADS2 score > or = 3 was related to an increase in the risk of CCV events (hazard ratio, 14.31; 95% confidence interval, 3.53 to 58.06). Furthermore, LAVi and the severity of coronary artery obstructive disease were also associated with an increased risk of CCV events. CONCLUSIONS: The CHADS2 score may be a useful prognostic tool for predicting CCV events in ACS patients with documented coronary artery disease.

Subclinical Hypothyroidism or Thyroid Autoimmunity and Variant Angina: By Chance? or with a Chance?

No abstract available.

Half-and-Half Palatoplasty

A 14-month-old child was diagnosed with a Veau Class II cleft palate. Von Langenbeck palatoplasty was performed for the right palate, and V-Y pushback palatoplasty was performed for the left palate. The child did not have a special problem during the surgery, and the authors were able to elongate the cleft by 10 mm. Contrary to preoperative concerns regarding the hybrid use of palatoplasties, the uvula and midline incisions remained balanced in the middle. The authors named this combination method "half-and-half palatoplasty" and plan to conduct a long-term follow up study as a potential solution that minimizes the complications of palatoplasty.

The diagnostic utility of chest computed tomography scoring for the assessment of amiodarone-induced pulmonary toxicity

BACKGROUND/AIMS: Amiodarone is one of the most widely used antiarrhythmic agents; however, amiodarone-induced pulmonary toxicity (APT) can be irreversible and sometimes fatal. The aim of this study was to evaluate the feasibility of chest computed tomography (CT) as a diagnostic tool for APT and to assess the utility of the CT APT score as an index for predicting the severity of APT. METHODS: Patients underwent amiodarone treatment for various reasons, most often atrial fibrillation, for more than 2 years, and those that received a cumulative dose > 100 g were enrolled. A total of 34 patients who underwent chest CT between December 2011 and June 2012 were enrolled, whether or not they had clinical symptoms. The APT CT score was defined as the number of involved regions in the lung, which was divided into 18 regions (right and left, upper, middle, and lower, and central, middle, and peripheral). The CT findings were evaluated according to the total dose and duration of amiodarone treatment and the results of a pulmonary function test. Clinical symptoms and outcomes were also evaluated according to APT CT scores. RESULTS: Seven patients had positive APT CT scores (interstitial fibrosis in five, organizing pneumonia in one, and mixed interstitial fibrosis and organizing pneumonia in one), and these patients exhibited significantly lower diffusion capacity for carbon monoxide in the lungs compared with patients without an increased APT CT score (70.2% +/- 6.9% vs. 89.7% +/- 19.4%; p = 0.011). Three of the seven patients experienced overt APT that required hospital admission. CONCLUSIONS: Chest CT is a useful diagnostic tool for APT, and the APT CT score might be a useful index for assessing the severity of APT.

Spindle Cell Lipoma: A Rare, Misunderstood Entity

Spindle cell lipoma, a rare variant of lipoma, is a benign tumor found in the posterior neck and shoulder. A 24-year-old man with a close family history of malignant lymphoma had presented with a large, firm, nodular mass found in the right supraclavicular area. Excision of the deeply located mass revealed a pale yellow, rubbery nodule which grossly resembled an enlarged lymph node, with a variant of lymphoma as a primary suspect. However, pathological studies revealed the lesion to be a spindle cell lipoma. Although atypical in location, spindle cell lipoma should always be kept in differential diagnosis of a newly-noted soft tissue mass, as this entity may be easily cured by simple excision.

Spindle Cell Lipoma: A Rare, Misunderstood Entity

Spindle cell lipoma, a rare variant of lipoma, is a benign tumor found in the posterior neck and shoulder. A 24-year-old man with a close family history of malignant lymphoma had presented with a large, firm, nodular mass found in the right supraclavicular area. Excision of the deeply located mass revealed a pale yellow, rubbery nodule which grossly resembled an enlarged lymph node, with a variant of lymphoma as a primary suspect. However, pathological studies revealed the lesion to be a spindle cell lipoma. Although atypical in location, spindle cell lipoma should always be kept in differential diagnosis of a newly-noted soft tissue mass, as this entity may be easily cured by simple excision.

Association between Central Obesity and Circadian Parameters of Blood Pressure from the Korean Ambulatory Blood Pressure Monitoring Registry: Kor-ABP Registry

Central obesity has been reported as a risk for atherosclerosis and metabolic syndrome. The influence of central obesity on diurnal blood pressure (BP) has not been established. In this study, we investigated the influence of central obesity on the circadian parameters of BP by 24 hr ambulatory BP monitoring. Total 1,290 subjects were enrolled from the Korean Ambulatory BP registry. Central obesity was defined as having a waist circumference> or =90 cm in males and > or =85 cm in females. The central-obese group had higher daytime systolic BP (SBP), nighttime SBP and diastolic BP (DBP) than the non-obese group (all, P or =65 yr) also showed a higher BP MD than within the younger group (daytime SBP MD 8.23 vs 3.87, daytime DBP 4.10 vs 1.59). In conclusion, central obesity has no influence on nocturnal dipping patterns. However, higher SBP and wider PP are associated with central obesity, which is accentuated in women.

Amiodarone-Induced Pulmonary Toxicity: Percutaneous Needle Aspiration Biopsy and Ultrastructural Findings / 이화의대지

Amiodarone has been widely used for supraventricular and ventricular arrhythmias and many patients benefit from its effectiveness in treating potentially life-threatening arrhythmias. However, this drug can cause multi-organ toxicity, including amiodarone-induced pulmonary toxicity (APT). Not only does amiodarone have a long half-life but also is lipophilic and therefore can easily accumulate in tissues. Hence, it is difficult to monitor therapeutic levels and side effects, making it difficult to predict toxicities. In this case, we describe multi-organ complications secondary to amiodarone use, especially APT combined with pneumonia with atypical pathogens and pulmonary hemorrhage. The patient reached a high cumulative dose of amiodarone despite a low maintenance dose of amiodarone. This case highlights an unusual presentation of APT with multi-organ toxicity and we review articles regarding the association between the cumulative dose of amiodarone and amiodarone-induced toxicities.

Antiphospholipid Syndrome Presenting Variceal Bleeding in Patient with Systemic Anaerobic Bacterial Infection / 이화의대지

Antiphospholipid antibody syndrome (APS) is characterized by raised levels of antiphospholipid antibodies (aPL), in association with thrombosis, recurrent fetal loss, and thrombocytopenia. Development of APS is related with idiopathic origin, autoimmune disease, malignancy and, on rare occasions, infection. However, in secondary APS combined with bacterial infections, aPL is usually shown with low titer and rarely associated with thrombotic events. A 52-year-old male was admitted due to pneumonia and multiple hepatosplenic abscesses. He had been treated with proper antibiotics, but he presented ascites and sudden variceal bleeding because of portal vein thrombosis. The bleeding was controlled by endoscopic variceal ligation. Acute portal vein thrombosis was successfully managed by low molecular weight heparin and hepatosplenic abscesses were completely resolved by antibiotics. This case suggests that systemic bacterial infection in immunocompetent patients possibly develops into secondary APS.

The Differences of Left Ventricular Geometry in Acute Myocardial Infarction and the Effects on Short Term Mortality / 이화의대지

OBJECTIVES: This study designed to find the differences of left ventricular (LV) geometry in acute myocardial infarction (AMI) between ST elevation myocardial infarction (STEMI) and non ST elevation myocardial infarction (NSTEMI) and the occurrences of adverse outcome according to the LV geometry. METHODS: Comprehensive echocardiographic analyses were performed in 256 patients with AMI. The left ventricular mass index (LVMI) and relative wall thickness (RWT) were calculated. LV geometry were classified into 4 groups based on RWT and LVMI: normal geometry (normal LVMI and normal RWT), concentric remodeling (normal LVMI and increased RWT), eccentric hypertrophy (increased LVMI and normal RWT), and concentric hypertrophy (increased LVMI and increased RWT). Cox proportional hazards models were used to evaluate the relationships among LV geometry and clinical outcomes. RESULTS: Patients with NSTEMI were more likely to have diabetes mellitus, hypertension, heart failure, stroke and previous myocardial infarction. By the geometric type, patients with NSTEMI were more likely to have eccentric hypertrophy (n=51, 34.7% vs. n=24, 22.0%, P=0.028). There was no significantly different adverse outcome between STEMI and NSTEMI patients. Fifteen patients (5.9%, 7 female [46.7%]) died and the median duration of survival was 10 days (range, 1 to 386 days). Concentric hypertrophy carried the greatest risk of all cause mortality (hazard ratios, 5.83; 95% confidence interval, 1.04 to 32.7). CONCLUSION: NSTEMI patients had more likely to have eccentric hypertrophy but adverse outcome after AMI was not different between STEMI and NSTEMI patients. Concentric hypertrophy had the greatest risk of short term mortality.

Progressive Lung Involvement during Steroid Therapy in Idiopathic Hypereosinophilic Syndrome / 결핵및호흡기질환

Hypereosinophilic syndrome (HES) is characterized by a sustained eosinophilia of 1,500/mm3 or more in the absence of any known causes or the signs and symptoms of organ involvement. We report a 64-year-old man with HES initially presenting with involvement of the liver and bone marrow. Despite controlling the eosinophilia by corticosteroid, he developed a cerebral infarction and later progressive interstitial pneumonia. Brain angiography revealed a severe stenosis of the proximal right internal carotid artery (ICA) and a complete obstruction of the intracranial ICA. An open lung biopsy revealed fibrosis and lymphoplasma cell infiltration without eosinophils, which were consistent with nonspecific interstitial pneumonia.

Study on the Role of Estrogen Receptor-Alpha in Yak-Kong and Soybean Induced Proliferation of MG-63 Human Osteoblastic Cells

Phytoestrogens, especially Yak-kong or soybean-derived isoflavones have been traditionally used as a supplement of estrogen for preventing postmenopausal osteoporosis in oriental folk medicine. In a previous study, we demonstrated that as Yak-kong and soybean increased MG-63 human osteoblastic cell proliferation, the expression of estrogen receptor alpha and beta (ERalpha: ERbeta) both were increased. However, the increased level of ERalpha is much higher than that of ERbeta. To determine whether the altered level of ERalpha expression affects Yak-kong or soybean induced MG-63 cell proliferation, we established cell lines stably expressing either ERalpha or antisense ERalpha RNAs. Increased expression of ERalpha in MG-63 cells (ERalpha-MG63) enhanced Yak-kong or soybean induced proliferation which paralleled with the enhanced expression of IGF-I. Inhibition of ERalpha expression by antisense ERalpha RNAs (As-ERalpha-MG63) caused these cells to insensitize Yakkong or soybean induced proliferation and IGF-I expression. Furthermore, the comparable effects between Yak-kong and the combined treatment of genistein and daidzein at 0.5 x 10-8M, which is a concentration of these two isoflavones similar to Yak-kong at 0.001 mg/ml, on cell proliferation and IGF-I expression in ERalpha-MG63 or As-ERalpha-MG63 cells demonstrate that ERalpha plays an important, active role in MG-63 cell proliferation induced by phytoestrogens, especially Yak-kong or soybean derived isoflavones.

A Patient Presenting Purulent Discharge From Open Window Thoracostomy / 결핵및호흡기질환

A 73-year-old man who had undergone a right pneumonectomy and open window thoracostomy due to tuberculous empyema, presented with purulent discharge from the previous operation site. The computed tomography of the chest showed diffuse pleural thickening and a low attenuated lesion, with air bubbles in a dependent portion of the right hemithorax. These air bubbles were revealed to be due to 7 pieces of retained surgical gauze by flexible bronchoscopy. The patient showed marked clinical improvement with diminished purulent discharge after removal of the foreign bodies.