In-Hospital and Post-Discharge Recovery after Acute Ischemic Stroke: a Nationwide Multicenter Stroke Registry-base Study

BACKGROUND: Using data from a large national stroke registry, we aimed to investigate the incidence and determinants of in-hospital and post-discharge recovery after acute ischemic stroke and the independence of their occurrence. METHODS: In-hospital recovery was defined as an improvement of 4 points or > 40% in the National Institutes of Health Stroke Scale (NIHSS) score from admission to discharge. Post-discharge recovery was defined as any improvement in the modified Rankin Scale (mRS) score from discharge to 3 months after stroke onset. Two analytic methods (multivariate and multivariable logistic regression) were applied to compare the effects of 18 known determinants of 3-month outcome and to verify whether in-hospital and post-discharge recovery occur independently. RESULTS: During 54 months, 11,088 patients with acute ischemic stroke meeting the eligibility criteria were identified. In-hospital and post-discharge recovery occurred in 36% and 33% of patients, respectively. Multivariate logistic regression with an equality test for odds ratios showed that 7 determinants (age, onset-to-admission time, NIHSS score at admission, blood glucose at admission, systolic blood pressure, smoking, recanalization therapy) had a differential effect on in-hospital and post-discharge recovery in the way of the opposite direction or of the same direction with different degree (all P values < 0.05). Both in-hospital and post-discharge recovery occurred in 12% of the study population and neither of them in 43%. The incidence of post-discharge recovery in those with in-hospital recovery was similar to that in those without (33.8% vs. 32.7%, respectively), but multivariable analysis showed that these 2 types of recovery occurred independently. CONCLUSION: Our findings suggest that, in patients with acute ischemic stroke, in-hospital and post-discharge recovery may occur independently and largely in response to different factors.

The Brain Donation Program in South Korea

PURPOSE: Obtaining brain tissue is critical to definite diagnosis and to furthering understanding of neurodegenerative diseases. The present authors have maintained the National Neuropathology Reference and Diagnostic Laboratories for Dementia in South Korea since 2016. We have built a nationwide brain bank network and are collecting brain tissues from patients with neurodegenerative diseases. We are aiming to facilitate analyses of clinic-pathological and image-pathological correlations of neurodegenerative disease and to broaden understanding thereof. MATERIALS AND METHODS: We recruited participants through two routes: from memory clinics and the community. As a baseline evaluation, clinical interviews, a neurological examination, laboratory tests, neuropsychological tests, and MRI were undertaken. Some patients also underwent amyloid PET. RESULTS: We recruited 105 participants, 70 from clinics and 35 from the community. Among them, 11 died and were autopsied. The clinical diagnoses of the autopsied patients included four with Alzheimer's disease (AD), two with subcortical vascular dementia, two with non-fluent variant primary progressive aphasia, one with leukoencephalopathy, one with frontotemporal dementia (FTD), and one with Creutzfeldt-Jakob disease (CJD). Five patients underwent amyloid PET: two with AD, one with mixed dementia, one with FTD, and one with CJD. CONCLUSION: The clinical and neuropathological information to be obtained from this cohort in the future will provide a deeper understanding of the neuropathological mechanisms of cognitive impairment in Asia, especially Korea.

Early Detection of Hidden Adenocarcinoma through the Prompt Pericardiocentesis in Patient with Small Pericardial Effusion / 이화의대지

Pericardial drainage is an important diagnostic and therapeutic option in the symptomatic patient with large amount of pericardial effusion (PE). However, when the amount of PE is relatively small, physicians are often reluctant to perform the invasive drainage of the fluid due to the increased risk of causing myocardial injury during the procedure. Even in some cases of suspected pericarditis with small amount PE, an initial empirical anti-inflammatory therapy is often recommended. A 65-year-old woman presented with mild dyspnea for two weeks. The echocardiography revealed small amount of PE. A careful fluoroscopy-guided pericardiocentesis, subsequent pericardial fluid cytology, and thorough whole body check-up demonstrated adenocarcinoma with no proven primary site. After the palliative chemotherapy, she had survived for 15 months until her death due to asphyxia. Although pericardiocentesis is considered dangerous in small amount of PE, a prompt and careful drainage may provide early detection of hidden malignancy and better survival outcome.

Pathological Significance of Tissue Trapped in Retrieved OptEase Vena Cava Filter at 18th Day after Installation in Patient with Deep Vein Thrombosis

The retrievable type of inferior vena cava filter has been widely used to prevent pulmonary thromboembolism in patients with deep vein thrombosis and contraindication of anticoagulation. Physicians make considerable efforts to remove the filter according to the manufacturer and US Food and Drug Administration safety advisory recommendation. However, forced filter retrieval might cause vascular injury within 3 weeks. Herein, we report pathologic and angiographic findings to suggest filter associated vascular injury during forced retrieval just within recommended period in a patient with deep vein thrombosis.

Clinical Evaluation of Rapid Diagnostic Test Kit for Scrub Typhus with Improved Performance

Diagnosis of scrub typhus is challenging due to its more than twenty serotypes and the similar clinical symptoms with other acute febrile illnesses including leptospirosis, murine typhus and hemorrhagic fever with renal syndrome. Accuracy and rapidity of a diagnostic test to Orientia tsutsugamushi is an important step to diagnose this disease. To discriminate scrub typhus from other diseases, the improved ImmuneMed Scrub Typhus Rapid Diagnostic Test (RDT) was evaluated in Korea and Sri Lanka. The sensitivity at the base of each IgM and IgG indirect immunofluorescent assay (IFA) in Korean patients was 98.6% and 97.1%, and the specificity was 98.2% and 97.7% respectively. The sensitivity and specificity for retrospective diagnosis at the base of IFA in Sri Lanka was 92.1% and 96.1%. ImmuneMed RDT was not reactive to any serum from seventeen diseases including hemorrhagic fever with renal syndrome (n = 48), leptospirosis (n = 23), and murine typhus (n = 48). ImmuneMed RDT shows superior sensitivity (98.6% and 97.1%) compared with SD Bioline RDT (84.4% at IgM and 83.3% at IgG) in Korea. The retrospective diagnosis of ImmuneMed RDT exhibits 94.0% identity with enzyme-linked Immunosorbent assay (ELISA) using South India patient serum samples. These results suggest that this RDT can replace other diagnostic tests and is applicable for global diagnosis of scrub typhus. This rapid and accurate diagnosis will be beneficial for diagnosing and managing scrub typhus.

Real-Time Quaking-Induced Conversion Analysis for the Diagnosis of Sporadic Creutzfeldt-Jakob Disease in Korea

BACKGROUND AND PURPOSE: The level of 14-3-3 protein in the cerebrospinal fluid (CSF) is increased in Creutzfeldt-Jakob disease (CJD) patients, which has led to it being used as a clinical biomarker for the ante-mortem diagnosis of human prion diseases. However, the specificity of the 14-3-3 protein is less reliable for CJD diagnosis. Newly developed assays including real-time quaking-induced conversion (RT-QuIC) have made it possible to detect the PrPSc-like abnormal prion isoform with a high sensitivity in animal and human specimens that might contain a minute amount of PrP(Sc) due to in vitro prion replication. METHODS: This study applied a highly sensitive RT-QuIC assay using recombinant human PrP to detect PrP(Sc) in the CSF of 81 patients with sporadic CJD (sCJD) in Korea. RESULTS: RT-QuIC analysis of the CSF samples based on the expression levels of 14-3-3 and total tau proteins revealed positivity in 62 of 81 sCJD patients (sensitivity of 76.5%) but no positive results in the 100 non-CJD patients. CONCLUSIONS: The sensitivity of the RT-QuIC in this study was similar to that in some previous reports, and the specificity of RT-QuIC was higher than that of 14-3-3 in CSF, suggesting that RT-QuIC analysis can complement the weakness of the specificity of 14-3-3 for the diagnosis of sCJD. These results indicate that RT-QuIC might be very useful for the rapid and specific diagnosis of sCJD and provide a practical novel method for the ante-mortem diagnosis of human prion diseases.

Dura Mater Graft-Associated Creutzfeldt-Jakob Disease: The First Case in Korea

Since 1987, dura mater graft-associated iatrogenic Creutzfeldt-Jakob disease (dCJD) has been reported in many countries. We report the first case of dCJD in Korea. A 54-yr-old woman, who underwent resection of the meningioma in the left frontal region and received a dura mater graft 23 yr ago presented with dysesthesia followed by psychiatric symptoms and ataxia. Her neurological symptoms rapidly progressed to such an extent that she exhibited myoclonus, dementia, and pyramidal and extrapyramidal signs within 8 weeks. The 14-3-3 protein was detected in her cerebrospinal fluid; however, an electroencephalogram did not reveal characteristic positive sharp wave complexes. Diffusion-weighted magnetic resonance images, obtained serially over 64 days, revealed the rapid progression of areas of high signal intensity in the caudate nucleus and cingulate gyrus to widespread areas of high signal intensity in the cortex and basal ganglia. Pathological examination of brain biopsy specimens confirmed the presence of spongiform changes and deposition of prion protein in the neurons and neuropils.

Microsatellite Instability and p53 Gene Loss of Heterozygosity in Hepatocellular Carcinoma

PURPOSE: Hepatocellular carcinoma (HCC) shows various molecular and genetic alterations in its development and progression. Recently, microsatellite instability (MSI) and the loss of heterozygosity (LOH), have been postulated as useful prognostic factors in many malignant tumors. LOH is related to the allelic loss of various tumor suppressor genes, however, MSI has been found to be the result of a mismatched DNA pairing. Our objectives were to evaluate MSI and p53 gene LOH and to correlate this to clinicopathological factors. METHODS: MSI analysis was performed by using polymerase chain reaction with 5 microsatellite markers (BAT25, BAT26, D2S123, D5S346 and D17S250 recommended in the 1998 NCI International Workshop) on 50 surgically resected tumors. p53 LOH was detected with 4 markers (D17S796, TP53, D17S5, D17S513). RESULTS: MSI and p53 LOH were detected in 30% and 66%, respectively. 18% of HCCs exhibited MSI in 5 NCI-recommended markers and 18% of HCCs demonstrated MSI in 4 p53 markers. MSI was mostly detected in BAT25 and BAT26 markers. MSI was more frequently detected in tumor grade I, small HCC, and non-lymphovascular group. For the most part, p53 LOH was detected by D17S513 marker (38.1%). p53 LOH results were correlated with higher tumor grade and invasiveness. LOH-High group showed a significant correlation with advanced HCCs and lymphovascular invasion. There was no demonstrated correlation between MSI and p53 LOH was not demonstrated. CONCLUSION: These results suggest that MSI may be involved to some extent in hepatocarcinogenesis and tumor invasion. Also MSI and p53 gene LOH may be a useful clinical indicator in determining the prognosis among patients with HCC.

A case of fulminant hepatic failure due to cyproterone acetate in a patient with cryptogenic liver cirrhosis / 대한내과학회지

Cyproterone acetate is an antiandrogenic drug that has been used in prostatic cancer. The drug is thought to be well-tolerated but has hepatotoxic effects. An 89 year-old man treated with cyproterone acetate 300 mg/d for prostatic cancer presented with a hepatotoxic reaction. Toxic hepatitis was diagnosed and cyproterone acetate was stopped immediately. The patient was treated with supportive management and a corticosteroid, but he died 28 days after administration due to liver failure. A liver biopsy performed after his death revealed the presence of acute hepatitis with cirrhosis. Underlying cirrhosis was not suspected before his death. Ultimately, the case was diagnosed as fulminant hepatic failure due to cyproterone acetate with underlying cryptogenic liver cirrhosis. This case and current literature highlight the hepatotoxic potential of cyproterone acetate and illustrate the importance of clinical surveillance, especially in patients with unrecognized liver disease.

An Ileal Duplication in a 12-year-old Girl which was Resected by Laparoscopy-assisted Surgery

Gastrointestinal duplication is a rare congenital anomaly which can occur anywhere along the digestive tract. The most common site is the mesenteric border of the terminal ileum. Intestinal duplication usually becomes symptomatic early in life with the severity of symptoms depending on the location and type of mucosal lining. Ectopic gastric mucosa is an associated possibility. Gastrointestinal hemorrhage is the most serious complication, which can cause severe anemia and shock. Another complication, although rare, is carcinoma in a duplicate cyst. We experienced an unusual case of a 12-years-old girl who presented with intermittent abdominal pain and hematochezia. There was no abnormality on Meckel's scan. Abdominal CT revealed a cystic mass in the pelvic cavity and subsequent transabdominal ultrasound showed the double-layered wall of the duplication. We performed laparoscopy-assisted, segmental resection of the ileum. The patient was discharged without any complication on the 7th postoperative day.

A Case of Autoimmune Hemolytic Anemia Associated with an Ovarian Teratoma

Autoimmune hemolytic anemia associated with an ovarian teratoma is a very rare disease. However, treating teratoma is the only method to cure the hemolytic anemia, so it is necessary to include ovarian teratoma in the differential diagnosis of autoimmune hemolytic anemia. We report herein on a case of a young adult patient who had severe autoimmune hemolytic anemia that was induced by an ovarian teratoma. A 25-yr-old woman complained of general weakness and dizziness for 1 week. The hemoglobin level was 4.2 g/dL, and the direct and indirect antiglobulin tests were all positive. The abdominal computed tomography scan revealed a huge left ovarian mass, and this indicated a teratoma. She was refractory to corticosteroid therapy; however, after surgical resection of the ovarian mass, the hemoglobin level and the reticulocyte count were gradually normalized. The mass was well encapsulated and contained hair and teeth. She was diagnosed as having autoimmune hemolytic anemia associated with an ovarian teratoma. To the best of our knowledge, this is the first such a case to be reported in Korea.

A Case of Hodgkin's Lymphoma of Palatine Tonsil / 대한이비인후과학회지

Most lymphoma occurs within the lymph node. A small portion of the lymphoma can have extranodal involvements such as the oral cavity, oropharynx, nasopharynx, paranasal sinuses, and larynx, etc. Especially, Hodgkin's lymphoma with primary manifestation in the palatine tonsil is an extremely rare entity and seldom documented in the literature. Recently, we experienced a case of palatine tonsil mass as a first symptom of Hodgkin's lymphoma. The patient underwent a surgical excision and radiotherapy. The authors report the first case of Hodgkin's lymphoma of the palatine tonsil in Korea with a review of literature.

A Case of Primary Gastric CD30-Positive Anaplastic Large-Cell Lymphoma

Gastric CD30-positive anaplastic large-cell lymphoma is a very rare disease. It is sometimes difficult to distinguish it from undifferentiated carcinoma, sarcoma and so on. We report here on a case of primary gastric anaplastic large-cell lymphoma. A 50-yr-old woman complained of epigastric pain and severe chest pain for 1 week. The gastroendoscopic examination revealed geographic mucosal irregularities with shallow ulceration at the antrum. She underwent a total gastrectomy. The gross finding of the resected stomach was an 8 x 4.5 cm sized ulceroinfiltrative lesion at the pyloric antrum along the lesser curvature. The microscopic examination revealed diffuse and solid proliferations of large atypical cells with pleomorphic nuclei. Immunohistochemically, the tumor cells were positive for CD30, vimentin and CD3, and this was a finding compatible with anaplastic large-cell lymphoma. To the best of our knowledge, this is the first such reported case in Korea.

A case of primary endobronchial actinomycosis associated with a foreign body / 대한내과학회지

Actinomycosis is an indolent, slowly progressive infection caused by anaerobic bacteria, primarily of the genus Actinomyces, that colonize the mouth, colon, and vagina. A vital step in the development of actinomycosis is disruption of the mucosal barrier. Actinomycosis occurs most frequently at a cervicofacial, abdominal, and pelvic region. Thoracic actinomycosis usually follows an indolent progressive course with involvement of the pulmonary parenchyma and/or the pleural space. Rarely, pulmonary nodules or endobronchial lesions can occur. We report a case of a 62-year-old woman of chronic cough with sputum and pulmonary mass with consolidation at the right lower lobe on chest radiography. Fiberoptic bronchoscopic findings revealed a polypoid tumor like mass completely obstructing RLL lobar bronchus and a hard bony material embedded there. Histologic examination of the biopsy specimens demonstrated acute and chronic inflammation with calcified material and a sulfur granule, which led to the diagnosis of endobronchial actinomycosis. The patient responded to several bronchoscopic procedures and intravenous penicillin G.

A case of primary endobronchial actinomycosis associated with a foreign body / 대한내과학회지

Actinomycosis is an indolent, slowly progressive infection caused by anaerobic bacteria, primarily of the genus Actinomyces, that colonize the mouth, colon, and vagina. A vital step in the development of actinomycosis is disruption of the mucosal barrier. Actinomycosis occurs most frequently at a cervicofacial, abdominal, and pelvic region. Thoracic actinomycosis usually follows an indolent progressive course with involvement of the pulmonary parenchyma and/or the pleural space. Rarely, pulmonary nodules or endobronchial lesions can occur. We report a case of a 62-year-old woman of chronic cough with sputum and pulmonary mass with consolidation at the right lower lobe on chest radiography. Fiberoptic bronchoscopic findings revealed a polypoid tumor like mass completely obstructing RLL lobar bronchus and a hard bony material embedded there. Histologic examination of the biopsy specimens demonstrated acute and chronic inflammation with calcified material and a sulfur granule, which led to the diagnosis of endobronchial actinomycosis. The patient responded to several bronchoscopic procedures and intravenous penicillin G.

Multiple Ulcerating Malignant Lymphoma of the Gastrointestinal Tract with Perforation

Malignant lymphoma of the gastrointestinal tract is a rare lesion, which comprises 1~4% of the malignant neoplasms of the gastrointestinal tract. Abdominal pain and weight loss are the most common symptoms and an abdominal mass, the most common physical finding. This tumor is often discovered at a late stage; a diagnosis should be done on all patients undergoing an emergency operation for an obstruction, hemorrhage, or perforation. We report a case of a multiple ulcerating malignant lymphoma of the gastrointestinal tract with perforation in a 60 year-old male. The patient visited our hospital because of a sudden onset of acute abdominal pain. The operative finding was multiple masses on the small bowel, sigmoid colon, and stomach, plus multiple perforations of the small bowel. We performed a multiple small bowel segmental resection and an anastomosis at the site of the perforated lesion. The pathologic evaluation diagnosed it as a malignant lymphoma and the patient was treated with cyclophosphamide, adreiamycin, and vincristine. We report this rare disease with a review of the literature.

Expression of p21, p53 and Ki-67, and Apoptosis in Colorectal Adenocarcinoma

BACKGROUND: The purpose of this study is to assess the roles of p21 protein, p53 protein, and Ki-67 expressions and apoptosis in colorectal tumorigenesis. METHODS: Fifty-seven colorectal cancers and 15 villotubular adenomas were investigated by immunohistochemical staining for p21 protein, p53 protein, Ki-67, and in situ labeling of apoptotic cells. Clinicopathologic values (tumor size, histologic grade, Dukes stage, and lymph node metastasis) were compared with the incidence of expressions of p21 protein and p53 protein, index of Ki-67 expression, and apoptosis. RESULTS: The incidence of p21 protein expression was decreased with lymph node metastasis (p<0.005), and that of p53 expression was increased with lymph node metastasis (p<0.005). There were no statistically significant correlations among the p21 protein or p53 protein expressions, tumor size, histologic grade and stage. The correlation between the Ki-67 labeling index and the clinicopathologic values was not statistically significant. The labeling index of apoptosis was increased with the Astler-Coller stage (p<0.05). Statistical analysis revealed a significant inverse correlation between the p21 protein and p53 protein expressions (p<0.05). CONCLUSIONS: It is suggested that p21 protein, p53 protein and the apoptotic labeling index are useful variables for the prognostic assessment of colorectal adenocarcinoma. Down-regulation of p21 protein expression may be associated with poor prognosis. Also, the expressions of p21 protein and p53 protein may play an important role in the tumorigenesis and progression of the colorectal adenoma-carcinoma sequence.

Partial Trisomy 13 (Patau Syndrome): An Autopsy Report

Trisomy 13 (Patau syndrome) is rare and usually fatal if contracted within the first six months of life. We report a case of a male fetus with the typical features of Patau syndrome. He was terminated in a 27-year-old mother at the gestational age of 32+4 weeks. In chromsomal analysis by GTG banding technique, the karyotype of the fetus was 46,XY,rec(13) dup(13q)inv(13)(p13q21.3)(=partial trisomy 13q); and his mother's karyotype was 46,XX, inv(13)(p13q21.3)(=pericentric inversion). His father had normal karyotype, 46,XY. Ultrasonography showed fluid-nature content, which was occupying the entire intracranium, but preserving the brain stem and cerebellum. Postmortem examination disclosed holoprosencephaly, hydrocephalus, a single nostril, bilateral anophthalmia, ventricular septal defect, and a single umbilical artery.

A Case of Squamous Cell Carcinoma of Bartholin's Gland / 대한산부인과학회잡지

We report a case of squamous cell carcinoma of Bartholin's gland for the first time in Korea. The patient had diagnosed unexpectedly by an incidental Rt. Bartholin's cystectomy at Chunchon Sacred Heart Hospital. She was transferred to Asan Medical Center and performed Rt. hemivulvectomy with ipsilateral inguinal-femoral lymph node dissection for staging. She was FIGO stage II (T2N0M0) and has been followed up for 9 months without any evidence of recurrence. Squamous cell carcinoma of Bartholin's gland is very rare among the female genital malignancies. The treatment of this malignancy is not established yet. So it should be individualized to the patient by the resectability and the status of resection margin involvement.

A Case Of Sclerosing Stromal Tumor Of The Ovary / 대한산부인과학회잡지

Sclerosing stromal tumor, which was first described by Chalvardjian and Scully in 1973, is a very rare benign tumor of the ovary. This tumor differs from the fibroma, thecoma and lipoid cell tumor clinically and pathologically by showing prominent pseudolobular pattern and hypervascularity. We experienced a case of sclerosing stromal tumor of the ovary in 38 year-old woman. We report this case with a brief review of the literature.