Sellar Chordoma Mimicking Pituitary Adenoma

Most chordomas involving the sellar region are parasellar or suprasellar, and largely or entirely sellar lesions are very rare. The authors report a case which chordoma involve pituitary fossa and surrounding structures and presented as nonfunctioning pituitary adenoma. Successful surgical removal was conducted via endonasal endoscopic approach. The pathology exhibited the typical histological patterns and immunophenotype of chordoma. The authors present a rare case of sellar chordoma and review the literature on that.

A Case of Anterior Papillary Muscle Rupture with Total Occlusion of Right Coronary Artery Resulting in Inferior Myocardial Infarction

The arterial supply of the posteromedial papillary muscle of the left ventricle arises from the terminal branches of the right or circumflex arteries, depending on the distribution of these arteries. The anterolateral papillary muscle of the left ventricle is supplied primarily by one or more branches from the left anterior descending coronary artery, although it may also be supplied by circumflex marginal branches. The anterolateral papillary muscle is supplied only by the branches of the left coronary artery. However, in our case, the patient demonstrated a total occlusion of the right coronary artery that resulted in acute inferior myocardial infarction with a complete anterolateral papillary muscle rupture of the left ventricule as well as acute mitral insufficiency.

Does ST-segment depression combined with R wave amplitude change improve the test accuracy of the EKG during exercise testing? / 대한내과학회지

BACKGROUND: Exercise electrocardiogram is the most widely used non-invasive test in those patients suspected of having coronary artery disease. However, sensitivity and specificity of this test are not satisfactory, especially when the exercise induced ST-segment depression is used as a single criterion of myocardial ischemia. Although many investigators have tried to improve diagnostic accuracy with R-wave amplitude change in addition to ST-segment depression, controversy exists whether this new criteria improve the test accuracy for coronary artery disease or not. The purpose of this study is to determine the test accuracy of R-wave amplitude change induced by exercise combined with the conventional ST-segment criterion for myocardial ischemia. METHODS: We reviewed our records of patients who visited to Korea University Anam Hospital with chest pain from January, 1998 to July, 1999. We included 130 patients with chest pain who had a tredmill test followed by a coronary angiography within 2 months. Patients with change in ST-segment depression (delta STD)> or = 1.00 mm and delta STD> or = 1.00 mm with R wave amplitude decrease (-delta R)> or = 1.00 mm in the same lead in any of 12 leads and delta STD> or = 1.00 mm with R wave amplitude increase (+delta R)> or = 1.00 mm in the same lead in any of 12 leads were compared. According to the findings of coronary angiograms, patients were divided into 4 groups ; normal coronary artery group, mild coronary artery stenosis group (> or = 30% to or = 50% to or = 70%). RESULTS: Fifty three patients (40.7%) had normal coronary angiograms and 77 patients (59.3%) had coronary artery stenosis. There was no significant difference in gender and age. But, patients with coronary artery stenosis had more diabetes mellitus, hyperlipidemia, smoking, previous myocardial infarction history and angina during exercise testing than those without coronary artery stenosis. The sensitivity of exercise EKG is significantly decreased when combined with delta R (delta STD, 74.0%, delta STD with -delta R, 45.5%, delta STD with +delta R, 30.0%, p<0.01), but the The test accuracy is delta STD; 73.7%, delta STD with -delta R; 61.5%, delta STD with +delta R; 57.7%. CONCLUSION: When ST-segment depression is combined with R-wave amplitude change as a marker for myocardial ischemia, the specificity is increased, but the test accuracy of exercise EKG is not improved.

A Case of Cryoglobulinemia-induced Acute Respiratory Distress Syndrome / 결핵

Cryoglobulinemia is the presence of globulins in the serum that precipitate on exposure to cold temperatures (cryoglobulins). Pulmonary complications of cryoglobulinemia include interstial infiltration, impaired gas exchange, small airway disease and pleurisy. Only one other acute respiratory distress syndrome(ARDS) case has been described in patients with cryoglobulinemia. A 55-years old man was admitted with dyspnea. He had been diagnosed as being a hepatitis B virus antigen carrier 15 years age. On the first admission, chest radiography showed a bilateral pleural effusion and a patchy infiltration on both lungs. On protein-and immuno-electrophoresis, cryoglobulinemia was confirmed. The patient was treated with corticosteroid and plasmapheresis. Forty-five days after the diagnosis, the patient complained of progressive dyspnea and showed a diffuse bilateral pulmonary infiltration on chest radiography. Despite intensive care with mechanical ventilation, the patient died as consequence of hypoxemia and multiple systemic organ failure. On a pathologic examination of the postmortem lung biopsy, multiple necrotizing vasculitis and increased infiltration of the lymphocytes and monocytes were observed. In conclusion, ARDS developed as a result of pulmonary hemorrhage due to cryoglobulinemia-associated vasculitis.

Activation Patterns Following Successful and Unsuccessful DC Cardioversion for Atrial Fibrillation

BACKGROUND AND OBJECTIVES: The mechanism by which atrial fibrillation (AF) electrically converts to sinus rhythm remains undefined. The purpose of this study was to assess in detail the electrograms recorded during cardioversion using direct current (DC) shock. SUBJECTS AND METHODS: In 23 patients with AF (chronic n=20, paroxysmal n=3, M:F=15:8, 50 - 70 years old), electrograms were recorded simultaneously from a 20-pole electrode catheters (Duo-deca, DAIG) in the right atrial free wall and the coronary sinus immediately after DC shock given transthoracically. The activation patterns following 45 trials consisting of 23 successful and 22 unsuccessful cardioversion were analyzed. RESULTS: Two distinct patterns following successful cardioversion were observed; either immediate resumption of normal sinus rhythm (n=5, 21%), or one or two activations immediately after shock preceded normal sinus rhythm (n=18, 79%). The energy levels of the two patterns were not significantly different (260 J, 250 J, respectively). Four patterns following unsuccessful cardioversion were noted; unchanged (n=10, 45%), converted to atrial flutter (n=4, 18%), production of three or four beats of more coordinated complexes and reverted to AF (n=5, 22%), and converted to sinus rhythm transiently and reinitiated AF by one or two atrial premature beats (n=3, 13%). The magnitude of the DC shock applied at these 4 different patterns was 196 J, 240 J, 264 J, and 340 J, respectively in which low energy levels made a simultaneous depolarization of the entire atria unlikely. CONCLUSION: Distinct activation patterns were identified following successful and unsuccessful cardioversion using DC shock for AF. These observations suggest that total depolarization of the entire atria is not a prerequisite for the conversion of AF into sinus rhythm.

Gastroesophageal Acid Reflux According to Different Meals: Flour Cake vs Rice Cake / 대한소화관운동학회지

BACKGROUND/AIMS: Gastroesophageal reflux disease (GERD) is known to be one of the contributing factors to cause epigastric soreness, which we often experience after intake of flour-based meals. The aim of this study was to evaluate gastroesophgeal reflux (GER) and its mechanism according to intake of different ingredients of meals. METHODS: We investigated the effect of meals of different ingredients on the lower esophageal sphincter (LES) pressure, the frequency of transient LES relaxation (tLESR) and GER in seven healthy volunteers. The meals used in this study were either rice cakes or flour cakes, which were isocaloric and isovolumetric. A mylohyoid electromyogram, LES pressure and esophageal pH were simultaneously recorded for 3 hours after ingestion of each meal on two different occasions. RESULTS: There was no significant difference in incidence of GER between two meals. CONCLUSION: The intake of isocaloric and isovolumetric meals of either flour or rice cake did not result in significant discrepancies in frequency of GER. The increase in the frequency of swallow- and strain-associated GER observed in the case of a flour cake may be caused by reduced LES pressure after ingestion.

Coronary Blood Flow Velocity and Coronary Flow Reserve in Normal Left anterior Descending Coronary Arteries

BACKGROUND: Recently, assessment of left anterior descending (LAD) coronary flow by transthorasic Doppler echocardiography (TTDE) has been emerged as a useful tool in evaluation of microcirculatory function of coronary circulation. The measuring site of coronary flow by TTDE is distal LAD. But it was not fully investigated whether the distal flow velocity is identical to that of proximal segment. The purpose of this study is to compare coronary blood flow velocity and coronary flow reserve (CFR) in normal LAD according to its level. METHOD: 9 patients (1 male, 8 females; mean age 52.8+/-11.1years) were included for this study. Coronary flow velocity was measured with intracoronary Doppler guide wire at the proximal (before first diagonal branch), mid (after second diagonal branch), and distal segments of LAD at baseline and after intracoronary bolus injection of 18 microgram adenosine. Baseline and hyperemic average peak velocity (APV) and CFR were compared between segment. RESULTS: Baseline and hyperemic APV appears to be diminished from proximal (24.6+/-3.5 cm/sec, 55.8+/-10.7 cm/sec) to distal (21.7+/-6.9 cm/sec, 49.7+/-17.2 cm/sec) LAD without statistical significance. But, CFR showed no significant difference in each segments (proximal, mid, and distal segment; 2.3+/-0.26, 2.3+/-0.32, 2.3+/-0.48, p=0.95). As the increment of peak systolic velocity (PSV) from baseline to hyperemic state was larger than that of peak diastolic velocity (PDV), diastolic to peak systolic velocity ratio (DSVR) was decreased significantly by hyperemic state in proximal and distal segment (baseline; 2.1+/-0.8, 2.1+/-0.5 vs hyperemia; 1.8+/-0.6, 1.7+/-0.3, p<0.05). CONCLUSION: Coronary blood flow velocity appears to be decreased from proximal to distal segment of normal LAD without statistical significance. There were no differences in CFR between proximal, mid and distal segment of normal LAD.