A Case of Sepsis Associated with Klebsiella pneumoniae Colitis in an Immunocompetent Adult

A 47-year-old female patient was admission for back pain after she fell down on the table. T12 compression fracture was found for spinal magnetic resonance imaging. Absolute bed rest and pain control for non-steroidal anti-inflammatory drugs and muscle relaxant were received. After 7 days, she complained febrile sense, abdominal pain, and diarrhea. Septic shock was suspected, and then use of antibiotics and proper management were performed. Computed tomography of chest and abdomen was not revealed specific finding. Blood culture showed growth of Klebsiella pneumoniae. After patients completely resolved symptoms, colonoscopy was performed that showed erosive lesions of cecum, proximal A-colon, and rectum.

Prevalence and clinical features of hypersensitivity reaction to contrast media after prescreening skin test

PURPOSE: Hypersensitivity reactions to contrast media (CM) are one of the most common causes of drug adverse reactions. The overall prevalence of immediate hypersensitivity reaction (IHR) was 0.16%–7.7% to nonionic CM. Although IHR to CM has been traditionally considered nonallergic, there is growing evidence that the mechanism of IHR to CM is mediated by IgE. It can be severe, even fatal, and a legal problem. To reduce IHR, the prescreening skin test is on the rise. METHODS: We reviewed cases of IHR to CM during enhanced computed tomography (CT) from 2008 to 2015 at a secondary hospital in South Korea. Patients who underwent enhanced CT were performed the 2-step prescreening skin test before nonionic CM-enhanced CT. If patients had adverse reactions to CM, the reactions were reported. IHR to CM was defined as an immediate reaction within 1 hour after CM administration. The Ring and Messmer system was used to classify the severity of reactions by grades I to IV, and we defined grades III and IV as severe reactions. RESULTS: A total of 30,105 CM-enhanced CT cases were recruited from 2008 to 2015. A total 46 patients with CM adverse reactions were reported. The IHR were noted in 30 of the total patients (0.1%), of which 6 had severe reaction. CONCLUSION: The prevalences of IHR and severe IHR to CM were 0.1% and 0.02%, respectively. Further studies are needed to evaluate the usefulness of prescreening skin tests to prevent IHR to CM.

Acute Pancreatitis after Extracorporeal Shock Wave Lithotripsy for a Urolithiasis / 대한췌담도학회지

48-year-old woman was admitted to emergency room due to left flank pain. It was diagnosed with left ureteral stone and underwent extracorporeal shock wave lithotripsy (ESWL). However, 12 hours later, the patient complained acute upper abdominal pain with pulmonary edema and low blood pressure. A diagnosis of moderate acute pancreatitis with local complication was considered and we decided conservative therapy including fluid resuscitation, inotropics and antibiotics. It was suggested that ESWL was responsible for the acute pancreatitis. The patient gradually recovered and was discharged on 13th day of admission. ESWL is considered the standard treatment for urolithiasis. Although, it has proved to be safe and effective, serious complications have been reported in 1% of patients, including acute pancreatitis, perirenal hematoma, urosepsis, venous thrombosis, biliary obstruction, bowel perforation, lung injury, and cardiac arrhythmia. Although the possibility of post-ESWL acute pancreatitis is extremely low, physicians should take care of this complication.

Infective Endocarditis in a Patient after Percutaneous Mitral Balloon Valvuloplasty / 대한내과학회지

Percutaneous mitral balloon valvuloplasty (PMBV) is the treatment of choice for mitral stenosis. Only a few reported cases have been reported in PMBV patients worldwide. In this study, a case of a 34 year-old female with infective endocarditis a year after PMBV is presented. The patient presented with fever, and peripheral vascular symptoms. Transthoracic echocardiography showed vegetation on the anterior mitral leaflets and Staphylococcus Viridans was isolated from blood cultures. The patient was successfully treated with Amoxicillin + Clavulate and Gentamicin. Further studies on the correlation between PMBV and infective endocarditis are needed.

Predictive Factors of Central Lymph Node Metastasis in Papillary Thyroid Microcarcinoma / 대한내분비외과학회지

PURPOSE: Despite the excellent overall prognosis for patients with papillary thyroid microcarcinoma (PTMC), the rate of central lymph node (CLN) metastasis has been reported to be as great as 60% and the optimal surgical extent of PTMC has been controversial. The aim of this study is to identify factors for predict CLN metastasis in patients with PTMC. METHODS: We conducted a retrospective study of 535 patients with PTMC who underwent total thyroidectomy with prophylactic CLN dissection between Jan. 2008 and Aug. 2011. We analyzed the association of CLN metastasis and clinicopathologic characteristics. RESULTS: CLN metastasis was found in 181 patients (33.8%). Results of univariate analysis showed an association of younger than 45 years of age, male gender, a tumor size greater than 5 mm, bilaterality, multiplicity, extrathyroidal extension, and positivity of resection margin with CLN metastasis. Of these, results of multivariate analysis showed that age (P=0.003), gender (P=0.004), tumor size (P5 mm), male gender, young age (<45 yr), extrathyroidal extension, and positive resection margin were determined as the predictive factors for CLN metastasis, which occurred in approximately one third of patients with PTMC. Therefore, prophylactic CLN dissectionshould be considered in patients with PTMC who have these factors through investigation before surgery.

Transumbilical Laparoscopic Assisted Single Port Appendectomy (Hybrid Appendectomy) in Children

PURPOSE: Laparoscopic appendectomy isused as a three port technique for appendectomy. In children, single port laparoscopic appendectomy is difficult because they have a small peritoneal cavity for manipulation of laparoscopic instruments. We performed transumbilical laparoscopic assisted single port appendectomy (hybrid appendectomy) in children. METHODS: From March 2010 to July 2012, we performed transumbilical laparoscopic assisted single port appendectomy in 53 children. We made a vertical incision to the umbilicus approximately 1.5 cm, and a wound retractor (Applied Medical Resources Co., Ltd., Rancho Santa Margarita) was placed in the umbilical incision, and appendix exteriorized the extraperitoneum through the wound retractor. Appendectomy was performed conventionally. We had no conversion cases for laparotomy. RESULTS: A total of 53 patients, 29 females and 24 males, with a mean age of 8.5+/-2.0 years were enrolled in this retrospective study. The mean operative time was 29.4+/-9.4 minutes. There was no occurrence of complication or mortality. BMI was 17.8+/-4.9 kg/m2. And mean hospital stay was 3.2+/-1.0 days. CONCLUSION: In children, transumbilical single port laparoscopic appendectomy is technically difficult because they have a small peritoneal cavity. However, transumbilical laparoscopic assisted single port appendectomy (hybrid appendectomy) appearsto be a safe and effective technique for use in children, which allows for achievement of nearly scarless surgery.

The Efficacy of Ultrasonography in Identifying Fracture Patterns of Nasal Bone

PURPOSE: The purpose of this study was to know whether ultrasonography is proper diagnostic tool for decision of treatment method or not, as compared the efficacy of US in allowing identifying fracture patterns of nasal bone with that of CT. MATERIALS AND METHODS: Fifty patients with nasal trauma were investigated prospectively by CT and US. According to CT and ultrasonographic findings, each case of nasal bone injury were rated as grade 1 (nasal injury but not fracture), grade 2 (simple fracture without displacement), grade 3 (unilateral simple fracture with displacement), grade 4 (bilateral simple fractures with displacement), and grade 5 (bilateral comminuted fractures with depression). Assessment for ultrasonographic method were defined as overestimations or underestimation according to whether the nasal fracture had been assigned a higher or lower grade at the review of the findings of CT. The correlation between the results of CT and ultrasonography were measured. RESULTS: In ultrasonographic estimation of grade of 50 cases of nasal bone injuries, there were correctly graded in 42 cases, overestimated in 5 cases, underestimated in 3 cases. In allowing accurate grading of nasal bone injury, images of nasal ultrasonography correlated closely with those of CT (r = 0.796). CONCLUSION: Nasal ultrasonography is a reliable method that allows appropriate grading of nasal bone injury and would be a useful first line imaging method in providing the detail necessary for proper management of patients with mild simple nasal bone injury.

alphaB-Crystallin is a Novel Oncoprotein Associated with Poor Prognosis in Breast Cancer / 한국유방암학회지

PURPOSE: alphaB-crystallin, a small heat shock protein, is an anti-apoptotic protein associated with aggressive tumor behavior. A recent study revealed that alphaB-crystallin is overexpressed in a metastatic variant of the GI101A human breast carcinoma cell line. The purpose of this study was to investigate whether alphaB-crystallin is related to other breast tumor markers and can predict a breast cancer prognosis. METHODS: Eighty-two patients who underwent breast cancer surgery at Hallym Sacred Heart Hospital were enrolled. alphaB-crystallin expression was determined by immunohistochemical staining. Estrogen receptor, progesterone receptor (PR), human epidermal growth factor receptor, lymphovascular invasion, histological grade, other tumor markers and time to recurrence were compared with alphaB-crystallin expression. RESULTS: alphaB-crystallin expression in breast cancer tissues was associated with PR (p=0.030), the number of metastatic lymph nodes (pN) (p=0.020), lymphovascular invasion (p=0.022), histological grade (p=0.004) and triple negative breast cancer (TNBC) (p=0.004). alphaB-crystallin expression significantly decreased time to recurrence (p=0.039). CONCLUSION: The results revealed a strong relationship between alphaB-crystallin and poor prognostic factors such as the number of metastatic lymph nodes (especially pN2), TNBC, and rapid time to recurrence. We believe that alphaB-crystallin could be a novel oncoprotein biomarker of a poor prognosis in breast cancer.

Effect of Selective Cyclooxygenase 2 Inhibitor in TCDD Pre-exposed Thyroid Papillary Carcinoma Cell Line

BACKGROUND: Cyclooxygenase 2 (COX-2) is related to carcinogenesis and progression of cancer. COX-2 has been detected in thyroid cancer. This suggests that COX-2 inhibitor may be useful to control the growth of thyroid cancer cells as well as the progression of thyroid cancer. Tetrachlorodibenzodioxin (TCDD), acting as an inflammatory cytokine, directly induces the expression of COX-2. We examine whether TCDD controls the effect of COX-2 inhibitor on thyroid cancer cells. METHODS: The effects of TCDD and celecoxib on thyroid papillary carcinoma cell line (SNU790) were examined using cell proliferation and fluorescence-activated cell sorting analysis. Western blot analysis was performed to determine the expressed COX-2 levels and the cell cycle-related proteins. The matrix metalloproteinase-2 (MMP-2) expression and gelatinolytic activity were examined using real time-polymerase chain reaction and zymography. RESULTS: TCDD directly induced the growth of SNU790 and the expression of cyclin D1, cyclin A, cyclin E, p21 and COX-2. Celecoxib suppressed the growth of SNU790 and the expression of cyclin D1 and cyclin E. Celecoxib reduced the MMP-2 expression and the gelatinolytic activity, but those effects were decreased in the SNU790 by either pre-treatment with TCDD or co-treatment with TCDD and celecoxib. CONCLUSIONS: Celocoxib effect is directly reduced depending on the exposure to TCDD. TCDD exposure should be considered in the treatment with Celecoxib.

Anti-inflammatory Activity of 1-docosanoyl Cafferate Isolated from Rhus verniciflua in LPS-stimulated BV2 Microglial Cells

Although various derivatives of caffeic acid have been reported to possess a wide variety of biological activities such as protection of neuronal cells against excitotoxicity, the biological activity of 1-docosanoyl cafferate (DC) has not been examined. The objective of the present study was to evaluate the anti-inflammatory effects of DC, isolated from the stem bark of Rhus verniciflua, on lipopolysaccharide (LPS)-stimulated BV2 microglial cells. Pretreatment of cells with DC significantly attenuated LPS-induced NO production, and mRNA and protein expression of iNOS in a concentration-dependent manner. DC also significantly suppressed LPS-induced release of cytokines such as TNF-alpha and IL-1beta . Consistent with the decrease in cytokine release, DC dose-dependently and significantly attenuated LPS-induced mRNA expression of these cytokines. Furthermore, DC significantly suppressed LPS-induced degradation of IKB, which retains NF-kB in the cytoplasm. Therefore, nuclear translocation of NF-kB induced by LPS stimulation was significantly suppressed with DC pretreatment. Taken together, the present study suggests that DC exerts its anti-inflammatory activity through the suppression of NF-kB translocation to the nucleus.

Paraesophageal Hernia with Small Bowel Strangulation

Paraesophageal hernias are usually classified into three distinct types: type I, sliding hernias; type II, paraesophageal hernias; type III, a combination of type I and II. Herniation of other abdominal organs can be classified as type IV, and is a rare situation at the esophageal hiatus. We report herein a 73-year-old female patient who presented with epigastric pain and diagnosed as type IV paraesophageal hernia. Initial evaluation was focused on myocardial ischemia. There was no evidence of myocardial ischemia in the coronary angiography, but follow-up chest X-ray revealed air-fluid levels in the left mediastinum suggested hiatal hernia. On computed tomography, herniation and strangulation of proximal jejunum into the hemithorax via left diaphragmatic defect was found. After reduction of small bowel and resection of strangulated segment, the defect was closed. Fluid collection in the hernia sac was detected at postoperative day nine, but she was discharged without complication.

Laparoscopic versus Open Appendectomy for Complicated Appendicitis / 대한내시경복강경외과학회지

PURPOSE: The value of laparoscopic appendectomy for complicated appendicitis is still controversial. The purpose of this clinical study was to evaluate the efficacy of laparoscopic appendectomy in patients with complicated appendicitis. METHODS: This study involved a total of 108 consecutive patients who had undergone appendectomy for complicated appendicitis between January 2008 and August 2009. Those patients were divided into two groups; laparoscopic appendectomy (LA) and open appendectomy (OA). The demographic data, the incidence of drainage tube insertion, the operative time, the duration of pain, the time to a soft oral diet, the hospital days and the complication rate for the two groups were analyzed. RESULTS: There were no significant differences of the operative time (OA group: 65.2+/-27.31 min vs the LA group: 64.6+/-23.6 min) (p=0.233). However, in the LA group, there were benefits for number of drainage tube insertions (OA group: 48/60 vs the LA group: 8/48) (p<0.001), the use of analgesics (OA group: 3.2+/-3.9 times vs the LA group: 1.4+/-1.3 times) (p<0.001), the time to start a soft diet (OA group: 2.8+/-1.3 days vs the LA group: 1.4+/-1.3 days) (p=0.020), the hospital stay (OA group 7.5+/-3.4 days vs LA group 3.7+/-2.2 days) (p=0.040) and the complication rate (OA group: 18/60 vs the LA group: 8/48) (p<0.001). CONCLUSION: These results suggest that laparoscopic appendectomy for treating complicated appendicitis is a safe procedure that may prove to have significant clinical advantages over open appendectomy.

Clinical Analysis of Inguinal Hernia in Adult Using Prolene Hernia System

PURPOSE: The aim of this study was to detail clinical experiences with a type of tension-free herniorrhaphy using the prolene hernia system (PHS) and analyze the system's usefulness. METHODS: We retrospectively reviewed the medical records of 122 patients who underwent an inguinal hernia repair using PHS between March 2004 and August 2008. RESULTS: There were 116 male and 6 female patients ages 14 to 99; 79 indirect, 33 direct, 10 pantaloon hernias. The right inguinal hernias were more frequent (64.7%). The mean operative time for inguinal hernia repair using PHS was 45.2+/-1.5 minutes and the mean postoperative hospital stay was 3.5+/-1.5 days (101+/-82.9 hours). The most frequent combined disease was hypertension. The most frequent complication of PHS repair was hematoma. The mean number of used analgesics was 3.1+/-3.3. There were no postoperative recurrences. CONCLUSION: Tension-free herniorrhaphy using PHS is thought to be a useful method of inguinal hernia repair in adults because it offers lower postoperative pain, shorter operation time and shorter postoperative hospital stay.

The Wound Healing Effect of a Silk Fibroin Film on Cutaneous Burn of Hairless Mice

PURPOSE: The aim of this study was to examine the effects of silk fibroin film on wound healing of cutaneous burn in hairless mice by using microscopic findings and stem cell markers (nestin, cytokeratin 15) and ki-67 proliferation marker. METHODS: Each mouse received two burns at the dorsal area by applying a metal rod heated with boiling water. Burn wound sites were dressed with Silk Fibroin Film and duoderm (SF group), Aquacel hydrofiber and duoderm (AC group) and duoderm only (Control group). All groups were covered externally with duodermas adhesive bands. Those mice were sacrificed at zero, two, seven, fourteen and twenty one days after burn. Histological findings and immunohistochemical staining for stem cell markers were observed. RESULTS: In SF group, inflammatory cell infiltration, formation of granulation tissue and inflammatory foci are greater than in AC and control group. Those factors appear to enhance mesenchymal stem cell markers such as nestin. Finally mesenchymal tissue regeneration was enhanced. In addition, the length of ki-67 expressed re-generating epithelium, which appeared to be associated with epithelial regeneration, was the longest in SF group. CONCLUSION: The results show that the wound healing effect of SF is the best among other treatment materials including AC in the experimental group and duoderm in the control group through mesenchymal regeneration and epithelial regeneration which are essential factors for wound healing.

Immunohistochemical Expression of Stem Cell Markers during the Wound Healing Process of Cutaneous Burn

PURPOSE: A cutaneous wound healing requires a well-orchestrated integration of the complex biological and molecular events of cell migration and proliferation, extracellular matrix deposition, angiogenesis and remodeling. Finally, skin regeneration is the main goal. Stem cells are self-renewing multipotent progenitors with the broadest developmental potential in a given tissue at a given time. The aim of this study was to examine the role of stem cells during the wound healing process of cutaneous burn in hairless mice by using immunohistochemical stainings (nestin, cytokeratin 15 and CD31). METHODS: Each mouse received 2 burns at the dorsal area by applying a metal stick heated in boiling water. Burn wound sites were dressed with duoderm. The mice were sacrificed at 0, 2, 7, 14 and 21 days after burn. Histological findings and immunohistochemical expression for stem cell markers were observed. RESULTS: Nestin was expressed in the stromal cells beneath the epidermis, hair follices, dermal cysts and endothelial cells. Cytokeratin 15 was expressed in the epidermis except in basal cells. On 7 and 14 days after burn, the regenerated epidermis didn't express cytokeratin 15. CD31 was expressed in the endothelial cells on 7 and 14 days after burn. The amount of nestin expression was the highest. CONCLUSION: Our results showed that nestin may have various effects on burn wound healing. Cytokeratin 15 was expressed before burn and after burn. It is likely that other cytokeratin may stimulate epithelial regeneration. CD31 may act in vascular regeneration during burn healing.

Gastric Polyposis Associated with Gastric Cancer

Gastric polyps encompass a wide variety of lesions that most commonly arise from the gastric epithelium. However, coincidental gastric carcinomas have rarely been reported, being found in only 2~3% of patients with hyperplastic polyps. A 68-year-old male was admitted to our hospital for bleeding control of a gastric polyp. The gastroscopy shows numerous polyps in the entire gastric mucosa and a huge ulcer with bleeding. The bleeding of the gastric ulcer could not be controlled by gastroscopic procedures. So, we performed total gastrectomy for bleeding control. The pathologic findings shows poorly differentiated adenocarcinoma with hyperplastic polyps. We performed treatment with Cisplatin and 5-FU for two cycles. Two months postoperative, he was admitted due to dyspnea associated with ascites. We performed a ckeckup by computer tomography. It revealed cancer recurrence with lymphatic and liver metastasis, and diffuse massive ascites with mesenteric cake, and it suggested cancer peritonei.

Inhibition of eNOS/sGC/PKG Pathway Decreases Akt Phosphorylation Induced by Kainic Acid in Mouse Hippocampus

The serine/threonine kinase Akt has been shown to play a role of multiple cellular signaling pathways and act as a transducer of many functions initiated by growth factor receptors that activate phosphatidylinositol 3-kinase (PI3K). It has been reported that phosphorylated Akt activates eNOS resulting in the production of NO and that NO stimulates soluble guanylate cyclase (sGC), which results in accumulation of cGMP and subsequent activation of the protein kinase G (PKG). It has been also reported that PKG activates PI3K/Akt signaling. Therefore, it is possible that PI3K, Akt, eNOS, sGC, and PKG form a loop to exert enhanced and sustained activation of Akt. However, the existence of this loop in eNOS-expressing cells, such as endothelial cells or astrocytes, has not been reported. Thus, we examined a possibility that Akt phosphorylation might be enhanced via eNOS/sGC/PKG/PI3K pathway in astrocytes in vivo and in vitro. Phosphorylation of Akt was detected in astrocytes after KA treatment and was maintained up to 72 h in mouse hippocampus. 2 weeks after KA treatment, astrocytic Akt phosphorylation was normalized to control. The inhibition of eNOS, sGC, and PKG significantly decreased Akt and eNOS phosphorylation induced by KA in astrocytes. In contrast, the decreased phosphorylation of Akt and eNOS by eNOS inhibition was significantly reversed with PKG activation. The above findings in mouse hippocampus were also observed in primary astrocytes. These data suggest that Akt/eNOS/sGC/PKG/PI3K pathway may constitute a loop, resulting in enhanced and sustained Akt activation in astrocytes.

Multilevel Duodenal Injury after Blunt Trauma

Duodenal trauma is an uncommon injury associated with significant mortality and morbidity. Upper gastrointestinal radiological studies and computed tomography may lead to the diagnosis of blunt duodenal trauma. Exploratory laparotomy remains as the ultimate diagnostic test if a high suspicion of duodenal injury continues even in the face of absent or equivocal radiographic signs. The majority of duodenal injuries may be managed by simple repair of the injured site. More complicated injuries require more sophisticated techniques. Here, we report a case of multilevel blunt duodenal injury successfully managed with duodenal diverticulization, Roux-en-Y gastrojejunostomy and catheter duodenostomy.

Pneumatosis Cystoides Intestinalis with Intestinal Volvulus

Pneumatosis cystoides intestinalis is an uncommon condition characterized by the presence of multiple gas-filled cysts within the wall of the gastrointestinal tract. It is still a poorly understood phenomenon, considered to result from primary mucosal insult from varying causes. However, it is associated with various diseases, including gastroenteral obstructive and connective vascular diseases and even pulmonary or endocrine diseases. Authors report a case of pneumatosis cystoides intestinalis with volvulus in the small intestine that developed in a 44-year-old man without history of any special underlying diseases.

Subclavian Steal Syndrome

The definition of subclavian steal is the reversal of vertebral blood flow resulting from the stenosis or occlusion of one of the subclavian arteries or the innominate artery. It is a rare disease resulting in a variety of ischemic neurologic symptoms such as vertigo, dizziness, diplopia, dysarthria, ataxia and nystagmus. Some patients show ischemic symptoms and digital necrosis of the involved arm. Among treatment options, Subclavian to carotid transposition is the most preferred method. We report a patient with subclavian steal syndrome who had 5th finger necrosis of the left hand without neurologic symptoms. It was successfully treated with a carotid-subclavian bypass with a 6 mm ePTFE graft.