Radiolucent Pure Matrix Stones on Computed Tomography Scan, Arising in Patient with Type I Diabetes and Chronic Kidney Disease: A Case Report / 가정의학회지

Kidney matrix stones are a rare form of calculi, which are challenging to diagnose. Matrix stones consist of a proteinaceous material which has a radiolucent appearance that might be overlooked on imaging. Recently, endourological intervention has been the standard treatment method for matrix stones. We report a case of urinary matrix stones in a patient with type 1 diabetes mellitus and chronic kidney disease, in whom the stones formed into a pure matrix and were not visualized in the computed tomography scan. The stones were found after additional work-up, and they were managed using a transureteral stone basket, not through endourological intervention.

Nrf2-Heme oxygenase-1 modulates autophagy and inhibits apoptosis triggered by elevated glucose levels in renal tubule cells

BACKGROUND: Autophagy is a highly balanced process in which lysosomes remove aged and damaged organelles and cellular proteins. Autophagy is essential to maintain homeostasis in the kidneys. METHODS: Using human renal tubule cells HK-2, we assessed the impact of high glucose (HG) on autophagy. We also evaluated the capability of sulforaphane (SFN) to protect the HK-2 cells from HG-induced apoptosis by modulating autophagy. RESULTS: SFN modulated autophagy and decreased apoptosis in the HK-2 cells that were cultured in 250 mM glucose medium for two days. The reactive oxygen species (ROS) levels increased, as expected, in the cells cultured in the 250 mM glucose medium. However, the SFN decreased the ROS levels in the HK-2 cells. The overexpression of heme oxygenase-1 (HO-1) by SFN decreased the expression of LC3 and beclin-1. LC3 and beclin-1 were involved in the downregulation of caspase-3 that was observed in the HG-induced cells. CONCLUSION: The activation of nuclear factor E2-related factor 2 (Nrf2)–HO–1 inhibited ROS expression and subsequently attenuated autophagy and cell apoptosis after HG injury was decreased. HG injury led to the activation of autophagy and HO-1 in order to combat oxidative stress and protect against cell apoptosis. Therefore, HO-1 activation can prevent ROS development and oxidative stress during HG injury, which considerably decreases autophagy and apoptosis.

Concurrent renal dysfunction with ischemic heart disease is an important determinant for cardiac and cerebrovascular mortality in patients on chronic digoxin therapy for atrial fibrillation

BACKGROUND: Major adverse cardiac and cerebrovascular events (MACCEs) are main concerns in patients with atrial fibrillation (AF); however, factors affecting MACCEs remain inconclusive in AF patients chronically treated with digoxin. We investigated the major clinical determinants for fatal MACCEs in AF patients treated with digoxin over a 10-year follow-up period. METHODS: We analyzed a retrospective cohort of 1,480 AF patients at Eulji University Hospital, Daejeon, South Korea from March 2004 to August 2015. Among this population, 402 consecutive patients receiving chronic digoxin therapy were selected for the study. Data for electrocardiography, medication history, laboratory values including the serum digoxin concentration (SDC) and fatal MACCEs were collected. All data were divided and compared between groups based on the occurrence of MACCEs. RESULTS: The overall incidence of fatal MACCEs among the 402 digoxin-treated AF patients (age, 68 ± 11 years; male, 40.3%) was 12.1%. These fatalities resulted from heart failure (46.1%), fatal stroke (26.9%), fatal myocardial infarction (15.3%) and sudden cardiac death (5.7%). A higher prevalence of diabetes, pre-existing ischemic heart disease (IHD), lower estimated glomerular filtration rate (eGFR), higher SDC, and junctional bradycardia were more frequently observed in patients with MACCEs compared to those without MACCEs. Multivariable analysis showed that an eGFR of ≤ 60 mL/min/1.73 m2 and pre-existing IHD had a hazard ratio of 3.35 and a confidence interval of 1.64–6.87 (P < 0.001) for fatal MACCEs. CONCLUSION: Chronic kidney disease stage III–V with pre-existing IHD is significantly associated with increased cardiac and cerebrovascular mortality in AF patients with chronic digoxin use.

Malignant Hypertension with Pulmonary Alveolar Hemorrhage Needing Dialysis / 이화의대지

A 35-year-old man presented with progressive dyspnea and hemoptysis. His blood pressure was 230/140 mmHg and serum creatinine level was 20.13 mg/dL. Chest radiography and computed tomography revealed pulmonary hemorrhage. His renal function was low, thus emergent renal replacement therapy was required. Malignant hypertension and acute kidney injury were diagnosed, and antihypertensive therapy and hemodialysis started immediately. Renal biopsy was performed to examine the underlying disease. Typical pathological changes of malignant hypertension, fibrinoid necrosis of the afferent arterioles, and proliferative endoarteritis at the interlobular arteries were observed. His renal function improved gradually and pulmonary hemorrhage completely disappeared with administration of antihypertensive agents. Here, we report this rare case of malignant hypertension with pulmonary alveolar hemorrhage and speculate that the hemorrhage may be related to vascular injuries at the alveolar capillary level caused by malignant hypertension.

Diastolic Dysfunction Induced by a High-Fat Diet Is Associated with Mitochondrial Abnormality and Adenosine Triphosphate Levels in Rats

BACKGROUND: Obesity is well-known as a risk factor for heart failure, including diastolic dysfunction. However, this mechanism in high-fat diet (HFD)-induced obese rats remain controversial. The purpose of this study was to investigate whether cardiac dysfunction develops when rats are fed with a HFD for 10 weeks; additionally, we sought to investigate the association between mitochondrial abnormalities, adenosine triphosphate (ATP) levels and cardiac dysfunction. METHODS: We examined myocardia in Wistar rats after 10 weeks of HFD (45 kcal% fat, n=6) or standard diet (SD, n=6). Echocardiography, histomorphologic analysis, and electron microscopy were performed. The expression levels of mitochondrial oxidative phosphorylation (OXPHOS) subunit genes, peroxisome-proliferator-activated receptor gamma co-activator-1alpha (PGC1alpha) and anti-oxidant enzymes were assessed. Markers of oxidative stress damage, mitochondrial DNA copy number and myocardial ATP level were also examined. RESULTS: After 10 weeks, the body weight of the HFD group (349.6+/-22.7 g) was significantly higher than that of the SD group (286.8+/-14.9 g), and the perigonadal and epicardial fat weights of the HFD group were significantly higher than that of the SD group. Histomorphologic and electron microscopic images were similar between the two groups. However, in the myocardium of the HFD group, the expression levels of OXPHOS subunit NDUFB5 in complex I and PGC1alpha, and the mitochondrial DNA copy number were decreased and the oxidative stress damage marker 8-hydroxydeoxyguanosine was increased, accompanied by reduced ATP levels. CONCLUSION: Diastolic dysfunction was accompanied by the mitochondrial abnormality and reduced ATP levels in the myocardium of 10 weeks-HFD-induced rats.

Fibrillary glomerulonephritis combined with chronic inflammatory demyelinating polyneuropathy

A 58-yr-old man presented with leg edema and subacute weakness of his bilateral lower extremities. Urinary and serum immunoelectrophoresis revealed the presence of lambda-type Bence Jones proteins. He was ultimately diagnosed with monoclonal gammopathy of undetermined significance (MGUS). A renal biopsy specimen showed fibrillary glomerulonephritis (FGN), which was randomly arranged as 12-20 m nonbranching fibrils in the basement membranes. Immunofluorescence studies were negative for immunoglobulin (Ig)G, IgM, IgA, C3, and kappa light chains in the capillary walls and mesangial areas. A Congo red stain for amyloid was negative. Electromyography and nerve conduction velocity examinations results were compatible with the presence of demyelinating polyneuropathy. This case showed a rare combination of FGN, without Ig deposition, and MGUS combined with chronic inflammatory demyelinating polyneuropathy (CIDP).

A Case of Acute Pancreatitis: Portal Vein Superimposed Thrombosis in a Nephritic Syndrome Patient / 대한내과학회지

Nephrotic syndrome is characterized by hypercoagulability and thrombosis of the renal and deep veins. We describe a case of unusual thrombosis in the portal and superior mesenteric veins of a 41-year-old female, admitted for treatment of abdominal pain, who simultaneously presented with nephrotic syndrome and acute pancreatitis. Laboratory analysis revealed hypoalbuminemia, hyperlipidemia, and proteinuria. Abdominal computed tomography revealed acute pancreatitis, thrombosis at the portal and superior mesenteric veins, and ischemic changes in the colon and small intestines. Anticoagulation therapy was started immediately. Abdominal pain was subsequently reduced and the ischemic lesion disappeared. Warfarin use could not be terminated immediately. Empirical steroid therapy commenced without a kidney biopsy. Complete remission occurred after 4 weeks. Following warfarin cessation, a kidney biopsy was performed, confirming the diagnosis of minimal change disease.

A Case of Different Organ Responses to Immunosuppressive Therapy In a Microscopic Polyangiitis Patient with Interstitial Lung Disease / 대한내과학회지

Microscopic polyangiitis (MPA) is an idiopathic autoimmune disease characterized by systemic vasculitis associated with antineutrophil cytoplasmic autoantibodies. Interstitial lung disease is a less recognized manifestation of MPA and has a poor prognosis. A 61-year-old man presented with persistent cough, sputum and dyspnea. Laboratory examination revealed microscopic hematuria and renal insufficiency. Perinuclear anti-neutrophil cytoplasmic autoantibodies were positive according to serological testing. Computed tomography scans showed bibasilar reticulation and honeycombing in a peripheral distribution. Therefore, renal biopsy was performed, and MPA was diagnosed. After treating with corticosteroids and immunosuppressive agents, the patient had a complete renal response but progressive interstitial lung disease. We report a case of MPA presenting with interstitial lung disease in which the patient experienced different responses in each organ.

A Case of Idiopathic Aortitis with Left Renal Vein Thrombosis

A 38-year-old man was admitted to the hospital because of abrupt left flank pain. He had no fever and physical examination revealed tenderness of the left costovertebral angle. Laboratory data revealed white blood cell 16,060/microL, C-reactive protein 0.93 mg/dL. Urinalysis showed more than 1/2 red cells per high-power field with severe proteinuria (4+). Enhanced computed tomography (CT) showed the thickened abdominal aorta wall with partial thrombus. The thickened aorta wall compressed the left renal vein and it caused left renal vein thrombosis. Abdominal CT findings suggested aortitis of the abdominal aorta with complication of left renal vein. We could exclude other types of aortitis including autoimmune aortitis, Takayasu's arteritis, giant cell arteritis, and infectious causes based on a serologic test and the history of the patient. Therefore, the patient was diagnosed with idiopathic aortitis and treated with glucocorticoid. After treatment, his symptoms disappeared and a follow-up CT showed decreased mural thickening of the abdominal aorta. Isolated idiopathic aortitis presented with renal vein thrombosis is extremely rare and has not been reported in Korea yet. We present a rare case report on idiopathic aortitis of the abdominal aorta with complication of left renal vein thrombosis.

A Case of Systemic Lupus Erythematosus Occurring after H1N1 Influenza Vaccination / 대한내과학회지

The recent worldwide outbreak of H1N1 has led to the universal administration of H1N1 influenza vaccination, including in South Korea. Several complications have been reported with use of H1N1 influenza vaccine, but systemic lupus erythematosus (SLE) has not been reported as a complication until now. Here, we report a case of SLE occurrence after H1N1 influenza vaccination. A 17-year-old girl who had not been diagnosed with SLE was hospitalized with fever, myalgia, and arthralgia after H1N1 influenza vaccination. Laboratory tests revealed increased levels of antinuclear antibody and anti-ds-DNA antibody, and decreased levels of C3 and C4 as well as proteinuria. The pathological findings confirmed a diagnosis of lupus nephritis. The patient was treated with high-dose corticosteroid and hydroxychloroquine. This is the first report of SLE following H1N1 influenza vaccination in South Korea.

Maintenance of Insulin Therapy by Desensitization in Insulin Allergy Patient / 당뇨병

Allergic reaction to human insulin is uncommon. But they can cause mild to severe symptoms such as dyspnea, hypotensive shock, etc. Here we report the case of a patient with type 2 diabetes and insulin allergy successfully managed with desensitization. A 60-year-old man with insulin allergy was transferred. He had poorly controlled type 2 diabetes (fasting blood glucose 230 mg/dL). He developed itching sense and erythema at the injection sites of human insulin in a few minutes. And serum IgE level was elevated to 1618.0 IU/mL. The insulin was changed to other preparations, including short and long-acting insulin analogues, with similar responses. He was commenced on twice a day injection protocol in addition to his oral hypoglycemic agents, and achieved fair control (fasting blood glucose 100 mg/dL) on 24 units of Novomix Flex Pen per day, with little or no skin or systemic reaction. This is the case report of insulin allergy in type 2 diabetes being successfully managed by desensitization.

Prevalence, Correlates, and Comorbidity of 12-Month Tobacco Dependence among Ever-smokers in South Korea, During 1984-2001

The rate of dependence among ever-users of a drug indicates the risk of developing dependence once an individual has been exposed to the drug. This is the first study to investigate 12-month tobacco dependence (TD) among ever-smokers in a community-based population. Analyses were based on two national studies of representative samples aged 18-64 in 1984 (n=5,025) and in 2001 (n=6,275), conducted with household visits and face-to-face interviews. The rates of 12-month TD among ever-smokers in men showed no significant difference between 51.6% in 1984 and 50.6% in 2001. On the contrary, the rates in women significantly increased from 33.3% in 1984 to 52.8% in 2001. After adjusting for the sociodemographic variables, 'male gender' was significantly associated with 12-month TD among eversmokers in 1984, but not in 2001. 'Unmarried' was significantly associated in 2001 but not in 1984. 'Alcohol dependence' was the only psychiatric disorder associated with 12-month TD in both study years. In conclusion, 12-month TD was found in about 50% of ever-smokers, and gender differences between the rates of 12-month TD which was observed in 1984 disappeared in 2001. Individuals with 12-month TD showed higher comorbidity with alcohol dependence than ever-smokers without TD.

Metronidazole-Induced Toxic Encephalopathy in A Hemodialysis Patient: A Case Report / 대한신장학회지

Metronidazole, one of the mainstay drugs for the treatment of anaerobic infections and protozoal infections, may produce some serious neurological side effects. Seizure, peripheral neuropathy, dizziness, vertigo, ataxia, confusion, irritability, headache and tremor have been reported among patients receiving metronidazole, particularly among those receiving high dose of the drug. However, no specific dose adjustment is recommended for patients with renal or hepatic dysfunction receiving metronidazole because the accumulation of the drug and its metabolites can occur in terms of severity of illness and patient tolerability. Although metronidazole is significantly removed by hemodialysis, no specific dose recommendations are made for this patient population. Recently, we experienced metronidazole-induced encephalopathy in a patient with end-stage renal disease, which was diagnosed by brain magnetic resonance imaging (MRI). Herein, we report a case with a review of literature.

Korean Epidemiologic Catchment Area(KECA) Study for Psychiatric Disorderscc: Prevalence of Specific Psychiatric Disorders / 신경정신의학

OBJECTIVES: This study aims to estimate the prevalence of the DSM-IV psychiatric disorders in Korean population using the Korean version of Composite International Diagnostic Interview (K-CIDI). METHODS: Subjects were selected by taking multi-stage, cluster samples of 7,867 adult household residents, 18 to 64 years of age, in ten catchment areas. Total 78 trained interviewers administered the K-CIDI to the selected respondents, from June 1 to November 30, 2001. RESULTS: Total 6,275 respondents completed the interview. Some 33.5% of respondents reported at least one lifetime disorder, 20.6% reported at least one-year disorder, and 16.7% reported at least one-month disorder. The most common lifetime disorders were alcohol abuse/dependence (17.24%), nicotine dependence/withdrawal (11.19%), specific phobia (5.16%), and major depressive disorder (4.25%). The lifetime prevalence of substance abuse/dependence (0.25%) and schizophrenia (0.16%) was very low. Nicotine and alcohol use disorder showed very high male/female ratio. Mood disorder and anxiety disorder were more prevalent among female than male. CONCLUSION: The prevalence of psychiatric disorders was high. In comparison with other studies, remarkable differences in distributions of psychiatric disorders across the areas and times were observed.

A case of Primary Serous Papillary Carcinoma of the Peritoneum / 대한부인종양콜포스코피학회잡지

Although the peritoneum is rare site for a primary neoplasm, certain malignant neoplasms may arise from it. A case of 63-year-old woman who had a serous papillary carcinoma of peritoneal origin is reported. Extraovarian peritoneal serous papillary carcinoma was characterized by ascites, malignant washings, and omental involvement with bulky infiltration and/or multiple tumor nodules. The symptoms caused by diffuse spreading of the neoplasm over the peritoneum are the most important manifestation for clinical diagnosis of malignant primary neoplasm of peritoneum, especially serous papillary carcinoma. This behaving tumor was at least partially responded to therapy. In this report, we describe a case of serous papillary carcinoma of peritoneum carring on proper management with brief review.

Preliminary Study for the Effect of No-smoking on Antipsychotics, Benztropine and Propranolol Dosage for Re-admitted Psychotic Patients / 신경정신의학

This study was designed to investigate the effect of no-smoking on the pattern of medication for 30 re-admitted psychotic patents in the no-smoking(smoking-prohibited) ward, who had been admitted and medicated previously in the smoking (smoking-allowed) ward, in Wonju Christian Hospital, by comparing daily mean dosage of antipsychotics, benztropine mesylate, and propranolol administered in smoking state and in no-smoking state of the same patients. The results were as follows: 1) The mean hospital stay was reduced to 46.0 days in no-smoking ward compared to 61.1 days in smoking-allowed ward. This means mean admission period was reduced significantly(p<0.05) and over two thirds of all subjects experienced reduction of hospital stay from 2 days to 92 days. 2) A statistically significant difference was fecund in the dosage of antipsychotics in all subjects. Calculated in terms of chlorpromazine equivalent, the daily mean was 296.8+/-180.7mg in no-smoking state, and 395.0+/-232.2mg in smoking state(p<.01), 3) In schizophrenics(n=13), the daily mean dosage of benztropine mesylate was 0.56+/-.62mg in no-smoking state and 0.14+/-0.21mg in smoking state, showing a significant difference(p<.05). In bipolar group, the mean dosage in no-smoking ward was also smaller than in smoking ward, though not significant. 4) The difference of the daily mean dosage of propranolol between two states was not significant. In conclusion, in no-smoking state psychotic patients required less hospital stays and significantly lower dosage of antipsychotics, and the schizophrenics required significantly higher dosage of benztropine mesylate for extrapyramidal symptoms. The authors suggest that psychiatric patients should be encouraged to stop smoking and recommend that psychiatrists monitor smoking state of their psychotic patients for proper and efficient drug therapy.

Efforts and Therapeutic Factors of Short-term Token Economy for Negative Symptoms of Schizophrenic In-patients / 신경정신의학

OBJECTIVE: The negative symptoms of schizophrenia usually are not responsive to drug therapy to persist and make schizophrenics more difficult in their rehabilitation. The authors investigated the therapeutic effect of token economy(TET) for negative symptoms of schizophrenic patients, and attempted to develop a TET program f3r psychiatric wards in general hospital. METHODS: Negative subscale of PANSS was rated for 35 schizophrenics with negative symptoms as their main problems before and after short-term TET(less than 3 months). Therapeutic factors were identified by comparing patient and program variables between the achieved and the non-achieved group of each level of target behaviors. RESULTS: 1) Subtotal of negative subscale of PANSS was decreased from 31.57+/-4.32 at baseline to 20.66+/-4.63 artier treatment. With TET, symptoms of difficulty in abstract thinking' and 'stereotypic thinking' were less responsive than the other 5 items of the scale Also the dose of antipsychotics prescribed was reduced to 291.21+/-287.74mg/day from 487.58+/-372.79mg/day. 2) The achievement rate of level I (self-help) was 75%, level II (ward-activity) 78%, and level III (social activity/occupation) 68%, resulting in average 74% for all target behaviors. 3) On level II, dose of antipsychotics was lower, and on level III, number of admission was lower and female sex was more frequent in achieving patient group than nonachieving group. The rate of achievement was higher in case of special flood, reception, and outing with family applied as a reinforcer on level I, and reception on level II . CONCLUSION: These results showed that TET was effective for schizophrenic patients with negative symptoms in psychiatric ward. Further investigations to refine the individual program of TET will be needed far enhancement of it s therapeutic efficacy and smart application of it.

Psychiatric Aspects of Hemodialysis and Kidney Transplantation

A series of clinical studies on the psychiatric aspects of hemodialysis and kidney transplantation were done with Korean patients, kidney donors, their families and unit nurses. All subjects were interviewed and evaluated for their psychiatric reactions and symptoms and for the underlying causes. Depression was the most common reaction, although the clinical features were somewhat different between groups studied. In addition, a unique and episodic psychotic syndrome was found in four patients. Depression and psychotic episodes seemed to reflect the psychodynamic components such as instinctual frustration, physical, familial and financial loss, dependency on a machine, sensory deprivation and the so-called fear of death and fear of life. These seemed to follow the unique features of hemodialysis and transplantation. The main defense mechanism seemed to be denial. The possible role of psychiatrists was discussed for evaluation, treatment, and prevention of these reactions and for the support of the family and the treatment team.