Carotid Artery End-Diastolic Velocity and Future Cerebro-Cardiovascular Events in Asymptomatic High Risk Patients

BACKGROUND AND OBJECTIVES: Prognostic value of additional carotid Doppler evaluations to carotid intima-media thickness (IMT) and plaque has not been completely evaluated. SUBJECTS AND METHODS: A total of 1119 patients with risk factors for, but without, overt coronary artery disease (CAD), who underwent both carotid ultrasound and Doppler examination were included in the present study. Parameters of interest included peak systolic and end-diastolic velocities, resistive indices of the carotid arteries, IMT, and plaque measurements. The primary end-point was all-cause cerebro-cardiovascular events (CVEs) including acute myocardial infarction, coronary revascularization therapy, heart failure admission, stroke, and cardiovascular death. Model 1 covariates comprised age and sex; Model 2 also included hypertension, diabetes and smoking; Model 3 also had use of aspirin and statin; and Model 4 also included IMT and plaque. RESULTS: The mean follow-up duration was 1386+/-461 days and the mean age of the study population was 60+/-12 years. Amongst 1119 participants, 43% were women, 57% had a history of hypertension, and 23% had diabetes. During follow-up, 6.6% of patients experienced CVEs. Among carotid Doppler parameters, average common carotid artery end-diastolic velocity was the independent predictor for future CVEs after adjustments for all models variables (HR 0.95 per cm/s, 95% confident interval 0.91-0.99, p=0.034 in Model 4) and significantly increased the predictive value of Model 4 (global chi2=59.0 vs. 62.8, p=0.029). CONCLUSION: Carotid Doppler measurements in addition to IMT and plaque evaluation are independently associated with future CVEs in asymptomatic patients at risk for CAD.

Acute Fulminant Myocarditis Recovered from Electro-Mechanical Dissociation in Scrub Typhus / 이화의대지

Scrub typhus, caused by Orientia tsutsugamushi, is an acute febrile illness. Characteristics of tsutsugamushi disease are fever, rash and eschar. However, severe complications might rarely occur, such as acute fulminant myocarditis caused by scrub typhus. Thus, there are few reports of recovery from seriously complicated cases. We report on an adult male with scrub typhus complicated with acute fulminant myocarditis with no previous comorbid illness who recovered successfully with proper treatment including antibiotics, ventilator support, percutaneous cardiopulmonary support, and continuous renal replacement therapy.

Prognostic Value of Elevated Homocysteine Levels in Korean Patients with Coronary Artery Disease: A Propensity Score Matched Analysis

BACKGROUND AND OBJECTIVES: We sought to determine whether an elevated homocysteine (Hcy) level is associated with a worse prognosis in Korean patients with coronary artery disease (CAD). SUBJECTS AND METHODS: A total of 5839 patients (60.4% male, mean age 61.3±11.2 years) with CAD were enrolled from 2000 to 2010 at Gangnam Severance Hospital. CAD was diagnosed by invasive coronary angiography. Laboratory values including Hcy level were obtained on the day of coronary angiography and analyses were performed shortly after sampling. Patients were divided into two groups according to their Hcy levels. Baseline risk factors, coronary angiographic findings, length of follow-up, and composite endpoints including cardiac death (CD) and non-fatal myocardial infarction (NFMI) were recorded. 1:1 propensity score matched analysis was also performed. RESULTS: Over a mean follow-up period of 4.4±2.5 years, there were 132 composite endpoints (75 CD and 57 NFMI) with an event rate of 2.3%. Mean Hcy level was 9.9±4.3 µmol/L (normal Hcy 7.9±1.5 µmol/L and elevated Hcy 13.9±5.1 µmol/L). Kaplan-Meier survival analysis showed an association of elevated Hcy level with worse prognosis (p<0.0001). In addition, a multivariate Cox regression analysis showed an association of elevated Hcy level with worse prognosis for both the entire cohort (hazard ratio [HR] 2.077, 95% confidence interval [CI] 1.467-2.941, p<0.0001) and the propensity score matched cohort (HR 1.982, 95% CI 1.305-3.009, p=0.001). CONCLUSION: Elevated Hcy level is associated with worse outcomes in Korean patients with CAD.

Endoscopic Submucosal Dissection for Recurrent or Residual Superficial Esophageal Cancer after Chemoradiotherapy: Two Cases

We report two cases of endoscopic submucosal dissection (ESD) for recurrent or residual esophageal squamous cell carcinoma (ESCC) lesions after chemoradiotherapy for advanced esophageal cancer. Case 1 involved a 64-year-old man who had previously undergone chemoradiotherapy for advanced ESCC and achieved a complete response (CR) for 22 months, until metachronous recurrent superficial ESCC was detected on follow-up esophagogastroduodenoscopy (EGD). We performed ESD and found no evidence of recurrence for 24 months. Case 2 involved a 59-year-old man who had previously undergone chemoradiotherapy for advanced ESCC. He responded favorably to treatment, and most of the tumor had disappeared on follow-up EGD 4 months later. However, there were two residual superficial esophageal lugol-voiding lesions. We performed ESD, and he had a CR for 32 months thereafter. ESD can be considered a viable treatment option for recurrent or residual superficial ESCC after chemoradiotherapy for advanced esophageal cancer.

A Case of Ampullary Neuroendocrine Tumor Treated by Endoscopic Papillectomy / 대한췌담도학회지

Ampullary neuroendocrine tumor is rare but requires total resection for treatment. Traditionally, pancreatic duodenal resection has been recommended for treatment of ampullary neuroendocrine tumor. Because of the morbidity and mortality associated with surgical resection, endoscopic papillectomy is increasingly used in selected cases with low grade, no metastasis, and no invasion of the pancreatic or bile duct. We present a case of an ampullary neuroendocrine tumor which was successfully and completely resected via endoscopic papillectomy. Endoscopic papillectomy can be a viable alternative for the resection of neuroendocrine tumor at the major duodenal papilla in cases with high surgical risks.

Synchronous Isolated Splenic Metastasis from Colon Cancer

Isolated splenic metastases from colon cancer has been rarely reported in English literatures. Furthermore synchronous isolated splenic metastasis is very rare. We report a 63-year-old man with synchronous isolated splenic meta-stasis from colon cancer. He was suspicious to ascending colon cancer with isolated splenic metastasis by colono-fiberoscope, abdominal CT, fusion PET scan and elevated CEA level. He underwent right hemicolectomy and splenectomy. Histologic examinations revealed colonic adeno-carcinoma with splenic metastasis. He was discharged uneventfully and was planned to take chemotherapy. Although it appears to be rare, splenic mass with colon cancer patient should be evaluated to rule out metastasis and splenectomy for isolated splenic metastasis from colon cancer is warranted.

Analysis of Pouchitis after Restorative Proctocolectomy / 대한소화기학회지

BACKGROUND/AIMS: Pouchitis is one of the most common and debilitating complications of a restorative proctocolectomy. We aimed to analyze the features of pouchitis after restorative proctocolecomy and to determine the risk factors related to its development. METHODS: A study was undertaken in 169 patients who underwent total proctocolectomy with ileal pouch-anal anastomosis between July 1989 and December 2003. Pouchitis was defined as change of bowel habit, change in stool consistency, hematochezia or abdominal pain, febrile sensation and/or low-grade fever improved by metronidazole or ciprofloxacin without evidence of infectious disease and sphincter damage. RESULTS: Among the 169 patients, patients with ulcerative colitis were 64, familial and attenuated adenomatous polyposis 44, Crohn's disease 2, and synchronous or hereditary non-polyposis colorectal cancer were 59 cases. Overall, pouchitis occurred in 15.9% of the patients. The incidence was 37.5% in ulcerative colitis, 1% in non-ulcerative colitis, and 50% in Crohn's disease. In ulcerative colitis group, most of the pouchitis (60.9%) occurred within 6 months after the operation and the remainder experienced the first attack within 1 year after operation. Three patients progressed to chronic pouchitis. There was no association between pouchitis rate and sex, history of smoking, steroid use, temporary ileostomy construction, involvement of appendix or proximal colon, and evidence of indeterminate colitis. Only age was significantly related to the occurrence of pouchitis. CONCLUSIONS: Pouchitis developed exclusively in ulcerative colitis than other disease groups. Pouchitis occurred most frequently within 6 months after the operation, therefore, it is important to investigate carefully during one year after the operation in patients with ulcerative colitis.

Is Routine Nasogastric Intubation Necessary for Elective Colorectal Surgery?: a Prospective Randomized Controlled Trial

PURPOSE: This study was performed to assess the complications and discomfort of patients with or without a nasogastric tube who underwent elective colorectal surgery and to evaluate the efficacy of the routine practice of employing a nasogastric tube after elective colorectal surgery. METHODS: This study involved a prospective, randomized trial of 100 patients undergoing elective colorectal surgery from February to July 2004. The patients were classified as the nasogastric tube inserted group (NG (+), n=50) and non-inserted group (NG (-), n=50). The inclusion criteria were elective colorectal surgery, age under 70 years and no previous abdominal surgery history. The exclusion criteria were an emergent operation, an overt preoperative bowel obstruction and extensive operations such as pouch surgery and multivisceral resection. RESULTS: The mean age of the subjects was 55 (24~70) years old. There was no difference in terms of age, gender, pathological diagnosis and surgical procedures between the NG (-) and NG (+) groups. A sore throat and nausea was more prevalent in the NG (+) group (P=0.000, P=0.046). The gas passage time was shorter in the NG (-) group than in the NG (+) group (P=0.028). The other variables, such as vomiting, postoperative ileus, postoperative fever, posto-perative atelectasis, postoperative leakage, intraoperativedecompression, stool passage time and the length of the hospital stay revealed no difference between the groups. CONCLUSION: Nasogastric intubation is an uncomfortable procedure for patients and offers no benefit in preventing postoperatve complications. The routine use of a nasogastric tube is not necessary in elective colorectal surgery.

Effect of Biofeedback Treatment in Patients with Fecal Incontinence

PURPOSE: We aimed to assess the efficacy of biofeedback therapy for patients with fecal incontinence (FI) according to the etiology. METHODS: Twenty-nine patients with fecal incontinence were treated with biofeedback therapy using a EMG-based system. The efficacy was assessed by using changes in the FI score (Cleveland Clinic, Florida: 0~20) and satisfaction based on a subjective evaluation score from 0 to 100. The median follow up duration was 12 (3~25) months. RESULTS: Ten patients had idiopathic fecal incontinence. Fourteen patients had fecal incontinence due to a sphincter saving operation for rectal cancer. Four cases had spinal cord injury and one patient had a major external sphincter tearing due to trauma. The mean age was 52 (16~78) years. The median number of biofeedback sessions was 10 (3~15) overall. The mean efficacy was 42.8%, and the mean satisfaction score was 56.6. Improvements in the FI score and in the patients' satisfaction varied according to the etiology, 69.5% and 71.5 in the idiopathic group, 28.5% and 49.3 in the postoperative group, and 35% and 24 in the spinal cord injury group. In the idiopathic group, 50% of the patients showed an improvement in the FI score of more than 75%, and 90% of the patients showed an improvement of more than 50%. The number of liquid incontinence episodes was improved 78.3% later in the biofeedback group, and this result was much better than in the postoperative incontinence group (31.8%, p=0.03). CONCLUSIONS: The success rate of the biofeedback therapy for fecal incontinence is acceptable. Subjective satisfaction is relatively higher than the improvement in the ecal incontinence score. Idiopathic fecal incontinence may be the best indication for biofeedback therapy.

Expression of the Low Molecular Weight Cyclin E is Early Event in Colorectal Carcinogenesis / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Cyclin E is essential for the transition from the G1 to S-phase of the cell cycle, and plays important roles in carcinogenesis in many cancers. Especially, low molecular weight cyclin E is overexpressed in breast cancer and its level of expression correlates well with the progression and prognosis. Although the cyclin E level is amplified, and overexpressed, in many cancers, including colorectal cancer, the role of low molecular weight cyclin E in colorectal cancer remains to be studied. Therefore, the expression of low molecular weight cyclin E in various stages of colorectal tumors was studied. MATERIALS AND METHODS: The expression of low molecular weight cyclin E was analyzed in 45 tumors, and compared with paired normal mucosa from the same patients (6 adenomas, 11 stage A, 14 stage B and 14 stage C colorectal cancers) by Western blot analysis. The expres sion of low molecular weight cyclin E was also analyzed in normal colon mucosa from 12 healthy normal controls. RESULTS: The low molecular weight cyclin E was expressed exclusively in all stages of colon tumors, but not in the normal mucosa from the same patients or in the normal controls. However, there was no correlation between tumor progression and the degree of expression of low molecular weight cyclin E. CONCLUSION: The expression of low molecular weight cyclin E is suggested to be an early event in colorectal carcinogenesis.

Result of MAST in bronchial asthma in Pusan area / 알레르기

OBJECTIVES: Allergen is closely related with local features and cultural environment and a new approach method regarding causes triggering aggravation is especially required due to complex and variety of ordinary residence and pollution of living environment recently. We, therefore, performed this study to inspire the necessity of identification of causative afeuts in aothmatic patients in pusan area. METHODS: We measured serum specific IgE antibody by means of chemiluminescent analyzer employing MAST, classified the level from class 0 to 4 and interpreted the result in order to identify allergen on total 262 patients consisted of inpatients and outpatients who had been presumed as extrinisic asthma and treated in this hospital during 2 and a half years from June of 1994 to December of 1996. RESULTS: 1. With regard to sex and age distribution, the rate of men versus women was 1 : 1.3, while in the distribution by age, the twenties and the thirties were the most as 29% and 26% respectively. 2. The result of interpretation of the test showed positive in 75%, 78% of which showed positive reaction compounded of 2 kinds or more. 3. If we take a look at the distribution of total IgE class in the positive area, we can find that ; Class III and class II showed the highest frequency as 47% and 37% respectively. 4. If we take a look at the distribution by age and allergen, the twenties(32%) and the thirties(30%) showed the highest frequency, the fifties, the forties and the teens showed middle frequency as 10~13% and the sixties and the seventies showed the lowest frequency as about 1%. The causative allergen appeared in the order of pollen(40%), dust(20%), food(18%), fungus(13%) and epidermis(8%). 5. The distribution of allergen by season generally showed high rate of positive appearance in spring and fall as pollen appeared in spring(44%) and fall(27%), dust appeared in fall(32%) and summer(23%), food appeared in spring(34%) and fall(29%), fungus appeared in fall(30%) and spring(28%) and epidermis appeared in spring(30%) and fall(28%). 6. With regard to the allergen: (1) In pollen allergens, trees showed higher positive frequency than weeds and trees were in the order of birch(14%), alder(13%) and hazelnut mix(12%) and weeds showed similar positive values. (2) In dust allergens, mite(D. pteronyssinus and D. farinae) showed high positive rate as 39% each. (3) In epidermal allergens, it also showed relatively even positive value among which cat's halr-dandruff was the highest as 40%. (4) In food allergens, shrimp showed the highest as 22% and others were similar as evenly positive values. (5) In fungus allergens, Candida and Stemphylium showed the highest value as 19% each. CONCLUSION: The analysis of allergen by means of MAST could be used as a valuable guide post for identifing cousative antigens for active treatment of extrinsic asthma.