The Timing and Route of Transfer for End-of-Life Care in Cancer Patients

BACKGROUND: We evaluated the timing and route of arrival of patients with cancer referred to a hospital near their residence for end-of-life care.METHODS: The medical records of patients with cancer receiving palliative systemic treatment at other hospitals who were transferred to our hospital for terminal care were reviewed retrospectively.RESULTS: Records of 60 patients (mean age, 57.4 years) were reviewed. The median survival after transfer was 40 days; 56.3% and 43.3% of the patients were referred to the outpatient and emergency departments of our hospital, respectively. Only 45% of the patients were enrolled in the hospice palliative care system. The most common reason for not enrolling was rejection of the patients or their families for hospice palliative care.CONCLUSION: For end-of-life care, the time from the referral to death was short, and many patients were transferred to the emergency department of our hospital.

Neuroprotective mechanisms of dieckol against glutamate toxicity through reactive oxygen species scavenging and nuclear factor-like 2/heme oxygenase-1 pathway

Glutamate toxicity-mediated mitochondrial dysfunction and neuronal cell death are involved in the pathogenesis of several neurodegenerative diseases as well as acute brain ischemia/stroke. In this study, we investigated the neuroprotective mechanism of dieckol (DEK), one of the phlorotannins isolated from the marine brown alga Ecklonia cava, against glutamate toxicity. Primary cortical neurons (100 µM, 24 h) and HT22 neurons (5 mM, 12 h) were stimulated with glutamate to induce glutamate toxic condition. The results demonstrated that DEK treatment significantly increased cell viability in a dose-dependent manner (1–50 µM) and recovered morphological deterioration in glutamate-stimulated neurons. In addition, DEK strongly attenuated intracellular reactive oxygen species (ROS) levels, mitochondrial overload of Ca²⁺ and ROS, mitochondrial membrane potential (ΔΨ(m)) disruption, adenine triphosphate depletion. DEK showed free radical scavenging activity in the cell-free system. Furthermore, DEK enhanced protein expression of heme oxygenase-1 (HO-1), an important anti-oxidant enzyme, via the nuclear translocation of nuclear factor-like 2 (Nrf2). Taken together, we conclude that DEK exerts neuroprotective activities against glutamate toxicity through its direct free radical scavenging property and the Nrf-2/HO-1 pathway activation.

Cockcroft-Gault, Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology Collaboration equations for estimating glomerular filtration rates in cancer patients receiving cisplatin-based chemotherapy

BACKGROUND: Although the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation has been recommended for accurate estimates of glomerular filtration rate (eGFR), there is little information regarding differences in GFR estimates obtained using the Cockcroft-Gault (CG) or Modification of Diet in Renal Disease (MDRD) equations in East Asian cancer patients. We investigated discrepancies in GFR and toxicities in patients treated with cisplatin-based chemotherapy using three equations equations. METHODS: A total of 229 patients were retrospectively recruited. We calculated eGFR using the three equations and separated patients into three categories based on GFR 50 (group C) mL/min/1.73m2. We analyzed chemotherapy toxicities. RESULTS: The mean eGFR calculated using the CG was the lowest of the values derived using the three equations. Estimates using the MDRD and CKD-EPI equations resulted in reclassifying 32 (71.1%) and 33 (73.3%) of 45 patients, originally placed in group B using the CG into group C. However, only 1 (7.7%) of 13 patients placed in group B using the MDRD were reclassified into group C using the CKD-EPI. Twenty-eight of 45 patients classified into group B using the CG equation were treated with reduced doses of cisplatin. However, these patients did not show significant differences in toxicities compared with other patients taking full doses of cisplatin. CONCLUSION: The CG equations underestimated GFR compared to the MDRD and CKD-EPI equations. Therefore, when GFR is estimated using CG equations, East Asian cancer patients may receive insufficient doses of chemotherapeutic agents, including cisplatin.

Two Cases of Hepatic Sinusoidal Dilatation Mimicking Hepatic Metastases / 대한소화기학회지

Hepatic sinusoidal dilatation is a rare benign vascular disorder characterized by focal dilatation of the sinusoidal spaces. In most cases, the underlying etiology is unclear but it may be related to the impairment of venous outflow or sinusoidal infiltration by diverse causes. Diagnosing hepatic sinusoidal dilatation based soley on imaging study is not easy since there are no pathognomonic radiologic findings indicative of this condition. Recently, the authors experience two cases of hepatic sinusoidal infiltration. The first patient was a 53-year-old man detected to have multiple hepatic nodules on ultrasonography (US) during a routine medical check-up. The second patient was an 82-year-old woman with abdominal discomfort who was referred from local clinic with high suspicion of hepatic metastases on US. In both cases, CT scan demonstrated multiple nodules with rim enhancement on arterial phase that became iso-dense to adjacent liver parenchyma on delayed phase. On MRI, these nodules showed rim enhancement on arterial phase, had high signal intensity on T2 weighted images, and became iso-intense with partial defect on hepatobiliary phase. Because imaging studies could not exclude the presence of hepatic metastases, liver biopsy was performed and it demonstrated hepatic sinusoidal dilatation with well preserved reticulin fiber without any evidence of malignancy. Herein, we report two cases of idiopathic hepatic sinusoidal dilatation mimicking hepatic metastases.

Radiation recall dermatitis induced by tamoxifen during adjuvant breast cancer treatment

Tamoxifen and radiotherapy are used in breast cancer treatment worldwide. Radiation recall dermatitis (RRD), induced by tamoxifen, has been rarely reported. Herein, we report a RRD case induced by tamoxifen. A 47-year-old woman had a right quadrantectomy and an axillary lymph node dissection due to breast cancer. The tumor was staged pT2N0; it was hormone receptor positive, and human epidermal growth factor receptor 2 negative. The patient received adjuvant chemotherapy followed by tamoxifen and radiotherapy. After 22 months of tamoxifen, the patient developed a localized heating sensation, tenderness, edema, and redness at the irradiated area of the right breast. The symptoms improved within 1 week without treatment. Three weeks later, however, the patient developed similar symptoms in the same area of the breast. She continued tamoxifen before and during dermatitis, and symptoms resolved within 1 week.

Vascular Complications in Patients with Essential Thrombocythemia / 대한혈액학회지

BACKGROUND: Essential thrombocythemia (ET) has a chronic course, but its main clinical features are thrombosis and hemorrhage. We evaluated the clinical features, including the vascular complications in patients with ET, during the disease courses and we determined the predictable risk factors for major vascular complications. METHODS: From 1991 to 2004, the medical records for 69 patients with ET were retrospectively reviewed for evaluating the clinical features, including the vascular complications, and the predictable risk factors for major vascular complications were analyzed. RESULTS: Major vascular thrombotic and hemorrhagic complications were observed in 16 patients (23.2%) and 6 patients (8.7%) at the time of diagnosis, and in 13 (18.8%) and 9 patients (13.0%) during follow-up. The incidence of major vascular thromboses in the older group (age >60 years) was higher than that in the younger group (< or =60 years) (34.2% vs 9.7%, respectively, P=0.016) at the time of diagnosis. During follow-up, the major vascular thrombosis risk was increased in patients with a previous thrombosis history (37.5% vs 13.2%, respectively, P=0.029) and in patients with 2 or more combined cardiovascular risk factors (44.4% vs 15.0%, respectively, P=0.035). The probability of 10-year survival in patients with thrombo-hemorrhagic complications during the disease course was lower than that in patients without complication (60.5% vs 93.7%, respectively, P=0.046). CONCLUSION: Advanced age, a previous thrombosis history and the combined cardiovascular risk factors were the risk factors for major vascular thrombosis in patients with ET. Prevention of thrombo-hemorrhagic complications is the most important therapeutic goal. Treatment strategies according to risk factors ought to be prospectively investigated.

A Case of Coexistent Chronic Lymphocytic Leukemia and Multiple Myeloma / 대한혈액학회지

Chronic lymphocytic leukemia (CLL) and multiple myeloma (MM) are both lymphoproliferative disease occurring in different stages of B cell oncogeny. An increased incidence of secondary malignancies in patients with CLL is well recognized, however, the coexistence of both disorders in the same patient was very rare. Furthermore, clonal relationship between these diseases has not been clearly established. We report the occurrence of MM during the course of CLL. A 68-year-old patient was presented with general weakness and bone marrow aspiration showed a hypercellular marrow with 80% mature lymphocytes. At 5 months after diagnosis of CLL, bone marrow of the patient showed increased immature plasma cells. Serum protein electrophoresis showed monoclonal gammopathy and serum immunoelectrophoresis IgG kappa type monoclonality. The patient received six cycles of VAD (vincristine, adriamycin, dexamethasone) chemotherapy, but died of pneumonia and sepsis.

Gefitinib Trial in a Fanconi's Anemia Patient with Multiple Squamous Cell Carcinomas and Hepatocellular Carcinoma / Journal of the Korean Cancer Association, 대한암학회지

FA (Fanconi's Anemia) is an autosomal recessive disorder that is characterized by pancytopenia with bone marrow hypoplasia, diverse congenital abnormalities and an increased predisposition towards malignancy. The mainstay of the treatment for these cancers has been surgery, because of the hypersensitive reactions of FA patients to DNA cross- linking agents or radiation. Therefore, there has been no effective therapy for advanced squa mous cell carcinoma. We report here on a patient suffering from advanced multiple squamous cell carcinoma and hepatocellular carcinoma along with an FA, and this patient was treated with gefitinib.

Clinical Features of Chronic Myeloproliferative Disease / 대한혈액학회지

BACKGROUND: Philadephia chromosome negative chronic myeloproliferative disease (CMPD) is a clonal disorder which includes polycythemia vera (PV), essential thrombocythemia (ET) and idiopathic myelofibrosis (IMF). CMPD has chronic course and different clinical features with low rate of conversion to leukemia. We evaluated the clinical features of CMPD. METHODS: Since 1990, 57 cases of CMPD (18 PV, 35 ET and 4 IMF) were analysed and their clinical characteristics, survival and manner of evolution were evaluated retrospectively. RESULTS: Median age of 57 CMPD patients was 61 (range, 14~90) years and male to female ratio was 1:0.8. Most common clinical manifestations were dizziness/weakness (38.6%), headache (21.2%), cardiovascular events (19.3%) and other symptoms. Treatment with hydroxyurea was most frequent during clinical course of CMPD. Anagrelide was introduced in 12 patients recently. Complication of disease itself and treatment was not frequent except bleeding (3 cases) and thrombotic event (10 cases). Conversion to acute lekemia was none. Ten year overall survival was 83.3% in PV, 60.1% in ET and 4 cases of IMF were all alive at the 6 year follow up. CONCLUSION: CMPD is a chronic disease and long term control is much improved but definitive treatment without complication should be further investigated.

Comparison of Midazolam versus Midazolam/Meperidine during Colonoscopy in a Prospective, Randomized, Double-Blind Study / 대한소화기학회지

BACKGROUND/AIMS: Colonoscopy is a painful procedure. Therefore conscious sedation is often used. However, the value of adding analgesics to sedatives has not been well evaluated. METHODS: The double blind, randomized controlled trial was carried out to compare patients' and endoscopist' assessments in both groups of patients: MP (Midazolam/Placebo) group (n=49) received midazolam plus placebo and MM (Midazolam/Meperidine) group (n=51) received midazolam plus meperidine. RESULTS: There was no significant difference of baseline characteristics except previous operation history. There were no significant difference of grade of tolerance, pain and willingness to another colonoscopy between the two groups. In endoscopist' satisfaction, the degree of difficulty was higher in MP group than in MM group (39.0 vs. 31.7,p<0.05). After the colonoscopy, systolic blood pressure, oxygen saturation, and pulse rate were significantly decreased (p<0.05) in both groups. However, there was no difference in the degree of decrease between the two groups. The incidence of adverse effect was not different in the two groups. However, one case of orthostatic hypotension with presyncope was noted in MM group. CONCLUSIONS: Adding meperidine to the midazolam before the colonoscopy does not seem to bring more beneficial effect to patients, whereas endoscopist favored the use of both medications.

The comparison on micro-tensile bond strengths of variable adhesive systems to Class V cavity / 대한치과보존학회지

No abstract available.

Complications of percutaneous endoscopic gastrostomy and risk factors of peristomal wound infection / 대한내과학회지

BACKGROUND: Percutaneous Endoscopic Gastrostomy (PEG) is a widely used method for providing nutritional support for patients who require prolonged tube feeding. This technique is known to be a safer, more convenient, and less expensive procedure than surgical gastrostomy. Although the overall incidence of complication is low, several complications such as peristomal wound infection, bleeding, panperitonitis, gastrocolic fistula, etc. were reported. Among these complications, peristomal wound infection is common and troublesome. METHODS: A retrospective review of medical records was conducted on patients undergoing PEG placement between January 1995 and March 2003. One hundred sixteen cases of 137 cases which were performed during this period were included, excluding 21 cases as exchanges of PEG. We reviewed the complications associated with PEG placement and analyzed the risk factors of peristomal wound infection. RESULTS: In 61 (52.6%) of 116 cases, several complications developed after the procedure. The peristomal wound infection occurred in 37 cases (31.9%) and bleeding in 2 cases (1.7%). Mild complications included peristomal pain in 37 cases (31.9%); stomal leakage in 2 cases (1.7%); and oozing in 1 case (0.9%). The rate of wound infection was significantly higher in patients who had Diabetes mellitus (p<0.01), who had leukocytosis (p<0.05) and who had not received prophylactic antibiotics (p<0.05). But the rate was not different according to age, sex or underlying disease. CONCLUSION: Peristomal wound infection was the most common complication of PEG. Diabetes mellitus and leukocytosis were risk factors of peristomal wound infection after PEG, and prophylactic antibiotics significantly reduced the risk of wound infection.

Eradication Rate of Lansoprazole-Based Triple Therapy in Peptic Ulcer Patients with Helicobacter pylori and Efficacy of Urea Breath Test in Evaluating Helicobater pylori Eradication

BACKGROUND: There are only a few studies on Helicobacter pylori (H. pylori) for its eradication rates of lansoprazole-based triple therapy in Korea, and the results are controversial. Therefore, we undertook to investigate the eradication rate of lansoprazole-based triple therapy, and compare the concordance rate of urea breath test (UBT) and rapid urease test (RUT) in evaluating H. pylori eradication. METHODS: Patients with acute peptic ulcer who were H. pylori-positive were recruited by prospective, consecutive manner. They received lansoprazole 30 mg b.d., amoxicillin 1 g b.d. and clarithromycin 500 mg b.d. for 1 week. Upper endoscopy was performed after 4 weeks to check for ulcer healing, and UBT and RUT were performed to evaluate H. pylori eradication status. RESULTS: A total of 46 patients were recruited, and they were all compliant. H. pylori eradication rate was 87.0% (40/46) and ulcer healing rate was 91.3% (42/46). Forty one patients showed negative in both UBT and RUT, and 4 patients revealed positive in both tests, therefore, the concordance rate of UBT and RUT was 97.8% (45/46). CONCLUSION: Our study showed that 1-week lansoprazole-based triple therapy was effective in H. pylori eradication and ulcer healing. UBT can be an effective, noninvasive method for evaluating H. pylori status after H. pylori eradication.

Eradication Rate of Lansoprazole-Based Triple Therapy in Peptic Ulcer Patients with Helicobacter pylori and Efficacy of Urea Breath Test in Evaluating Helicobater pylori Eradication

BACKGROUND: There are only a few studies on Helicobacter pylori (H. pylori) for its eradication rates of lansoprazole-based triple therapy in Korea, and the results are controversial. Therefore, we undertook to investigate the eradication rate of lansoprazole-based triple therapy, and compare the concordance rate of urea breath test (UBT) and rapid urease test (RUT) in evaluating H. pylori eradication. METHODS: Patients with acute peptic ulcer who were H. pylori-positive were recruited by prospective, consecutive manner. They received lansoprazole 30 mg b.d., amoxicillin 1 g b.d. and clarithromycin 500 mg b.d. for 1 week. Upper endoscopy was performed after 4 weeks to check for ulcer healing, and UBT and RUT were performed to evaluate H. pylori eradication status. RESULTS: A total of 46 patients were recruited, and they were all compliant. H. pylori eradication rate was 87.0% (40/46) and ulcer healing rate was 91.3% (42/46). Forty one patients showed negative in both UBT and RUT, and 4 patients revealed positive in both tests, therefore, the concordance rate of UBT and RUT was 97.8% (45/46). CONCLUSION: Our study showed that 1-week lansoprazole-based triple therapy was effective in H. pylori eradication and ulcer healing. UBT can be an effective, noninvasive method for evaluating H. pylori status after H. pylori eradication.

Comparison of Clinical Significance Between Chest CT Scan and Bronchoscopy Prior to Bronchial Artery Angiography and Outcome of Embolization in Patients with Hemoptysis / 결핵

BACKGROUND: Emergency management in hemoptysis is bronchial artery angiography and embolization. This study was designed to investigate the accuracy of localization of bleeding site by simple roentgenogram, computed tomography(CT) and bronchoscopy prior to embolization and to evaluate the outcome of embolotherapy. METHOD: We retrospectively evaluated 50 patients performed bronchial artery embolization(BAE), admitted to tertiary university hospital due to hemoptysis. RESULTS: The most common causes were pulmonary tuberculosis, old tuberculous related parenchymal damage, aspergilloma, and bronchiectasis. The success rate of BAE within one month was 90%; within 3 months was 88%; during follow up period of mean 11.6 months was 76%. The concordant rate of simple roentgenogram with angiographic outcome in terms of bleeding site is 70%; in chest CT 80%; in bronchoscopy 81%; in combined information of simple roentgenogram and CT 83%; in combined information of simple roentgenogram and bronchoscopy 78%. CONCLUSION: The diagnostic accuracy for the bleeding site was similar between chest CT and bronchoscopy, showing high diagnostic yield. The success rate of BAE was comparative to prior studies. Further study will be needed in a large scale in near future.

Comparison of Clinical Significance Between Chest CT Scan and Bronchoscopy Prior to Bronchial Artery Angiography and Outcome of Embolization in Patients with Hemoptysis / 결핵

BACKGROUND: Emergency management in hemoptysis is bronchial artery angiography and embolization. This study was designed to investigate the accuracy of localization of bleeding site by simple roentgenogram, computed tomography(CT) and bronchoscopy prior to embolization and to evaluate the outcome of embolotherapy. METHOD: We retrospectively evaluated 50 patients performed bronchial artery embolization(BAE), admitted to tertiary university hospital due to hemoptysis. RESULTS: The most common causes were pulmonary tuberculosis, old tuberculous related parenchymal damage, aspergilloma, and bronchiectasis. The success rate of BAE within one month was 90%; within 3 months was 88%; during follow up period of mean 11.6 months was 76%. The concordant rate of simple roentgenogram with angiographic outcome in terms of bleeding site is 70%; in chest CT 80%; in bronchoscopy 81%; in combined information of simple roentgenogram and CT 83%; in combined information of simple roentgenogram and bronchoscopy 78%. CONCLUSION: The diagnostic accuracy for the bleeding site was similar between chest CT and bronchoscopy, showing high diagnostic yield. The success rate of BAE was comparative to prior studies. Further study will be needed in a large scale in near future.

Identification of Patients More Susceptible to Severe Anal Pain after Colonoscopy and Effect of Topical Treatment of Lidocaine Gel in Reducing the Anal Pain: A Prospective, Randomized, Controlled Study (Identification and Management of Patients Susceptibl / 대한소화기내시경학회지

BACKGROUND/AIMS: The aim of this study was to identify which patients are more susceptible to severe anal pain after colonoscopy and to determine the usefulness of lidocaine gel in reducing the anal pain. METHODS: A prospective trial was performed with 150 consecutive outpatients who underwent a colonoscopic examination. The patients were randomized into three groups: they received topical treatment of lidocaine gel (n=48) or lubricant gel (chlorhexidine gluconate) (n=48), or no treatment (n=54) just after the procedure. Data regarding the procedures were collected and the patients were phone-interviewed on the next day. RESULTS: Seventy of 150 (46.7%) had moderate to severe pain (VAS score>or=4). A multiple regression analysis found that the presence of hemorrhoid was significantly (p<0.05) associated with severe anal pain after colonoscopy. Among three groups, there was no significant difference of the pain scores on the procedure day on the next day. However, patients' subjective evaluation about the usefulness of the gel was significantly better in the lidocaine group than in the placebo group in patients who had moderate to severe pain (79.2% vs. 43.5%, p<0.05). CONCLUSIONS: A palliative management is more required for patients who complain moderate to severe pain just after colonoscopy or those with hemorrhoid

Circulating Cytokine Levels and Changes During the Treatment in Patients with Active Tuberculosis in Korea / 결핵

BACKGROUND: The cell-mediated immune reaction to tuberculosis infection involves a complex network of cytokines. The extent of inflammation, tissue damage and severity of the disease suggested to be determined by the balance between extent and duration of the proinflammatory cytokine response versus those of the suppressive cytokines. The systemic cytokine response in pathogenesis of tuberculosis can be assessed by measuring serum cytokine levels. METHOD: Serum interleukin-1 beta(IL-1 ), IL-2, IL-4, IL-6, IL-10, IL-12(p40), tumor necrosis factor-alpha(TNF-alpha), interferon-gamma(IFN-gamma) and transforming growth factor-beta(TGF-beta) levels were measured in 83 patients with pulmonary tuberculosis, 10 patients with endobronchial tuberculosis before treatment and 20 healthy subjects by using a sandwich ELISA. In patients with pulmonary tuberculosis, they were divided into mild, moderate and far advanced group according to the severity by ATS guidelines. To compare with those of pretreatment levels, we measured serum IL-1beta, IL-2, IL-4, IL-6, IL-10, IL-12(p40), TNF-alpha, IFN-gamma and TGF-beta levels in 45 of 83 patients with pulmonary tuberculosis after 2 and 6 months of treatment. RESULTS: 1) In sera of patients with active pulmonary tuberculosis(n=83), IL-1beta, IL-6(p<0.05), TNF-alpha, and IFN-gamma were elevated and TGF-beta was decreased comparing to control. IL-2, IL-12(p40), IL-4 and IL-10 were similar between the patients with tuberculosis and control. 2) In endobronchial tuberculosis, IL-6 and TNF-alpha were elevated and TGF-beta was decreased comparing to control. IL-12(p40) seemed to be elevated comparing to pulmonary tuberculosis. 3) Far advanced tuberculosis showed markedly elevated IL-6 and IFN-gamma level(p<0.05). 4) The significant correlations were noted between IL-1, IL-6 and TNF-alpha and between IL-12, IL-2 and IL-4(p<0.01). 5) After 2 and 6 months of standard treatment, the level of IL-6 and IFN-gamma was significantly decreased(p<0.05). CONCLUSION: These results showed that an altered balance between cytokines is likely to be involved in the extent of inflammation, tissue damage and severity of the disease tuberculosis. But, it should be considered diversities of cytokine response according to type of tuberculosis and immunity in clinical application and interpreting future studies.

A Case of Stercoral Ulcer in the Proximal Colon / 대한소화기내시경학회지

Stercoral ulcer is the ulcerated colonic mucosa due to the pressure effects of hard, scybalous feces. It is a rare clinical entity that usually occurs in the elderly, or the bedridden patients with chronic constipation, and usually located in the rectosigmoid area. If stercoral ulcer is presented with fatal complications such as massive hemorrhage or perforation, emergent operation is needed. There has been very few reports of stercoral ulcer found in the proximal colon. We experienced an unusual case of stercoral ulcer in the proximal colon in a middle-aged woman who had not suffered any organic disease, and she recovered completely after medical conservative treatment only, so we report this case with a review of the literature.

Remission of Intractable Diarrhea in Secondary Amyloidosis Associated with Rheumatoid Arthritis / 대한류마티스학회지

Intractable diarrhea associated with secondary amyloidosis in rheumatoid arthritis (RA) is a serious clinical entity with poor prognosis. We describe a 39-year-old male RA patient who presented with intractable diarrhea. Biopsy findings of terminal ileum and colon revealed amyloidosis secondary to RA. Effective treatment of rheumatoid arthritis resulted in remission of intractable diarrhea caused by amyloid protein deposition.