Identification of Healthy and Unhealthy Lifestyles by a Wearable Activity Tracker in Type 2 Diabetes: A Machine Learning-Based Analysis

Lifestyle is a critical aspect of diabetes management. We aimed to define a healthy lifestyle using objectively measured parameters obtained from a wearable activity tracker (Fitbit) in patients with type 2 diabetes. This prospective observational study included 24 patients (mean age, 46.8 years) with type 2 diabetes. Expectation–maximization clustering analysis produced two groups: A (n=9) and B (n=15). Group A had a higher daily step count, lower resting heart rate, longer sleep duration, and lower mean time differences in going to sleep and waking up than group B. A Shapley additive explanation summary analysis indicated that sleep-related factors were key elements for clustering. The mean hemoglobin A1c level was 0.3 percentage points lower at the end of follow-up in group A than in group B. Factors related to regular sleep patterns could be possible determinants of lifestyle clustering in patients with type 2 diabetes.

Null Association between BRAF V600E Mutation and Tumor Recurrence in Patients with Papillary Thyroid Microcarcinoma in South Korea

Background and Objectives@#The clinical implications of the BRAF V600E mutation in papillary thyroid microcarcinoma (PTMC), defined as ≤1.0 cm of tumor size, remain controversial. We investigated the association between the BRAFV600E mutation and PTMC recurrence in a retrospective cohort of patients with thyroid cancer. @*Materials and Methods@#This study included 2319 patients with PTMC (median age, 50 years [interquartile range (IQR), 41-57 years]) who underwent thyroid surgery from 2010 to 2019 at a single tertiary medical center. The median follow-up time was 75 months (IQR, 30-98 months). Tumor recurrence was confirmed by histological, cytological, radiographic, and biochemical criteria, combined with persistent and recurrent disease. @*Results@#A total of 60.2% (1395/2319) patients with PTMC had the BRAF V600E mutation. The tumor recurrence rate was 2.1% (19/924) in BRAF mutation-negative patients and 2.9% (41/1395) in BRAF mutation-positive patients, with a hazard ratio (HR) of 1.05 (95% confidence interval [CI], 0.61-1.84) after adjusting for clinicopathological risk factors. Similar results were found in patients with high-risk PTMC (adjusted HR, 1.09; 95% CI, 0.56-2.11) who had lymph node metastasis (LNM), extrathyroidal extension (ETE), or distant metastasis (DM) at diagnosis and in patients with low-risk PTMC (adjusted HR, 1.00; 95% CI, 0.35-2.83) who had no LNM, ETE, or DM. @*Conclusion@#The finding that the BRAF V600E mutation was not associated with tumor recurrence in our cohort of Korean patients with PTMC, especially in patients with low-risk PTMC, suggests that its value in the prediction of disease progression is limited.

Role of Interleukin-7 in the Development of and Recovery from Radiation-Induced Lymphopenia: A Post-hoc Analysis of a Prospective Cohort / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#Radiation-induced lymphopenia is associated with worse outcomes in solid tumors. We assessed the impact of interleukin-7 (IL-7), a key cytokine in lymphocyte homeostasis, on radiation-induced lymphopenia. @*Materials and Methods@#A post-hoc analysis was performed in a prospective cohort of 98 patients with hepatocellular carcinoma who were treated with radiotherapy in 2016-2018. Blood IL-7 levels were assayed before and at the end of radiotherapy. Acute severe lymphopenia (ASL) was defined as a total lymphocyte count of < 200/μL during radiotherapy. Cox and logistic regression analyses were performed to identify predictors of survival and ASL development, respectively. @*Results@#Patients with ASL (n=41) had significantly poorer overall survival than those without (12.0 months vs. 25.3 months, p=0.001). Patients with lymphocyte recovery showed significantly longer overall survival than those without (21.8 months vs. 10.3 months, p=0.042). ASL was an independent predictor of poor survival (hazard ratio, 2.07; p=0.015). Patients with ASL had significantly lower pre-radiotherapy IL-7 levels (2.07 pg/mL vs. 3.01 pg/mL, p=0.010). A high pre-radiotherapy IL-7 level was an independent predictor of a reduced risk of ASL development (hazard ratio, 0.40; p=0.004). IL-7 levels reflected a feedback response to ASL, with a higher ΔIL-7 in patients with ASL and a lower ΔIL-7 in those without ASL (0.48 pg/mL vs. –0.66 pg/mL, p < 0.001). Post-radiotherapy IL-7 levels were significantly positively correlated with the total lymphocyte counts at 2 months. @*Conclusion@#IL-7 is associated with the development of and recovery from ASL, which may impact survival. To overcome radiation-induced lymphopenia, a novel strategy using IL-7 may be considered.

Diagnosis for Pheochromocytoma and Paraganglioma: A Joint Position Statement of the Korean Pheochromocytoma and Paraganglioma Task Force

Pheochromocytoma and paraganglioma (PPGLs) are rare catecholamine-secreting neuroendocrine tumors but can be life-threatening. Although most PPGLs are benign, approximately 10% have metastatic potential. Approximately 40% cases are reported as harboring germline mutations. Therefore, timely and accurate diagnosis of PPGLs is crucial. For more than 130 years, clinical, molecular, biochemical, radiological, and pathological investigations have been rapidly advanced in the field of PPGLs. However, performing diagnostic studies to localize lesions and detect metastatic potential can be still challenging and complicated. Furthermore, great progress on genetics has shifted the paradigm of genetic testing of PPGLs. The Korean PPGL task force team consisting of the Korean Endocrine Society, the Korean Surgical Society, the Korean Society of Nuclear Medicine, the Korean Society of Pathologists, and the Korean Society of Laboratory Medicine has developed this position statement focusing on the comprehensive and updated diagnosis for PPGLs.

Time to Reach Target Glycosylated Hemoglobin Is Associated with Long-Term Durable Glycemic Control and Risk of Diabetic Complications in Patients with Newly Diagnosed Type 2 Diabetes Mellitus: A 6-Year Observational Study

Background@#To evaluate the association of time to reach the target glycosylated hemoglobin (HbA1c) level with long-term durable glycemic control and risk of diabetic complications in patients with newly diagnosed type 2 diabetes mellitus (T2DM). @*Methods@#In a longitudinal observational cohort, 194 patients with T2DM newly diagnosed between January 2011 and March 2013 were followed up over 6 years. Patients were classified according to the time needed to reach the target HbA1c (<7.0%): <3, 3 to 6 (early achievement group), and ≥6 months (late achievement group). Risks of microvascular complications including diabetic retinopathy, nephropathy, and neuropathy as well as macrovascular events including ischemic heart disease, ischemic stroke, and peripheral arterial disease were assessed by multivariable Cox proportional hazards analysis. @*Results@#During a median follow-up of 6.53 years, 66 microvascular and 14 macrovascular events occurred. Maintenance of durable glycemic control over 6 years was more likely in the early achievement groups than in the late achievement group (34.5%, 30.0%, and 16.1% in <3, 3 to 6, and ≥6 months, respectively, P=0.039). Early target HbA1c achievement was associated with lower risk of composite diabetic complications (adjusted hazard ratio [HR, 0.47; 95% confidence interval [CI], 0.26 to 0.86 in <3 months group) (adjusted HR, 0.50; 95% CI, 0.23 to 1.10 in 3 to 6 months group, in reference to ≥6 months group). Similar trends were maintained for risks of microvascular and macrovascular complications, although statistical significance was not reached for macrovascular complications. @*Conclusion@#Early target HbA1c achievement was associated with long-term durable glycemic control and reduced risk of diabetic complications in newly diagnosed T2DM.

Statin Therapy and the Risk of Osteoporotic Fractures in Patients with Metabolic Syndrome: a Nested Case-Control Study

Objective@#We aimed to investigate the association between statin use and the risk of major osteoporotic fractures in patients with metabolic syndrome (MetS). @*Methods@#A nested case-control study was performed in patients with MetS (≥50 years) who had no history of osteoporotic fracture using the Korean National Health Insurance ServiceHealth Screening Cohort. This study included 17,041 patients diagnosed with new-onset osteoporotic fractures and controls matched in a 1:1 ratio by age, sex, body mass index, cohort entry date, and follow-up duration. Conditional logistic regression analysis was used to evaluate covariate-adjusted odds ratios (ORs) and 95% confidence intervals (CIs). @*Results@#During a 4-year follow-up period, the risk of major osteoporotic fractures was significantly reduced by 9% (OR, 0.91; 95% CI, 0.85–0.97) in statin users compared with that in non-users. Among subtypes of major osteoporotic fracture, a risk reduction with statin therapy was significant for vertebral fracture (OR, 0.86; 95% CI, 0.79–0.94) but not for non-vertebral fracture (OR, 0.97; 95% CI, 0.88–1.06). Longer duration (OR, 0.97; 95% CI, 0.96–0.99, per 1-year increase) and higher cumulative dose (OR, 0.97; 95% CI, 0.95–0.99, per 365 defined daily doses) of statins were negatively associated with the risk of major osteoporotic fracture. @*Conclusion@#This study supports the hypothesis that statin therapy has a beneficial effect on major osteoporotic fractures, especially vertebral fractures, in patients with MetS.

Diagnosis for Pheochromocytoma and Paraganglioma: A Joint Position Statement of the Korean Pheochromocytoma and Paraganglioma Task Force

Pheochromocytoma and paraganglioma (PPGLs) are rare catecholamine-secreting neuroendocrine tumors but can be life-threatening. Although most PPGLs are benign, approximately 10% have metastatic potential. Approximately 40% cases are reported as harboring germline mutations. Therefore, timely and accurate diagnosis of PPGLs is crucial. For more than 130 years, clinical, molecular, biochemical, radiological, and pathological investigations have been rapidly advanced in the field of PPGLs. However, performing diagnostic studies to localize lesions and detect metastatic potential can be still challenging and complicated. Furthermore, great progress on genetics has shifted the paradigm of genetic testing of PPGLs. The Korean PPGL task force team consisting of the Korean Endocrine Society, the Korean Surgical Society, the Korean Society of Nuclear Medicine, the Korean Society of Pathologists, and the Korean Society of Laboratory Medicine has developed this position statement focusing on the comprehensive and updated diagnosis for PPGLs.

Time to Reach Target Glycosylated Hemoglobin Is Associated with Long-Term Durable Glycemic Control and Risk of Diabetic Complications in Patients with Newly Diagnosed Type 2 Diabetes Mellitus: A 6-Year Observational Study

Background@#To evaluate the association of time to reach the target glycosylated hemoglobin (HbA1c) level with long-term durable glycemic control and risk of diabetic complications in patients with newly diagnosed type 2 diabetes mellitus (T2DM). @*Methods@#In a longitudinal observational cohort, 194 patients with T2DM newly diagnosed between January 2011 and March 2013 were followed up over 6 years. Patients were classified according to the time needed to reach the target HbA1c (<7.0%): <3, 3 to 6 (early achievement group), and ≥6 months (late achievement group). Risks of microvascular complications including diabetic retinopathy, nephropathy, and neuropathy as well as macrovascular events including ischemic heart disease, ischemic stroke, and peripheral arterial disease were assessed by multivariable Cox proportional hazards analysis. @*Results@#During a median follow-up of 6.53 years, 66 microvascular and 14 macrovascular events occurred. Maintenance of durable glycemic control over 6 years was more likely in the early achievement groups than in the late achievement group (34.5%, 30.0%, and 16.1% in <3, 3 to 6, and ≥6 months, respectively, P=0.039). Early target HbA1c achievement was associated with lower risk of composite diabetic complications (adjusted hazard ratio [HR, 0.47; 95% confidence interval [CI], 0.26 to 0.86 in <3 months group) (adjusted HR, 0.50; 95% CI, 0.23 to 1.10 in 3 to 6 months group, in reference to ≥6 months group). Similar trends were maintained for risks of microvascular and macrovascular complications, although statistical significance was not reached for macrovascular complications. @*Conclusion@#Early target HbA1c achievement was associated with long-term durable glycemic control and reduced risk of diabetic complications in newly diagnosed T2DM.

Genetic Analysis and Clinical Characteristics of Hereditary Pheochromocytoma and Paraganglioma Syndrome in Korean Population

Background@#Pheochromocytoma and paragangliomas (PPGL) are hereditary in approximately 30% to 40% cases. With the advancement of genetic analysis techniques, including next-generation sequencing (NGS), there were attempts to classify PPGL into molecular clusters. With NGS being applied to clinical settings recently, we aimed to review the results of genetic analysis, including NGS, and investigate the association with clinical characteristics in Korean PPGL patients. @*Methods@#We reviewed the medical records of PPGL patients who visited Severance hospital from 2006 to 2019. We documented the clinical phenotype of those who underwent targeted NGS or had known germline mutations of related genes. @*Results@#Among 57 PPGL patients, we found 28 pathogenic germline mutations of susceptibility genes. Before the targeted NGS was implemented, only obvious syndromic feature lead to the Sanger sequencing for the specific genes. Therefore, for the exact prevalence, only patients after the year 2017, when targeted NGS was added, were included (n=43). The positive germline mutations were found in 14 patients; thus, the incidence rate is 32.6%. Patients with germline mutations had a higher likelihood of family history. There were significant differences in the type of PPGLs, percentage of family history, metastasis rate, presence of other tumors, and biochemical profile among three molecular clusters: pseudohypoxic tricarboxylic acid cycle-related, pseudohypoxic von Hippel-Lindau (VHL)/endothelial PAS domain-containing protein 1-related, and kinase-signaling group. Germline mutations were identified in seven PPGL-related genes (SDHB, RET, VHL, NF1, MAX, SDHA, and SDHD). @*Conclusion@#We report the expected prevalence of germline mutations in Korean PPGL patients. NGS is a useful and accessible tool for genetic analysis in patients with PPGLs, and further research on molecular classification is needed for precise management.

Genetic Analysis and Clinical Characteristics of Hereditary Pheochromocytoma and Paraganglioma Syndrome in Korean Population

Background@#Pheochromocytoma and paragangliomas (PPGL) are hereditary in approximately 30% to 40% cases. With the advancement of genetic analysis techniques, including next-generation sequencing (NGS), there were attempts to classify PPGL into molecular clusters. With NGS being applied to clinical settings recently, we aimed to review the results of genetic analysis, including NGS, and investigate the association with clinical characteristics in Korean PPGL patients. @*Methods@#We reviewed the medical records of PPGL patients who visited Severance hospital from 2006 to 2019. We documented the clinical phenotype of those who underwent targeted NGS or had known germline mutations of related genes. @*Results@#Among 57 PPGL patients, we found 28 pathogenic germline mutations of susceptibility genes. Before the targeted NGS was implemented, only obvious syndromic feature lead to the Sanger sequencing for the specific genes. Therefore, for the exact prevalence, only patients after the year 2017, when targeted NGS was added, were included (n=43). The positive germline mutations were found in 14 patients; thus, the incidence rate is 32.6%. Patients with germline mutations had a higher likelihood of family history. There were significant differences in the type of PPGLs, percentage of family history, metastasis rate, presence of other tumors, and biochemical profile among three molecular clusters: pseudohypoxic tricarboxylic acid cycle-related, pseudohypoxic von Hippel-Lindau (VHL)/endothelial PAS domain-containing protein 1-related, and kinase-signaling group. Germline mutations were identified in seven PPGL-related genes (SDHB, RET, VHL, NF1, MAX, SDHA, and SDHD). @*Conclusion@#We report the expected prevalence of germline mutations in Korean PPGL patients. NGS is a useful and accessible tool for genetic analysis in patients with PPGLs, and further research on molecular classification is needed for precise management.

Association of Geriatric Syndromes with Urinary Incontinence according to Sex and Urinary-Incontinence-Related Quality of Life in Older Inpatients: A Cross-Sectional Study of an Acute Care Hospital / 가정의학회지

BACKGROUND: Geriatric syndromes are associated with morbidity and poor quality of life (QOL). Urinary incontinence (UI) is one of the most prevalent geriatric syndromes. However, there is little research on the association of UI and UI-related QOL with other geriatric syndromes. We investigated the relationship between geriatric syndromes and UI according to gender and UI-related QOL among older inpatients. METHODS: This study was conducted among 444 older inpatients (aged 65 years and older) between October 2016 and July 2017. We examined geriatric syndromes and related factors involving cognitive impairment, delirium, depression, mobility decline, polypharmacy, undernutrition, pain, and fecal incontinence. UI-related QOL was assessed using the International Consultation on Incontinence Questionnaire-Short Form. Multiple logistic regression analysis was used to evaluate these associations. RESULTS: Geriatric syndromes and related factors were associated with UI. Mobility decline (odds ratio [OR], 4.16; 95% confidence interval [CI], 2.29–7.56), polypharmacy (OR, 3.35; 95% CI, 1.89–5.92), and pain (OR, 6.80; 95% CI, 3.53–13.09) were related to UI in both genders. Especially, delirium (OR, 7.55; 95% CI, 1.61–35.44) and fecal incontinence (OR, 10.15; 95% CI, 2.50–41.17) were associated with UI in men, while cognitive impairment (OR, 4.19; 95% CI, 1.14–15.44) was significantly associated with UI in women. Patients with depression were more likely to have poor UI-related QOL (OR, 8.54; 95% CI, 1.43–51.15). CONCLUSION: UI was associated with different geriatric syndromes and related factors according to gender. Care for patients with depression, related to poor UI-related QOL, should be considered in primary care to improve the UIrelated QOL of these individuals.

Mobile Text Messaging Interventions for Smoking Cessation: A Systematic Review

BACKGROUND: Smoking is one of the most serious health problems worldwide. The aim of this systematic review was to demonstrate the effect of text messaging-based interventions on smoking cessation.METHODS: Electronic databases were searched using specific key terms. The inclusion criteria were (1) articles that employed a randomized controlled trial and (2) articles that examined the effect of text messaging interventions on smoking cessation. However, studies employing multimedia messaging service and smartphone apps were excluded.RESULTS: In total, six randomized controlled trial studies with seven interventions were included in this systematic review. Of these six studies, almost all concluded that text-messaging interventions had no significant effect on smoking cessation. However, one study conducted in England revealed that text messaging intervention groups had a higher rate of six-month prolonged abstinence from smoking than did the control group.CONCLUSION: Text messaging interventions could be effective for those who want to quit smoking. We aimed to determine the effectiveness of using text messaging interventions for smoking cessation. However, there were only six studies that employed randomized controlled trials to determine such effectiveness. More studies on the effect of text messaging interventions for smoking cessation using subjects from various age groups and socioeconomic backgrounds are needed in the future.

Inter-alpha Inhibitor H4 as a Potential Biomarker Predicting the Treatment Outcomes in Patients with Hepatocellular Carcinoma / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Early prediction of treatment outcomes represents an essential step towards increased treatment efficacy and survival in patients with hepatocellular carcinoma (HCC). In this study, we performed two-dimensional electrophoresis (2-DE) followed by protein profiling to identify biomarkers predictive of therapeutic outcomes in patients with HCC who received liver-directed therapy (LDTx) involving local radiotherapy (RT), and studied the underlying mechanisms of the identified proteins. MATERIALS AND METHODS: 2-DE analysis was conducted by pooling sera from patients with a good or poor prognosis; serum proteomic profiles of the two groups were compared and analyzed using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Identified proteins were confirmed via enzyme-linked immunosorbent assay. An invasion assay was performed after overexpression and knockdown of target protein in Huh7 cells. RESULTS: Levels of inter-alpha inhibitor H4 (ITIH4), fibrinogen gamma chain, keratin 9/1 complex, carbonic anhydrase I, and carbonmonoxyhemoglobin S were changed by more than 4-fold in response to LDTx. In particular, pre-LDTx ITIH4 expression was more than 5-fold higher in patients with a good prognosis, compared to patients with a poor prognosis. The migration ability of Huh7 cells was significantly suppressed and enhanced by ITIH4 overexpression and knockdown, respectively. The tumors of patients with HCC and a good prognosis expressed high levels of ITIH4, compared to those of patients with a poor prognosis. CONCLUSION: Taken together, ITIH4 may be a potential therapeutic target that could inhibit cancer metastasis, as well as a prognostic marker for patients with HCC who are receiving LDTx.

Determinants of Long-Term Durable Glycemic Control in New-Onset Type 2 Diabetes Mellitus

BACKGROUND: Long-term durable glycemic control is a difficult goal in the management of type 2 diabetes mellitus (T2DM). We evaluated the factors associated with durable glycemic control in a real clinical setting. METHODS: We retrospectively reviewed the medical records of 194 new-onset, drug-naïve patients with T2DM who were diagnosed between January 2011 and March 2013, and were followed up for >2 years. Glycemic durability was defined as the maintenance of optimal glycemic control (glycosylated hemoglobin [HbA1c] <7.0%) for 2 years without substitution or adding other glucose-lowering agents. Clinical factors and glycemic markers associated with glycemic durability were compared between two groups: a durability group and a non-durability group. RESULTS: Patients in the durability group had a higher baseline body mass index (26.1 kg/m² vs. 24.9 kg/m²) and lower HbA1c (8.6% vs. 9.7%) than the non-durability group. The initial choice of glucose-lowering agents was similar in both groups, except for insulin and sulfonylureas, which were more frequently prescribed in the non-durability group. In multiple logistic regression analyses, higher levels of education, physical activity, and homeostasis model assessment of β-cell function (HOMA-β) were associated with glycemic durability. Notably, lower HbA1c (<7.0%) at baseline and first follow-up were significantly associated with glycemic durability (adjusted odds ratio [OR], 7.48; 95% confidence interval [CI], 2.51 to 22.3) (adjusted OR, 9.27; 95% CI, 1.62 to 53.1, respectively), after adjusting for confounding variables including the types of glucose-lowering agents. CONCLUSION: Early achievement of HbA1c level within the glycemic target was a determinant of long-term glycemic durability in new-onset T2DM, as were higher levels of education, physical activity, and HOMA-β.

Importance-performance Analysis of Patients' and Nurses' perspectives on Rehabilitation Nursing Services / 재활간호학회지

PURPOSE: This study attempted to understand patients' and nurses' perspectives on the priority of rehabilitation nursing services using Importance-Performance Analysis (IPA). METHODS: This study used descriptive research design. Data were collected from 121 patients and 144 nurses using self-reported questionnaires. Statistical analysis included an independent t-test, analysis of variance (ANOVA), and IPA conducted using SPSS/WIN 21.0 version. RESULTS: There were no statistical differences between the patients' and nurses' mean scores on perceptions of the importance (t=-0.83, p=.409) and performance (t=-0.32, p=.751) of rehabilitation nursing services. The IPA matrix showed a difference between patients and nurses in terms of their perceived priority of nursing services. Regarding the perception of patients, "helping a patient to continue to practice bedside physiotherapy and occupational therapy", "providing information on the proper care agency and community resources", and "providing education for the prevention of complications" fell in the "concetrate here" area (2nd quadrant). CONCLUSION: The results showed that the priorities of patients and nurses did not match in terms of some of the rehabilitation nursing services. Thus, rehabilitation nursing services need to be provided based on the patients' needs. Allocation of resources for the service items that fell in the "concentrate here" area of the IPA need be reconsidered for the quality in nursing care.

A clinical study on the trocar-guided mesh repair system for pelvic organ prolapse surgery

OBJECTIVE: To evaluate the complication and recurrence rates in patients undergoing trocar-guided mesh implant for pelvic organ prolapse (POP) treatment. METHODS: A retrospective study was performed based on the medical records of patients who had undergone mesh implant by one surgeon from May 2006 to August 2013 at the Presbyterian Medical Center in Korea. We evaluated perioperative complications such as bladder injury, mesh exposure, urinary symptoms, infections, and chronic pelvic pain. Recurrence was defined as a POP-quantification system stage ≥II or any symptomatic prolapse. RESULTS: Sixty-seven patients were evaluated, and the mean age of patients was 65.4±7.2 years. Stage ≥III POP-quantification Ba was noted in 61 patients (91%). Intraoperative complications included three cases of bladder injury (4.5%). The mean follow-up period was 44.1±7.9 months. Postoperative complications occurred in seven women (10.5%): four cases of urinary symptoms (6%), two cases of infections (3%), and one case of chronic pelvic pain (1.5%). Mesh exposure did not occur (0%). Prolapse recurrence was reported in five patients (7.5%). CONCLUSION: Based on our operational result, the trocar-guided mesh implant seems to provide safe and effective outcomes.

Interferon-Alpha Induced Severe Hypothyroidism Followed by Graves' Disease in a Patient Infected with Hepatitis C Virus

Interferon-alpha (IFN-alpha) is an important therapeutic agent for hepatitis C virus (HCV) infection, but has various side effects including thyroiditis. We report a case of interferon-induced non-autoimmune hypothyroidism followed by autoimmune-medicated Graves' disease. A 59-year-old woman was diagnosed with chronic active hepatitis C; she had been treated with IFN-alpha and ribavirin for 24 weeks. Before starting the IFN-alpha, her thyroid function was normal and she was negative for autoantibodies. Severe hypothyroidism developed 5 weeks after halting the IFN-alpha, with the Graves' disease phase arising at 32 weeks. For accurate diagnosis and appropriate treatment of thyroid dysfunction during treatment with IFN-alpha, we need to understand and consider rare cases of multiphasic disorder involving both non-autoimmune and autoimmune thyroiditis induced by IFN-alpha.

Primary Hyperparathyroidism with Extensive Brown Tumors and Multiple Fractures in a 20-Year-Old Woman

A brown tumor is a benign fibrotic, erosive bony lesion caused by localized, rapid osteoclastic turnover, resulting from hyperparathyroidism. Although brown tumors are one of the most pathognomonic signs of primary hyperparathyroidism, they are rarely seen in clinical practice. In this report, we present a case of 20-year-old woman with recurrent fractures and bone pain. Plain digital radiographs of the affected bones revealed multiple erosive bone tumors, which were finally diagnosed as brown tumors associated with primary hyperparathyroidism due to a parathyroid adenoma. This case shows that multiple, and clinically severe form of brown tumors can even occur in young patients.

A Rare Manifestation of Hypothyroid Myopathy: Hoffmann's Syndrome

Hypothyroid myopathy is observed frequently and the resolution of the clinical manifestations of myopathy following thyroid hormone replacement is well known. However, a specific subtype of hypothyroid myopathy, Hoffmann's syndrome, characterized by increased muscular mass (pseudohypertrophy), proximal muscle weakness, muscle stiffness and cramps, is rarely reported. Herein, we describe a 34-year-old male who presented with proximal muscle weakness and non-pitting edema of the lower extremities. He initially visited the neurology department where he was suspected of having polymyositis. Additional laboratory evaluation revealed profound autoimmune hypothyroidism and elevated muscle enzymes including creatine kinase. The patient was started on levothyroxine treatment and, subsequently, clinical symptoms and biochemical parameters resolved with the treatment. The present case highlights that hypothyroidism should be considered in the differential diagnosis of musculoskeletal symptoms even in the absence of overt manifestations of hypothyroidism. To our knowledge, this is the first case reported in Korea.

Uncommon Ocular Manifestations of Neurofibromatosis: Case Report and Review

PURPOSE: To report and review several cases of uncommon ocular manifestations in neurofibromatosis patients. CASE SUMMARY: A 19-year-old woman diagnosed with type 2 neurofibromatosis visited our hospital with amblyopia of the right eye and mild visual disturbance of the left eye. Best corrected visual acuity was 20/250 in the right eye, 20/25 in the left eye and relative afferent pupillary defect in the right eye was observed. Fundus examination of both eyes showed papilledema. Magnetic resonance imaging showed schwannoma from the optic nerve to the optic chiasm. A 28-year-old woman diagnosed with type 2 neurofibromatosis visited our hospital with amblyopia of the right eye. Best corrected visual acuity was finger count in the right eye, 20/20 in the left eye and relative afferent pupillary defect in the right eye was observed. Fundus examination of the right eye showed a slightly elevated lesion at the macula, as well as dragged optic disc and retinal vessels to the macula. An 8-year-old girl diagnosed with type 1 neurofibromatosis visited our hospital with enophthalmos and strabismus of the left eye. On exophthalmometry, enophthalmos in the left eye was found; measurements were 15.0 mm in the right eye and 13.0 mm in the left eye. Three-dimensional computed tomography revealed sphenoidal hypoplasia and a left lateral orbital wall defect. CONCLUSIONS: The authors of the present study report on neurofibromatosis patients who had an uncommon ocular manifestation. Neurofibromatosis can represent various ocular manifestations but reports of compressive optic neuropathy, dragged disc syndrome and sphenoidal hypoplasia are rare.