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Volume 31(2); December 2016
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Original article
The Role of Vitamin D in Menopausal Medicine
Mijin Kim, Tae-Hee Kim, Hae-Hyeog Lee, Heung Yeol Kim, Min-Jung Oh
Kosin Med J. 2016;31(2):97-102.   Published online January 20, 2016
DOI: https://doi.org/10.7180/kmj.2016.31.2.97
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Abstract

Menopause is the time at which menstruation stops in women. After menopause, women are more susceptible to some diseases, especially osteoporosis and cardiovascular disease. Vitamin D has a protective effect against osteoporosis by facilitating the absorption of calcium and affecting parathyroid hormone. Vitamin D also affects cardiovascular function by lowering the blood pressure, which affects the renin–angiotensin system and alters the low-density lipoprotein receptor activity. This paper discusses supplemental vitamin D in postmenopausal women with osteoporosis and cardiovascular disease.

Review article
Women, Stress and Heart Health: Mindfulness-Based Stress Reduction and Cardiovascular Disease
Kyoung-Im Cho
Kosin Med J. 2016;31(2):103-112.   Published online January 20, 2016
DOI: https://doi.org/10.7180/kmj.2016.31.2.103
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Abstract

Psychological stress including depression and anxiety are independent risk factors for cardiovascular disease morbidity and mortality, especially in women. Emotional regulation plays a mediating role in the development of depression and physical illness, and can alter resting physiologic responses associated with the stress response. Mindfulness-based stress reduction (MBSR) is a structured group program that employs mindfulness meditation to alleviate suffering associated with physical, psychosomatic, and psychiatric disorders. MBSR was originally developed for the management of chronic pain, which is now used widely to reduce psychological morbidity associated with chronic illnesses and to treat emotional and behavioral disorders. In cardiovascular disease, MBSR may be helpful for controlling several risk factors for coronary heart disease such as hypertension, type 2 diabetes mellitus, dyslipidemia, oxidative and psychosocial stress, obesity, and smoking, and improvements in submaximal exercise responses and heart rate variability. Although the most effective mode of stress reduction therapy is yet to be established, increasing recognition is being given to MBSR therapy.

Original articles
The Synergistic Effect of Intrathecally Administered Dexmedetomidine and Ketorolac on Mechanical Allodynia in Rats with Spinal Nerve Ligation
Yong Kwan Cheong, Yeon Dong Kim, Ju Hwan Lee, Hyang Do Ham, Seung Won Choi, Seon Jeong Park
Kosin Med J. 2016;31(2):113-121.   Published online January 20, 2016
DOI: https://doi.org/10.7180/kmj.2016.31.2.113
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Abstract Objectives

This research was carried out to identify the synergistic effect of dexmedetomidine and ketorolac on neuropathic pain alleviation.

Methods

The anti-allodynic effect of intrathecal dexmedetomidine and ketorolac was investigated in rats after L5 spinal nerve ligation (SNL). Mechanical allodynia was assessed using Von Frey filaments. Every day for 3 consecutive days, beginning on the 10th day after SNL, behavioral tests were carried out at 1, 2, and 4 hr after drug injection.

Results

Significant increases in ipsilateral paw withdrawal thresholds (PWTs) were observed 1, 2, and 4 hr after drug injection in the groups of rats which received intrathecal injection of either dexmedetomidine (group D) or ketorolac (group K), compared to group S (P< 0.05). And group DK, which received simultaneous intrathecal injection of both dexmedetomidine and ketorolac, showed statistically significantly higher ipsilateral PWTs than groups D and K, which received only one of them (P< 0.05).

Conclusions

The results of this research demonstrated the anti-allodynic effect of dexmedetomidine and ketorolac on neuropathic pain induced by SNL in rats. They also suggest that synergistic analgesia can be induced by the simultaneous injection of dexmedetomidine and ketorolac, and that combination therapy is an effective approach to treating chronic neuropathic pain syndrome.

Prognostic Significance of Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio in Diffuse Large B-Cell Lymphoma Patients Treated with R-CHOP
Lee Chun Park, Ho Sup Lee, Eun Mi Lee, Seong Hoon Shin, Yang Soo Kim
Kosin Med J. 2016;31(2):122-133.   Published online January 20, 2016
DOI: https://doi.org/10.7180/kmj.2016.31.2.122
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Abstract Objectives

The both values of neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) were reported as indexes of systemic inflammation and readily available and inexpensive prognostic markers in patients with solid cancer. The objective of this study was to clarify whether the NLR and PLR were significant prognostic markers in Korean diffuse large B-cell lymphoma (DLBCL) patients treated with R-CHOP as a first line therapy.

Methods

: We retrospectively collected the clinical data of ninety nine DLBCL patients treated with R-CHOP from 2004 to 2012 and analyzed. NLR and PLR were calculated from complete blood count (CBC) and differential leukocyte count.

Results

: In univariate analysis, NLR was significantly associated with 5-year progression free survival(PFS) rate (P= 0.039), but not significantly associated with 5-year overal survival (OS) rate (P= 0.276). PLR was not significantly associated with 5-year PFS (P= 0.632) and OS rate (P= 0.855). In multivariate analysis, NLR was not a significant independent prognostic factor for 5-year PFS (P= 0.415) and OS rate (P= 0.991).

Conclusion

: The NLR can be considered a useful predictor of survival outcome. The PLR is not a valid predictor of survival outcome.

A Computer-Assisted, Real-Time Feedback System for Medical Students as a Tool for Web-Based Learning
Hyunyong Hwang
Kosin Med J. 2016;31(2):134-145.   Published online January 20, 2016
DOI: https://doi.org/10.7180/kmj.2016.31.2.134
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Abstract Objectives

Medical students sometimes do not receive proper feedback from their instructors. This study evaluated a newly developed automated and personalized real-time feedback system intended to address this issue.

Methods

Third- and fourth-year medical students participated in quizzes focusing on 17 learning objectives and a five-scale survey that queried their prior knowledge related to blood transfusions. Immediately after completing the quizzes, the students received automated and personalized, real-time feedback and were instructed to take part in self-directed learning. This activity was followed by a final quiz. After completion of the final quiz, the students responded to the five-scale survey that probed the usefulness of and satisfaction with the automated, personalized, real-time feedback system.

Results

Eighty students took part in this study. The third-year group had a higher score for prior knowledge and also on the first quiz (P= 0.008, P= 0.046, respectively). There was no significant difference in final quiz scores between the third- and fourth-year groups (P= 0.633). The scores for usefulness of and satisfaction with the automated, real-time feedback system were 4.45 and 4.34, and 4.55 and 4.40 in the third- and fourth-year students, respectively.

Conclusions

The automated, personalized, real-time feedback system provided timely and effective feedback for medical students and was helpful for their self-directed learning.

Predictive Factors for the Therapeutic Response to Concomitant Treatment with DPP-4 Inhibitors in Type 2 Diabetes with Short-Term Follow-Up
Jong-Ha Baek, Bo Ra Kim, Jeong Woo Hong, Soo Kyoung Kim, Jung Hwa Jung, Jaehoon Jung, Jong Ryeal Hahm
Kosin Med J. 2016;31(2):146-156.   Published online January 20, 2016
DOI: https://doi.org/10.7180/kmj.2016.31.2.146
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Abstract Objectives

To evaluate the efficacy and predictive factors of Dipeptidyl peptidase-4 (DPP-4) inhibitors in type 2 diabetes mellitus (T2DM) patients who were not well controlled with other oral antidiabetic drugs or insulin in real clinical practice.

Methods

From December 2012 to January 2014, retrospective longitudinal observation study was conducted for patients with T2DM who were not reached a glycemic target (glycated hemoglobin [HbA1c] > 6.5%) with other oral antidiabetic drugs or insulins. Type 1 diabetes or other types of diabetes were excluded. Responders were eligible with decreased HbA1c from baseline for more than 5% during follow up period.

Results

Of total 135 T2DM patients having an average 9.0 months follow-up period, 84 (62.2%) of patients were responder to DPP-4 inhibitors. After concomitant treatment with DPP-4 inhibitors, patients had a mean decrease in HbA1c of 0.69 ± 1.3%, fasting plasma glucose of 13 ± 52 ㎎/㎗, and postprandial plasma glucose of 29 ± 85 ㎎/㎗ from baseline (all P< 0.05). Independent predictive factor for an improvement of glycemic control with DPP-4 inhibitors was higher baseline HbA1c (odds ratio 2.07 with 95% confidence interval 1.15–3.72) compared with non-responders.

Conclusions

A clinical meaningful improvement in glycemic control was seen when DPP-4 inhibitors were added to other anti-diabetic medications in patients with T2DM regardless of age, duration of T2DM, type of combination treatment regimen. Patients who had higher HbA1c were more easily respond to DPP-4 inhibitors treatment in short-term follow-up period.

Obesity and Insulin Resistance According to Age in Newly Diagnosed Type 2 Diabetes Patients in Korea
Ju Won Lee, Nam Kyu Kim, Hyun Joon Park, Jun Yeob Lee, Seon Yoon Choi, Eun Mi Lee, So Young Ock, Su Kyoung Kwon, Young Sik Choi, Bu Kyung Kim
Kosin Med J. 2016;31(2):157-166.   Published online January 20, 2016
DOI: https://doi.org/10.7180/kmj.2016.31.2.157
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Abstract Objectives

With the rapid increase in the prevalence of diabetes, the age groups of diabetic patients are becoming diversified. This study will examine the degree of obesity, insulin resistance, and insulin secretion ability among patients first diagnosed with diabetes according to age and gender.

Methods

The subjects of this study included 616 patients who were first diagnosed with diabetes during a routine physical examination. This sample was obtained from a total of 28,075 adults aged 19 years and older who received the examination among 33,829 participants in the Korea National Health & Nutrition Examination Survey (KNHANES) from 2007–2010. The subjects were categorized by age into young age (age: 19 – 39 years), middle age (age: 40 – 59 years), and old age (age: 60 years and older). The degree of obesity was categorized according to body mass index (BMI) into normal weight (BMI: 18.5 ∼ 22.9), overweight (BMI: 23 ∼ 24.9), and obesity (BMI: 25 or above). Insulin resistance was evaluated by homeostatic model assessment of insulin resistance (HOMA-IR).

Results

It was found that 14.1% (n = 87) of a total of 616 subjects (324 men, 292 women) were in the young age group, 43.8% (n = 270) were in the middle age group, and 42.1% (n = 259) were in the old age group. In addition, 83.3% of men that were overweight or obesity were in the young age group, while 79.2% and 60.5% were in the middle age and old age groups, respectively. A total of 82.2% of women that were overweight or obesity were in the young age group, while 79.5% and 77% were in the middle age and old age groups, respectively. For men, the more obesity they were in all age groups, the higher their HOMA-IR. For women, the more obesity they were in the young age and middle age groups, the higher their HOMA-IR; however, women in the old age group showed the highest HOMA-IR when they were of normal weight.

Conclusion

Among diabetic patients first diagnosed with the disease in Korea, the youth population had the highest obesity rate. Insulin resistance increases as an individual's weight increases among those patients who are first diagnosed with diabetes; the only exception noted is for elderly women.

Catheter Fracture of a Totally Implantable Venous Device Due to Pinch Off Syndrome in Breast Cancer: A Case Report
Yoonseok Kim
Kosin Med J. 2016;31(2):167-172.   Published online January 20, 2016
DOI: https://doi.org/10.7180/kmj.2016.31.2.167
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Abstract

Totally implantable venous devices are used in medical care for parenteral nutrition, vascular access, administrating chemotherapeutic agents and so on. Although the large variety of catheter complications, catheter fracture is a rare but serious complication. The pinch off syndrome is caused by the compression of the catheter between the clavicle and first rib, and may lead to fracture and possible dislocation of the catheter. We report here the case history of a patient with metastatic breast cancer who developed a rare complication of subclavian catheter fracture as a consequence of pinch off syndrome.

Case reports
Endoscopic Removal of Remained Drawstring After Percutaneous Transhepatic Biliary Drainage
Tae Wook Yoon, Geun Yong Jung, Young Jun Park, Jun Young Choi, Jee Hwan Jung, Tae Gyoon Kim
Kosin Med J. 2016;31(2):173-178.   Published online January 20, 2016
DOI: https://doi.org/10.7180/kmj.2016.31.2.173
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Abstract

The percutaneous transhepatic biliary drainage (PTBD) is an effective intervention as a palliative therapy for relieving a jaundice and cholangitis. It may be used in place of Endoscopic retrograde cholangiopancreatography (ERCP) in the obstructive biliary disease. Recently, by developing invasive procedures, the incidence of the complications such as bleeding and perforation has been increasing in the diagnosis and treatment of hepatobiliary disease. We report here on a case of remained drawstring after PTBD in a 85-year-old man. The patient was conducted PTBD for relieving a jaundice and cholangitis. And then the patient had complained of abdominal pain constantly. A few days later, we removed PTBD and attempted ERCP for removal of CBD stone. The ERCP showed remained drawstring around ampulla of vater and we removed it by IT knife. The drawstring was successfully removed.

A Case of Cerebral Venous Thrombosis in a Patient with Graves' Disease
Bo Ra Kim, Jung Hwa Jung, Jong Ryeal Hahm, Jaehoon Jung, Hee Jung Park, Soo Kyoung Kim
Kosin Med J. 2016;31(2):179-183.   Published online January 20, 2016
DOI: https://doi.org/10.7180/kmj.2016.31.2.179
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Abstract

Superior sagittal sinus thrombosis is an uncommon disease, and 25% of cases are considered to be idiopathic. Hypercoagulability, local bloodstream stasis, and vessel wall abnormalities may contribute to the development of this condition. The thyrotoxic phase of Graves' disease is associated with venous thrombosis caused by hypercoagulability, which is in turn induced by increased levels of homocysteine and factor VIII and decreased fibrinolytic activity. Here, we report the case of a 39-year-old male who presented with superior sagittal sinus thrombosis and concomitant hyperthyroidism.

Knot Formation at Removal of an Epidural Catheter Placed Against Insertion Resistance Encountered at the Entrance of the Epidural Space
Byung Tae Kil, Bong Il Kim, Jong Hae Kim
Kosin Med J. 2016;31(2):184-190.   Published online January 20, 2016
DOI: https://doi.org/10.7180/kmj.2016.31.2.184
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Abstract

Knotting of an epidural catheter occurs very rarely with an estimated incidence of 0.0015%. We present a case of an epidural catheter knot formed at removal of an epidural catheter following a forceful insertion of the catheter against resistance met at the entrance of the epidural space during threading of the catheter through Tuohy needle placed uneventfully in a 65 year-old male patient undergoing epidural anesthesia. During removal of the epidural catheter, significant resistance was encountered on traction and it was found that approximately 1.5 ㎝ portion of the catheter had been retained within the patient's subcutaneous tissue. Firm traction was employed to withdraw the catheter against the resistance. The catheter was pulled out uneventfully from the patient. A knot estimated to be formed during removal of the catheter was observed at 0.6 ㎝ proximal to the catheter tip. No complications and side effects were noted until the patient's discharge.

Biliary Cystadenoma Causing Esophageal Varices
Sung Ju Kang, Tae Hee Lee, Min Gyu Seok, Hyo Jin Yun, Ye Seul Jang, Jun Hyun Byun
Kosin Med J. 2016;31(2):191-196.   Published online January 20, 2016
DOI: https://doi.org/10.7180/kmj.2016.31.2.191
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Abstract

Biliary cystadenomas are benign but potentially malignant cystic neoplasm. The preferred treatment is radical resection because it is difficult to differentiate a benign from a malignant biliary cystadenoma. A 40 year-old woman presented with moderate abdominal discomfort. Esophageal varix was found up to mid-esophagus on endoscopy. She has no prior history of liver disease or chronic alcohol ingestion. About 15cm sized biliary cystadenoma was diagnosed by ultrasonography, computed tomography and magnetic resonance imaging. Serum level of bilirubin, alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase and tumor marker were elevated. The patient underwent US-guided aspiration. Tumor markers from the aspirated fluid are increased. Left hepatectomy was performed to completely remove the cyst. Histology of the resected specimen confirmed a biliary cystadenoma of the liver with ovary-like stroma. Without prior history of liver disease or chronic alcoholic ingestion, incidental finding of esophageal varix could show an important clue for diagnosis of biliary cystadenoma.


KMJ : Kosin Medical Journal