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Volume 32(1); June 2017
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Review articles
An Overview of the Clinical Efficacy and Safety of Tissue Selective Estrogen Complex: From the Selective Estrogens, Menopause, and Response to Therapy (SMART) Trials
Sung Wook Chun
Kosin Med J. 2017;32(1):5-16.   Published online June 30, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.5
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

Hormone therapy (HT) is the most effective treatment for menopausal symptoms, and reduces both spinal and non-spinal postmenopausal osteoporotic fractures. However, a Women's Health Initiative (WHI) trial revealed that progestin-containing HT is associated with higher incidences of breast cancer and coronary heart disease than those associated with placebo. Tissue selective estrogen complex (TSEC) is a novel progestin-free HT option composed of conjugated estrogens (CE) and a selective estrogen receptor modulator. CE at a dose of 0.45 mg combined with 20 mg of bazedoxifene was the first TSEC medication approved in the United States and Korea for women with moderate to severe menopause-related vasomotor symptoms (VMS) and for preventing postmenopausal osteoporosis. This review summarizes the clinical efficacy, safety, and tolerability of TSEC as obtained from the five SMART clinical trials.

Current Medical Therapy for Uterine Leiomyomas
Suk Bong Koh
Kosin Med J. 2017;32(1):17-24.   Published online June 30, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.17
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

Uterine leiomyomas are benign tumors arising from the myometrium and largely prevalent in the woman's reproductive years. The majority of women with leiomyomas either remain asymptomatic or develop symptoms gradually over time. When patients are symptomatic, the nature of their complaints is often attributable to the number, size, and/or location of their fibroids. Depending on a patient's symptomatology and reproductive plans, treatment options include expectant management, medical management (hormonal and non-hormonal), or surgical management (myomectomy or hysterectomy).

Original articles
Effect of Rheumatoid Factor on Vascular Stiffness in General Population without Joint Symptoms
Ji Hyun Lee, Hee Sang Tag, Geun Tae Kim, Min Jeong Kim, Seung Geun Lee, Eun Kyung Park, Dong Wa Koo
Kosin Med J. 2017;32(1):25-35.   Published online January 19, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.25
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM
Objectives

The role of rheumatoid factor (RF) in vascular stiffness and cardiovascular risk in subjects without joint symptoms remains unclear. We investigated vascular stiffness in subjects without joint symptoms using pulse wave velocity (PWV), calculated Framingham risk scores (FRS), an estimator of cardiovascular risk, and analyzed whether vascular stiffness and FRS were affected by RF.

Methods

Two hundred forty-two subjects were included in this population-based study. RF was quantified with turbid immunometry using a cut-off of RF > 15 IU/ml to denote RF positivity. Information was then obtained on joint symptoms. Brachial-ankle PWV (baPWV) was measured using an automated device.

Results

Of the 242 subjects, 15 were RF-positive. RF-positive subjects without joint symptoms had a higher baPWV and FRS than RF-negative subjects without joint symptoms, but the difference did not reach statistical significance. However, when we stratified the subjects into two groups (group A – high RF: RF ≥ 40 IU/ml; group B – low RF: RF < 40 IU/ml), group A showed significantly higher baPWV (1640.7 ± 179.6 ㎝/s vs. 1405.7 ± 225.7 ㎝/s, P= 0.008) and FRS (25.7 ± 4.87 vs. 11.8 ± 9.6, P< 0.001). Multiple regression analysis was used to examine potential confounders, and RF exhibited significant but modest effects on baPWV (adjusted R-squared = 0.038, P= 0.030).

Conclusions

In a sample of the general population without joint symptoms, higher levels of RF were associated with increased vascular stiffness, suggesting a pathophysiologic link between RF and endothelial dysfunction.

Hemodynamic Effects of Co-administration of Midazolam during Anesthesia Induction with Propofol and Remifentanil in Hypertensive Patients
Ju Deok Kim, Joo Won Kim, His Chiang Kung, Jun Hong Kang, Hye Young Shin, Doo Sik Kim, Sie Jeong Ryu, Kyung Han Kim
Kosin Med J. 2017;32(1):36-46.   Published online June 30, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.36
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM
Objectives

Propofol, midazolam and remifentanil are commonly used for clinical anesthesia. We compared the effects of midazolam-propofol-remifentanil and propofol-remifentanil on hemodynamic responses during anesthesia induction in hypertensive patients.

Methods

Seventy-six hypertensive patients with ASA II-III were assigned to receive midazolam-propofol (group MP; n = 38) or propofol (group P; n = 38). Anesthesia was induced with midazolam 0.03 mg/kg (group MP) or saline 0.03 ml/kg (group P). After two minutes, propofol 1.0 mg/kg (group MP) or 1.5 mg/kg (group P) i.v. bolus was administered. Simultaneously, 4 ng/ml of remifentanil target controlled infusion (TCI) was administered in both groups. Anesthesia was maintained using sevoflurane and 2 ng/ml of remifentanil TCI. Systolic, diastolic, and mean blood pressure (SBP, DBP, and MBP) and heart rate (HR) were measured before induction, 2 min after midazolam or normal saline, 2 min after propofol, 1 min after rocuronium, and immediately, 1 min, 2 min, and 3 min after intubation.

Results

SBP, DBP, and MBP decreased after propofol administration and increased immediately after intubation in both groups (P < 0.05). After intubation, SBP, DBP, and MBP decreased more than baseline values in either group. Although the overall BP of Group P was lower than that of Group MP, there were no significant differences except for SBP at 2min after intubation (P < 0.05). HR was no significant difference in either group.

Conclusion

Our results suggest that midazolam-propofol-remifentanil has similar hemodynamic effect with propofol-remifentanil during anesthesia induction in hypertensive patients.

Performance of Half-dose Chest Computed Tomography in Lung Malignancy Using an Iterative Reconstruction Technique
Hee Kang, Jung Gu Park, Se Kyoung Park, Beom Su Kim, Ki Nam Lee, Kyeung Seung Oh
Kosin Med J. 2017;32(1):47-57.   Published online June 30, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.47
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM
Objectives

The purpose of this study was to evaluate the performance of half-dose chest CT using an iterative reconstruction technique in patients with lung malignancies.

Methods

The Dual-source CT scans were obtained and half-dose datasets were reconstructed with 5 different strengths in 38 adults with lung malignancies. Two radiologists graded subjective image quality; noise, contrast and sharpness at the central/peripheral lung, mediastinum and chest wall of the reconstructed half-dose images, compared with those of standard-dose images, using a three-point scale. A lesion assessment; lesion conspicuity and diagnostic confidence, was also performed. The quantitative image noises; contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were measured and compared with those of standard-dose images.

Results

The subjective image noise in the half-dose images was less than that of the standard-dose images. The contrast in strengths 2 to 5 was superior, the sharpness of the lung parenchyma in strengths 3 to 5 was inferior, and the CNR/SNR in all strengths were higher than those of standard-dose images (P < 0.05). The improvement of subjective image noise and contrast, the decrease in sharpness, were correlated with strength level (P < 0.05). The lesion conspicuity in half-dose images of strengths 4 and 5 was decreased. The diagnostic confidence of the half-dose images of all strengths was comparable to that of the standard-dose images (P < 0.05).

Conclusions

Half-dose chest CT images using an iterative reconstruction technique show decreased image noise, increased contrast, and diagnostic confidence comparable to standard-dose images. Images reconstructed with strength 2 and 3 appear to be the optimal choice in clinical practice.

Relationships of Total Lymphocyte Count and Subpopulation Lymphocyte Counts with the Nutritional Status in Patients Undergoing Hemodialysis/Peritoneal Dialysis
Ye Na Kim, Ho Sik Shin
Kosin Med J. 2017;32(1):58-71.   Published online January 19, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.58
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM
Objectives

Dialysis patients’ nutritional indicators are quite subjective and complex and cannot be easily measured in clinical settings. Based on previous reports that total lymphocyte count (TLC) and subpopulation lymphocyte counts (SLCs) are associated with nutritional status in patients with dialysis, we designed this study to examine the relationships of the TLC and SLCs with clinical outcome and nutritional status in patients undergoing maintenance hemodialysis (HD) and peritoneal dialysis (PD).

Methods

In this prospective, observational study, we enrolled 66 patients (50 HD patients and 16 PD patients) receiving stable maintenance dialysis. We evaluated the baseline parameters of height; weight; TLC; SLCs expressing CD3, CD4, CD8 and CD19; CBC; iron profile (iron, TIBC, ferritin); BUN; Cr; Na; K; total CO2; Ca; P; iPTH; protein; albumin; total cholesterol; HDL; LDL; uric acid and CRP and calculated Onodera’s prognostic nutritional index (OPNI) and the Geriatric Nutritional Risk Index (GNRI) at baseline and three months. To analyze differences in the TLC and SLCs between the HD group and the PD group, we performed an independent samples t-test. Logistic regression analysis was performed to predict malnutrition in dialysis patients. In addition, to analyze changes in TLC, SLCs expressing each marker (CD3, CD4, CD8 and CD19) and other nutritional markers, we performed general linear model (GLM)-repeated measures ANOVA.

Results

Mean age was 55.8 ± 12.7 years in HD paitents and 49.8 ± 14.5 years in PD patients. The duration of dialysis was 59.7 ± 52.9 months in HD patients and 66.1 ± 33.6 years in PD patients. Logistic regression analysis revealed that patients aged 60 years or older, women, and those whose CD19 SLCs were lower than 100 had a higher risk of developing malnutrition. In GLM-repeated measures ANOVA, CD19 SLCs were significantly higher in women and in patients with a shorter period of dialysis.

Conclusions

Our results indicate that GNRI, OPNI, TLC and SLCs (especially CD19 count) may be significant nutritional markers in HD and PD patients.

Utility of Regular Radiological Follow-up on Early Detection of Contralateral Malignancy and Long-term Outcomes in Metachronous Bilateral Breast Cancer Patients
Hyo Sun Kim, Sun Hee Kang
Kosin Med J. 2017;32(1):72-83.   Published online June 30, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.72
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM
Objectives

We investigated the utility of regular radiological follow-up on the early detection of contralateral breast cancer(CBC) and prognosis in patients with metachronous bilateral breast cancer.

Methods

Between 1983 and 2010, 49(2.1%) metachronous bilateral breast cancer patients were identified among a total of 2,343 cases of invasive or in situ breast carcinomas. We reviewed the patients' medical records including age, stage, duration between the first and second breast cancer diagnosis, operation method, recurrence, and breast cancer-specific survival.

Results

The mean ages at the first and second breast cancer diagnosis were 43.8 and 49.2 years, respectively. The mean duration between the first and second breast cancer diagnosis was 68.9 months (range, 7–266 months). Regular radiological follow-up with annual mammography(MMG) with or without ultrasonography was conducted in 28 patients (63.6%, Group 1), and no regular follow-up was performed in 12 patients (27.3%, Group 2). The median follow-up duration was 150 months. In a comparative analysis, Group 1 patients exhibited more stage 0 and stage 1 malignancies (82.1% vs. 25%, P =0.006) as second cancer and the same or an improved stage (71.4% vs. 33.3%, P =0.042) of second cancer compared to Group 2 patients. Breast cancer-specific survival rates between the two groups after the first cancer occurrence were higher in Group 1 patients compared to Group 2 patients, although this did not reach statistical significance.

Conclusion

Screening for CBC with regular radiological follow-up could result in early detection of CBC, less invasive surgical procedures, and enhanced breast cancer-specific survival outcomes.

Case reports
A Case of Protein Losing Enteropathy as Only Clinical manifestation of Systemic Lupus Erythematosus
Tae Hyun Kim, Yu Hee Choi, Lae Hyung Kang, Hyeong Jin Kim, Jin Ho Jang, Min Wook So
Kosin Med J. 2017;32(1):84-89.   Published online June 30, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.84
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

Protein losing enteropathy (PLE) due to systemic lupus erythematosus (SLE) is relatively uncommon. PLE may be appeared sequentially after the diagnosis of SLE or concurrently with SLE. In most of concurrent cases, PLE was diagnosed one of various symptoms of SLE. Cases of PLE as the initial and only clinical presentation of SLE have been rarely reported. We described a 30-year old woman with general edema and abdominal distension was diagnosed PLE after stool alpha 1 antitrypsin clearance test. Her symptoms were getting worse even though the treatment with intravenous albumin. She was finally diagnosed PLE associated with SLE by additional laboratory findings (positive antinuclear antibody and anti-dsDNA IgG and low C3, C4 and CH50). She was treated with high dose of steroids and her symptoms were improved.

A Case of Steroid Resistant Minimal Change Disease Associated with Portal Vein Thrombosis Treated by Combined Immunosuppressive Agents
Hyo Jin Jung, Su Mi Lee, Seo Hee Rha, Seong Eun Kim, Young Ki Son, Ki Seung Kim, Won Suk An
Kosin Med J. 2017;32(1):90-98.   Published online June 30, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.90
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

Minimal change disease (MCD) is a common cause of nephrotic syndrome and relatively well responds with steroid treatment. However, nearly half of patients with MCD experience recurrence of nephrotic syndrome. Thromboembolic events including renal vein thrombosis may occur in patients with MCD, but portal vein thrombosis rarely occurs. We experienced a case of frequent relapse/steroid dependent MCD with nephrotic syndrome progressed to steroid resistance associated with portal vein thrombosis. This patient showed complete remission of MCD and resolution of portal vein thrombosis after treatment with corticosteroid, cyclosporine, mycophenolate mofetil, and anticoagulant.

Bronchial Varices in a Patient with Behçet's diasese: A Case Report
Joon Cheol Song, Bo Geun Park, Chai Ho Jeong, Hye Seon Kang, Joong Hyun Ahn, Ju Sang Kim
Kosin Med J. 2017;32(1):99-104.   Published online June 30, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.99
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

We report a case of a 65-year-old man with Behcet's disease who presented with massive hemoptysis caused by bronchial varices. A computed tomography (CT) scan and bronchoscopy were performed to identify the bleeding site. The CT scan revealed pneumonia and a combined hemorrhage in the right-middle and lower lobes. Massive bleeding was detected during the bronchoscopy and emergency embolization was attempted but angiographic findings were normal. An anteriojugulo-right femoral bypass operation was performed to relieve the tortuous and hypertrophied jugular venous obstruction. However, thrombectomy and thrombolysis followed because of graft thrombosis six days post-surgery. The patient was treated with steroid and high-dose cyclophosphamide therapy for his Behçet's disease, which caused the venous obstructions; the saccular bronchial varices in the right-middle and right lower lobes on bronchoscopy regressed slightly after four cycles of cyclophosphamide therapy

A Case of Lactate Containing Peritoneal Dialysis Solution Induced Lactic Acidosis Corrected by Changing to Hemodialysis
Eun Bin Kim, Ki Seung Kim, Su Mi Lee, Young Ki Son, Seong Eun Kim, Won Suk An
Kosin Med J. 2017;32(1):105-110.   Published online June 30, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.105
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

Elevated lactate levels are associated with acute illnesses, and the mortality is high. Here, we report a case of lactate-containing peritoneal dialysis (PD) solution inducing lactic acidosis corrected by changing to hemodialysis (HD). This 70-year-old female patient was treated with PD 8 months previously for end-stage renal disease caused by diabetes mellitus. She was admitted complaining of general weakness. Initial lactate level was 22.1 mg/dL and increased to 62.4 mg/dL showing high anion gap metabolic acidosis and compensatory hyperventilation. There are no definite causes of lactic acidosis besides the use of PD solutions containing a lactate component. The patient's lactate level was decreased after temporarily changing the dialysis modality to HD. Her lactate level was increased again after restarting PD, and decreased to normal after restarting HD. We report this case because physicians should consider lactate-containing PD solution as a possible cause of lactic acidosis.

A Case of Cardiac Arrest due to Multivessel, Diffuse Coronary Spasm in Moyamoya Disease
Young Min Choi, Jung Woo Choi, Dong Ho Kang, Choong Hwan Kwak, Jin Yong Hwang, Jin Sin Koh
Kosin Med J. 2017;32(1):111-117.   Published online January 19, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.111
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

Moyamoya disease is characterized by progressive stenosis of the distal portion of the internal carotid arteries and fragile collateral vessels in the brain. The precise pathogenesis is still not known. Although extracranial vessel involvement is very rare, coronary arterial involvement has recently been reported. Here, we report a case of diffuse, multivessel coronary spasm leading to cardiac arrest and myocardial infarction in a 47-year-old man with moyamoya disease with no underlying emotional or physical stress.

A Case of Treatment with Steroid and Hydrochloroquine of Thrombocytopenia in Primary Sjögren's Syndrome
Yeong Seop Yun, Ji Wook Choi, Young Jae Doo, Tae Hyung Kim, Hye Lim Oh, Ji Min Oh
Kosin Med J. 2017;32(1):118-126.   Published online June 30, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.118
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

Sjögren's syndrome is a systemic autoimmune disease characterized by sicca symptoms and extraglandular manifestations. Anemia, leukopenia, thrombocytopenia and lymphoproliferative disorders are well-known extraglandular, hematological complications of Sjögren's syndrome. These hematologic alterations are usually mild and respond well with steroid therapy. We report a case of a 52-year-old female patient who was initially presented with thrombocytopenia. The patient was then diagnosed with primary Sjögren's syndrome and initially treated with steroid. The patient's platelet count was decreased when steroid was tapered. The dose of steroid could be effectively reduced after combined medication with hydroxychloroquine.

Aortic Dissection after Intravenous Thrombolysis in Acute Cerebral Infarction
Young Rok Do
Kosin Med J. 2017;32(1):127-132.   Published online June 30, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.127
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

Use of recombinant tissue plasminogen activator (rt-PA) for the treatment of acute cerebral infarction secondary to aortic dissection is challenging because of a narrow time window and potential life-threatening complications. An 80-year-old woman with right middle cerebral artery infarction was treated with rt-PA. Although she had no history, symptoms, or sign of aortic dissection, carotid CT angiography revealed aortic arch dissection. Mediastinal widening, which did not show on initial chest X-ray, developed on follow-up chest X-ray. This observation indicates that physicians should monitor patient symptoms for signs of aortic dissection during thrombolysis and perform chest X-ray or carotid angiography immediately after thrombolysis even if the patient has no symptoms or signs of aortic dissection on onset of acute cerebral infarction.

Kearns-sayre Syndrome Treated with Permanent Pacemaker Insertion for Complete Atrioventricular Block
Eun Hye Park, Sung Ho Her, Myung A Ha, Hyo Suk Kim, Jae Hyuk Jang
Kosin Med J. 2017;32(1):133-138.   Published online June 30, 2017
DOI: https://doi.org/10.7180/kmj.2017.32.1.133
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

Kearns-Sayre syndrome (KSS) is a rare multisystem mitochondrial disorder associated with progressive external ophthalmoplegia, atypical pigmentary degeneration of the retina, and complete heart block. KSS can lead to a risk of sudden death because of the potential progression of conduction abnormalities such as right or left bundle branch block or complete atrioventricular (AV) block. Here we describe the case of a KSS patient with type I diabetes who experienced syncope in the presence of complete AV block, confirmed by muscular biopsy.


KMJ : Kosin Medical Journal